Category Archives: Health

The MWS Podcast 130: Daniel P Keating on Epigenetics, Anxiety and Social Inequality

Our guest today is Daniel P Keating, a professor of Psychology, Psychiatry, and Paediatrics at the University of Michigan. He’s the author of several books including ‘Developmental Health and the Wealth of Nations’, ‘Nature and Nurture in Early Child Development’ and he’s here to talk to us today about his latest book ‘Born Anxious: The lifelong impact of Early Life Adversity and how to break the cycle.

MWS Podcast 130: Daniel P Keating as audio only:
Download audio: MWS_Podcast_130_Daniel_P_Keating
Click here to view other podcasts

From Medieval to Modern Medicine: A Journey of (Not So Straightforward) Progress.

During a recent(ish) podcast, in which Peter Goble and I discussed issues surrounding the experience and management of pain, I suggested that the distinctions between mind and body – which have existed in modern medicine – are beginning to be broken down; that scientific medicine was embracing holistic ideas and practices with more than mere lip service. This, in part, has been in response to the apparent rise of ‘holistic’ or ‘complementary’ therapies (I say ‘apparent rise’ because I think that therapies offering alternatives to the mainstream have been popular in one form or another for a very long time). Despite harbouring some doubts about such theories, usually regarding their underlying theories or their general efficacy, I have long thought that the tendency to treat the ‘whole person’ rather than focus solely on specific diseases is a good one. If we take lung cancer, as one obvious example, then it’s right to say that it’s a disease that can be identified in one area of the body and treated locally. If it’s found early enough it can even be surgically removed and the patient can be ‘cured’.  All of this can be achieved without much thought for the individual involved, but it shouldn’t be. There are many reasons why a holistic approach should accompany (or rather form part of) the medical approach. A person’s lifestyle or environment can be manipulated to aid recovery, or even help reduce the risk of getting lung cancer in the first place, and the person’s emotional needs should also be considered. Getting lung cancer is not just a physical event; there will likely be considerable emotional effects too – which, like physical symptoms will be different for each individual.

Such things are increasingly being contemplated and acted upon by the medical community, which is interesting when one considers that the humoral model had been doing this for centuries, before being rejected roughly 200 years ago, by the scientific model.  From the 10th to the 19th century CE the established medical orthodoxy was based, almost entirely, on the ancient ideas of thinkers such as Hippocrates, Aristotle and Aelius Galen.  This system was based on the belief that the human body consisted of four fluids (or humours): Yellow Bile, Pure Blood, Black Bile and Phlegm.  Each humour had unique properties and were related to such factors such as Aristotle’s four elements andThe_four_elements,_four_qualities,_four_humours,_four_season_Wellcome_V0048018 the four seasons of the year.  So, the properties of Yellow Bile were considered to be ‘hot and dry’ meaning that it was related to the ‘element’ fire and the summer season.  Phlegm, on the other hand, was ‘wet and cold’ and thus associated with ‘water’ and ‘winter’.  Each person had an optimum ratio of these four humours, which was specific to them; personality, emotion and physical condition were all determined by this ratio (or complexion).  One’s health was the product of one’s complexion; if the ratio of humours became deranged then ill health would follow.  Factors such as environment, food or the position of celestial bodies could all alter the amount of each humour.

Diseases were not thought to be specific entities in of themselves.  Every incidence of disease was specific to the person who was suffering, and thus treatments were tailor made to address the specific conditions that were responsible.  If a set of symptoms were thought be caused by a surplus of Yellow Bile, then any treatment would have the opposite properties of cold and wet.  Such treatments could include a prescription to change the properties of ones environment or diet, as well as for medical concoctions and surgery.  By considering psychology, physicality, lifestyle and environment as deeply interrelated factors, thereby focusing on the whole patient as an individual, humoral medicine was truly holistic.  It was impressively versatile too; from Christianity, through the emergence of human dissection, to the enlightenment, challenges to the ancient system came from many sources.  Often, such challenges would be integrated into the existing theory.  God became the primary cause of disease, causing it and allowing it to spread as a punishment for sin, and new treatments based on chemical experimentation were added to the long list of remedies and concoctions.  What did not change, and what was not readily challenged within the mainstream, were the core ideas of the classical scholars.  It was widely believed that the work of those such as Galen could not be bettered, only expanded upon (although this too was a matter of debate).  Even when human dissection showed that anatomy differed from what Galen proposed (Galen only dissected animals) it was frequently assumed that the anatomist, not Galen, had made a mistake.  Some scholars would even alter their descriptions to fit the Galenic sources.  Mainstream medicine spent over 1000 years being based on a, largely, unchallenged appeal to authority.  Those who dared practise outside of its dogmatic sphere could find themselves the unfortunate victims of persecution.

A combination of factors (theoretical, technological, political & social), occurring up to and throughout the late 18th to the mid 19th century, eventually led to the decline of this long lived classical theory.  The emergence of increasingly scientific medical theories led to a general shift in focus from the patient – as an individual to be treated as a whole – to a specific part of the body or an external, disease causing, entity.  As such the patient, in many cases, came to be viewed as an incidental part of the disease process.  That’s not to say there was a clearly defined shift from the ways of the old to those of the new; there rarely is.  Nor was there a move from a wholly holistic practice to one where such considerations were completely absent.  Nevertheless, the medical community was becoming increasingly specialised and all to often the human being was becoming lost in the detail.

I’m not going to argue that this process shouldn’t have happened.   The tendency to specialise and focus on diseases as distinct entities and specific parts of the body has given us incalculable benefits.  If faced with the prospect of a Tuberculosis outbreak, I’ll take the scientific explanation and subsequent course of action over that of a humoral practitioner any day.  Similarly, if I ever need complex cardiac surgery and I’m given the option of a surgeon that is warm, kind and empathetic with an above average mortality rate or a sociopath with a rude, unpleasant bedside manner, who has a very low mortality rate, I’ll take the latter every time.  Of course, it would be much better if I could have a surgeon who combines the best of both.  This might be a bit idealised, and it would be unrealistic to expect every practitioner to experience and radiate the same levels of empathy, just as one could not expect every surgeon to have the same technical skills, but that does not mean it shouldn’t be aimed for.  A surgeon would probably not think much of the notion that they should always endeavour to become as technically skilled as they possibly can be, but the suggestion that the same principle should apply to bedside manner might not always be met with enthusiasm.  I think that it’s an oversimplification to claim that patient’s are viewed merely as objects rather than individuals but there is some truth to this, as demonstrated by this very funny video (which is only funny because there is more than a whiff of truth, and familiarity for anybody that works in an operating department).  I’ve even fallen into such language myself:

‘Are we doing the abscess next’?

Although I’m glad to say, that in my experience, I’ve always (rightly) been pulled up on such utterances by a colleague:

‘We are not “doing an abscess”, we are treating a person who has an abscess’.

I think that there have been many improvements – from wider environmental and lifestyle concerns to the understanding that our physical or psychological conditions cannot always (if at all) be considered in isolation from each other.  Pain management services (in Britain, at least) are a good example where services are being integrated, but there is still a long way to go.  The provision for the psychological well being of those staying in hospital, for example, is often inadequate (a situation potentially made worse if you also happen to suffer from a mental illness) – of course a positive emotional experience will not fix that broken hip, but it may well assist in your recovery and help prevent you form developing a new founded, and avoidable, phobia of hospitals.  There are obviously financial and logistical factors at play here, which can be hard to overcome – but this is not an excuse for the wider needs of patients to be neglected.

Modern medicine has many advantages over humoral medicine.  It is demonstrably more effective at preventing and treating disease and it is not based upon such dogmatic appeals to authority.  Clearly, there is dogma and there are appeals to authority, but due to the requirements for evidence and expectations for innovation, such dogmas are short lived – perhaps lasting a generation or so, but falling far short of the 1000 years that Medieval medical orthodoxy managed to exist.  However, the shift away from the old ideas probably went to far and our focus became too narrow, meaning, in some respects, we have spent the last 200 or so years rediscovering some of the valuable ideas which had become obscured.  The Middle Way Philosophy is unapologetically inspired by many, sometimes apparently incompatible, sources; a ‘magpie’s nest of influences’ made up from those aspects of other ideas which, after critical analysis, have been deemed useful.  Good science and, by extension, good medicine also does this, but all too often there is hesitation, often borne from suspicion of ideas that do not fit neatly into the current orthodoxy.  There are plenty of ‘alternative/ complementary’ therapies that are widely popular and don’t hold up to scientific scrutiny.  To dismiss them all, in their entirety, because of this may be a mistake.  Yes, such and such therapy might not treat what it says it treats, in the way that it claims, but that doesn’t mean there is no value to be found.  If a GP prescribes a contraceptive pill, it will almost certainly work (if used correctly).  As far as I know there is not a Homeopathic equivalent to the contraceptive pill, but the extended consultation that one is likely to receive from a Homeopath could provide many other benefits that GP could not hope to achieve in a 5-10 minute consultation.  We shouldn’t be uncritically open to all ideas that come our way, or to the ones that are currently in vogue, but neither should we dismiss them out of hand (even if one aspect has already proven unhelpful).  This is not easy to do and we will continue to take wrong turns, just as we have in the past.  However, in general, I believe that we will continue to move in something like the right direction, albeit in a haphazard, uneven and uncertain fashion.  I also believe that the five principles of the Middle Way, and the wider philosophy that emerges from them, are well placed to help us avoid many of the hindrances of the past.

Picture: The four elements, four qualities, four humours, four season. From Wellcome Library, London (CC BY 4.0), via Wikimedia Commons


The MWS Podcast 103: Matt Robert on Open Source Recovery

We are joined today by Matt Robert. Matt runs multiple “recovery“ oriented groups in the greater Boston area in the US. Some are open to the public, some are in detoxes, psychiatric units, shelters, etc.. He uses the platform of SMART Recovery (Self-Management And Recovery Training), and the thrust of his groups is about helping people examine their intention and motivation to change. The groups include people with substance use issues, as well as any behaviour with undesired negative consequences that build up over time and get in the way living one’s life as desired. He also does this in the context of hybrid 12-Step groups that incorporate mindfulness, meditation and Buddhist philosophy.

MWS Podcast 103: Matt Robert as audio only:
Download audio: MWS_Podcast_103_Matt_Robert

Click here to view other podcasts

The 12 Steps of Addiction Recovery: Are they in the spirit of the Middle Way?

A dialogue between Robert M. Ellis and Peter Sheath

(Robert’s contributions are in black throughout, and Peter’s in red)

Robert: The 12 Steps are a successful method of addiction recovery that has been used by Alcoholics Anonymous and its sister organisations since the 1930’s. After my recent discussions with Marc Lewis about addiction, and also inspired by this interview with a pair of philosophers who have analysed the 12 steps, I have been interested in looking more closely at the 12 steps to see how far their success can be attributed to a compatibility with the Middle Way. My thesis is that at least a part of their practical success in facilitating recovery must be due to the ways in which they help addicts avoid explicit or implicit absolutisations, whether positive or negative. Whether a particular text operates as an absolutisation or helps people to avoid it, however, depends entirely on its practical interpretation in context. This is a particularly interesting point in relation to the 12 steps, which use a lot of religious language, though it seems that this language has been interpreted in a very practical way.Greed_for_alcohol_-_Annie_Besant_Thought_Form_-_Project_Gutenberg_eText_16269

Lacking any practical knowledge of the interpretative context of AA and associated organisations myself, I am pleased to be able to collaborate with Peter Sheath by getting him to bring his practical experience to bear in commenting on the accuracy (or otherwise) of my suggested interpretations of the 12 steps. Peter has long experience of working with addiction recovery, and was recently interviewed by Barry in the Middle Way Society podcast.

The way I will proceed, then, is to offer commentary on each of the 12 steps and how they might be interpreted in relation to the Middle Way. Peter can then add his response to each one. I will be quoting the original wording of the 12 steps, though I understand that variations have been introduced by different groups.

Peter: I get your point here. It’s akin to most quasi-religious/spiritual teachings in that, for some, the text becomes ten commandmentish, fundamental and dogmatic. I believe the 12 step programme was never intended to become that, but considering the background, the Oxford group, the temperance movement it’s no wonder it did. As you point out, the language is very religious and can lead to it being interpreted in that way. I guess that’s why sponsorship and finding a meeting that fits you is so important this is how the often “absolutist” text gains context and nuance and develops psychological flexibility.For me context is everything and my interpretation and subsequent application of the 12 step programme has changed quite dramatically over the years.

There are a few things we probably need to discuss before we get to offering our interpretations of the steps;

The 12 steps are part of a much wider recovery landscape based on fellowship, honesty, open mindedness, willingness, sponsorship, service, anonymity, change and values based living. The steps are mainly for the individual but there are also 12 traditions, for the group. As well as working through the steps, with someone who has integrated them into their life (sponsor), it is recommended that people offer service (making tea, greeting, etc.), attend as many meetings as possible, remain anonymous as far as possible, learn to meditate and/or pray, learn to listen, and practice humility and honesty.

Fellowship is very important because, for most people, their substance use and/or behaviours will have led to social isolation, loneliness, and a feeling that there is only me suffering like this. One of the constructs of this kind of fellowship is the honesty with which group members share their stories. At my first meeting I heard people talking about all the personal experiences I had kept hidden for all of my life. For the first time I heard people talking openly about thoughts, fantasies and feelings that had been going on in my mind, since childhood, and for which I felt deeply ashamed of. I also heard people talking about things they had done which I had done that I was absolutely convinced no one else had. I can’t begin to tell you just how relieved it felt to know, in that instant, that I was not alone.

This is why honesty is also very important because it is probably the thing that attracts people back to their next meeting. Anonymity is also very important, it’s important on one level to ensure that people attending the group have their identity protected and feel that they can say things within the confidence of the group with the reasonable reassurance that it stays there. On another level, and what I feel is probably more important, is that anonymity is often the antidote to egotism and hubris. It helps to take the self, or more importantly, the false selfish self of addiction, out of the picture and becomes the vehicle through which we learn things like humility, being of service and altruism.

Personally I think the beauty of 12 step programmes lies in their flexibility and adaptability. As a sponsor I always ask people to read widely before committing to a particular way of working through them. Some will prefer a quite fundamental/religious and very rigorous way of doing it, others will opt for a kind of Gestalt more serendipitous process using the steps and the programme as a kind of social scaffolding around which they construct their recovery. Many in 12 step land will disagree with me here and would probably say something like, “strict adherence to the programme is not optional.” I like to help people to find what is going to work for them, I also like to work at their pace in their time and meet them, psychologically, where they are.

I’ve found that the programme works for some at a very classical conditioning, almost rote learning, level. The whole thing becomes more a behavioural/rational/academic/objective exercise rather than a subjective/emotive/spiritual/often irrational psychic journey. People often learn to quote verbatim whole chapters and learn to recite them at every opportunity. Don’t get me wrong this does actually work for many people and lots have achieved decades of sobriety in this way. What I will endeavour to do is to illustrate this duality as I elaborate on what you have written for each step.

All of the steps begin with “we”, this is very important as it begins to shift a “me” or “I” perspective, associated with the culture of addiction, to a “we “perspective more in line with a culture of recovery. Subtle messages like this can be found throughout the programme.

  1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

This on the face of it sounds like a deterministic starting point that denies our ability to change our relationship with addictions, but it could hardly function or have been interpreted in that way in practice. After all, it stands at the start of a process in which addicts are gaining control of their lives rather than losing control. Jerome A. Miller, in the interview linked above, suggests that I would say that “the first step is all about realizing that efforts to be in control really are self-defeating”, and I think that should probably be clarified still further – that efforts to be in complete control are self defeating.

Maybe there’s a bit more to step one, especially in the context of “control” as you talk about it here. As I see it, control, or maybe the illusion of control or even the ego’s desperate attempts to maintain control, are fundamental drivers in addiction. There is a cliché, that I picked up many years ago and use to this day, that I believe illustrates this really well, It goes, “when I take control, I lose control”, and I believe that this is the point of self-awareness that step 1 is trying to achieve. I’ve heard all sorts of metaphors like, “the disease”, “the sleeping rat”, “my addict”, that attempt to help this process of awareness raising. The ego, being as it is, wrapped up in mid brain survival functioning, this awareness raising and subsequent ego surrender is no mean feat. This part of you has served you well for many, many years and, for some including myself, has probably prevented them from killing themselves. Although there will be some kind of recognition that what is happening is problematic on one level, on another level it will be seen as far from problematic and may even be the only solution they have ever found. If we are to “change our relationship with addictions”, through a psychospiritual process, which I believe the 12 steps are, then there needs to be some sort of shift away from ego reliance to something other.

The extremes of freewill and determinism both seem to be absolutising traps for those trying to address any kind of difficult condition in their lives. We have to acknowledge that we do not have complete control over the conditions we are working with, whether these are within or beyond ourselves. We cannot simply change all these conditions by an ‘act of will’ and those who believe that we can are failing to recognise the power of entrenched synaptic circuits. On the other hand, neither are we powerless. If we were really powerless we would just be giving way to a problem like addiction rather than trying to address it in a helpful context like AA. The solutions have to involve long-term purposes and reframing of our beliefs about the addiction. So this first step seems to involve just the recognition of these conditions, and that we cannot just overcome a problem as deeply-rooted as addiction by an ‘act of will’. “Our lives had become unmanageable” may also mean a recognition of how negative the effects of addiction had become, and that those effects must be accepted rather than denied.

So what at first seems deterministic here, must have in practice been pointing people towards the ambiguous space between freewill and deterministic explanation: a space in which we can experience progress, but cannot ultimately prove its basis.

For some step one will be very behavioural and fall in line with the learning process of unconscious incompetence, conscious incompetence, conscious competence and unconscious competence. It also follows Procheska and DeClementi’s cycle of change precontemplation, contemplation, action, maintenance. In both models for learning and/or change to take place there must be some acknowledgement that the way I’m currently doing things is no longer working so I need to stop and render myself teachable.

On a deeper level, and probably more in line with a Marc Lewis neurological perspective, words like powerlessness and unmanageability begin to become relevant. Maybe there is a realisation that the addiction is much more serious and all-consuming than what was first thought. Maybe this realisation brings with it a recognition that life has become more about survival and the ego (willpower) has become so depleted that it can no longer be called upon to support quitting. Maybe this recognition, in turn, brings with it a real and awful sense of the extent of the unmanageability of your life and the desperation it entails.

On a more spiritual level perhaps there has been a collapse in the psychospiritual culture associated with the addiction. Maybe it’s got to the end of the road, all options have been exhausted and it’s entered a dark night of the soul. The only option left is to surrender everything to it, in a very profound way, making room for a power greater than you to become active in your life. It’s very difficult to explain this within an objective, rational, scientific context. The experience is wholly subjective, probably irrational to the observer and probably wouldn’t stand up to scientific scrutiny. Nevertheless it is a very real, very human experience that is probably best described as a spiritual awakening.

  1. Came to believe that a Power greater than ourselves could restore us to sanity.

Step one can be a very scary, painful and guilt provoking experience. It can leave people feeling worthless, emotionally raw, shameful, angry and guilty. In the narcotics anonymous step working guide there are over 90 questions specifically designed to get you to realise the impact your addiction has had/is having on you, your family and the world around you. Almost immediately after completion of step one you will need to begin your healing process with the belief that only a power greater than yourself can restore you to sanity.

Again, for some, this power may be a sponsor, the group, the 12 step programme. It’s kind of saying, “I definitely can’t but I believe, at this stage, we can.” Step one can make the whole experience of addiction appear quite insane and irrational, hearing others with similar experiences, reading about it in the literature and/or discovering a possible connection with the divine (a power greater than ourselves) helps to begin a healing process out of the pain of the surrender.

  1. Made a decision to turn our will and our lives over to the care of God as we understood Him.

On the face of it, these two steps (2&3) seem like an appeal to God to take over responsibility for the addict’s life. But again, it may in practice have been interpreted in terms of the need to relax our belief that we can fix long-term problems through acts of will. The stress on “God as we understood him” seems to indicate a God of individual archetypal experience rather than a transcendent God who merely gives us instructions or merely fixes everything for us.

A God of archetypal experience would mean getting in touch with a wider experience, wider goals, and thus a more integrated experience. A Jungian account of God as an archetype here sees him as a projection of the integrated or individuated self – that is, of a self who has overcome the conflicts created by addiction and become more whole. By turning themselves over to God, then, addicts could be effectively committing themselves to acting in harmony with their more integrated selves.

Addicts trying to practise this step are often portrayed as praying, and such prayer could have the crucial function of interrupting a habitual narrow focus and allowing wider awareness to re-emerge. This could be linked with body awareness, mindfulness, and the relaxation of the absolutised goals of the over-dominant left hemisphere of the brain: allowing in more of the open, silent experience associated with the right hemisphere. It’s only by relaxing the obsessive way we may represent our goals in an addicted state that we can begin to connect to more profound and longer-term goals that may have been temporarily neglected.

To move towards the new reality, new identity, and new responsibility, associated with the culture of recovery, a profound and sustainable shift needs to occur in almost everything. This “handing over of our lives and our will to the care of god, as we understood him,” enables us to begin to develop our belief from step two and make it into something we can trust, inherently know as a force for good and form a relationship with. I have found that, for some including myself, this was a very tall order. I have had major trust issues for much of my life and religion, which I thought initially was on offer here, had little or no appeal to me. Furthermore I had really struggled with getting intimate with anything which seemed to be a pre-requisite of this step.

The god of my understanding I eventually went with was and, in many ways, still is is a combination of nature and love. Both seem to underpin everything, connecting the universe and the people in it. They involve constants, laws, synchronicity and vibrations which don’t tend to happen in addiction so if I was going to find my place within this, then I needed to begin to hand my will and my life over to it.

I have also discovered since that addiction exists mainly as part of mid brain survival mechanisms. Cortex activity like thinking things through, predicting the future, awareness of consequences and conscience become more and more limited as the instant grat of the mid brain becomes the only show in town. It’s going to be really difficult to think yourself out of this but having a belief in a higher power and a faith that it can put you right may offer a solution.

  1. Made a searching and fearless moral inventory of ourselves.

The ‘searching and fearless moral inventory’ does strongly suggest the Protestant tradition of moral self-accounting. Here the left hemisphere must more strongly come into play by developing clear ideas about oneself and one’s situation. This must primarily be about the addict recognising that they are addicted, and accepting how hard it will be to end that addiction.

The value of this step seems to be one of clarification. To engage in any long-term course of action you do need to have a clear model of what you are trying to do, but it also needs to be an adequate model that incorporates as much information as possible. If the scale of difficulty is not clear, it would be easy for the addict to deceive themselves that they were making progress when they were actually rationalising the path back into a relapse.

I really like your points here around left hemisphere, recognition of the addiction and the acceptance of the difficulties of terminating the relationship with it. It is indeed about clarification and, the always present, propensity for the return to addictive thinking and self-deception. All of this can find itself framed within a very rational context because of it’s, often seemingly inseparable links to survival instincts like procreation, gregariousness, safety and stress avoidance. It is very difficult to separate instinctual/survival drives/drivers from those associated with addiction. Step 4 goes some way towards helping with this process. The best illustration I have come across in this area is a book called the steps we took by Joe McQ.

When almost everything, for many years, has been about survival, using, medicating and social isolation it’s very difficult to even contemplate a different perspective. Lots and lots of coping and mental defence mechanisms will have been created, embedded and served you well probably since childhood. Many of these will be fully integrated into the false self/ego state that rules the roost in addiction often burying the real self and superego under a veneer of things like arrogance, manipulation, deceit, lies and justifications. The real self has become somewhat lost and in a constant state of submission to the power and control of the ego. By shining a light on this false self, looking at specific examples of it in action and experiencing the consequences in the here and now you can begin to make some sort of sense of it. By listening to others sharing their step 4 and reading step 4 material you begin to realise that it’s not just you.

Resentments play a big part in step 4. Often these will be quite longstanding, totally unproductive and often have either lost their validity or may even have been more from a position of fantasy in the first place. Sometimes these resentments can be quite delusional and involve intricate but very tenuous connections that have become quite paranoid.

The process also becomes quite cathartic as it moves towards step 5 and it forms the basis of the list of amends for steps 8 & 9.

  1. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

This step seems to involve a lot of what will be required to make the previous one effective. It’s no good just having a clear model of your wider recovery goals if that model is too much constructed in an over-dominant left hemisphere state – an over-certain self-constructed reality. Admitting it to God, on the account of God given above, would amount to checking your model of the situation against that of your more integrated self. In practice that might mean dwelling in the silence of prayer or meditation and listening for aspects of your own recognition that it might not be accurate. Others are also a great resource in providing a more objective view from beyond a potentially obsessed state.

Again your reflections around step 5 are pretty much spot on. The steps are progressive and don’t really make much sense individually as each one is designed to build on the work done in the previous one. It is an almost Gestalt-like process needing the sum of the previous work to make sense of the collective whole. As you have rightly pointed out, there are always and also external factors that enable the Gestalt moments that can and will occur. Put together the written inventory, higher power, and empathic other and you have a very powerful recipe for a higher/more objective view point and potentiality to move beyond attachment.

Step 5 is a very proactive process involving both the sponsor and sponsee sharing their experiences. On one level it’s a kind of confessional exercise and the beginning of a process of forgiveness. On another level its more about finding the real self amongst the defense mechanisms and hackneyed narrative of the false self. I have often found the paranoid networks created from delusional resentments tend to crumble as a result of this process. Something written down, then subsequently shared with another begins to loosen its power in the face of objectivity.

  1. Were entirely ready to have God remove all these defects of character.
  2. Humbly asked Him to remove our shortcomings.

This seems to mean, again, that having fully recognised the difficulties of overcoming addiction, we recognise that it will not be sufficient to merely try to impose one will or plan that will resolve that position. Instead, we will need to reframe it. The humility involved might also be the recognition that we do not have things rightly framed to begin with, and that we will need to continually adjust our understanding of how the long-term integrative goal of overcoming addiction can be achieved.

“Reframing and humility” are very common themes throughout all the steps. The serenity prayer does encapsulate this particularly well and is constant reminder of the maintenance work that will need to be done to “reach and sustain the long-term integrative goal of overcoming addiction.” Although the programme does suggest that we never fully overcome addiction and it is a life long journey, I am somewhat ambivalent about this.

6&7 are a direct extension of the work culminating in step 5. I have been asked about these steps on lots of occasions so have developed, what I see, a fairly simple answer. How I see it 6 is about all the things you are doing, thinking and/or believing that are probably not going to be conducive to your recovery. 7 is about all the things that maybe you will need to do to make your recovery probable and sustainable that you currently, for whatever reason, aren’t doing. The thinking goes that because these things are so firmly embedded within your psyche you are not going to be able to remove them by will power alone.

I question whether these things are ever fully removed or is it that as we meet new situations, that we used to deal with using defects and/or shortcomings, we now have choices and alternative mechanisms we can adopt. Maybe the default position is to revert to type but every situation you encounter from here on presents you with learning and resilience building opportunities.

  1. Made a list of all persons we had harmed, and became willing to make amends to them all.
  2. Made direct amends to such people wherever possible, except when to do so would injure them or others.

These two steps involve the recognition that integrating addiction is not just a question of working with our own individual relationship to our desires and goals. It is also a matter of moral and social relationships. If an addiction has had negative effects on others (which is very likely) then those others play a large part in representing both the conflict in ourselves and the possibility of healing it. By making amends we might gain the forgiveness of others and thus gain important positive feedback that will help our own healing process. Even if they don’t forgive us, we may still have got closer to reconciling our own inner construction of that person with our own sense of guilt.

In relation to the Middle Way, this is a reminder of the way the absolutes that we are trying to avoid on either side of the Middle Way are socially reinforced. An addict is very likely to have been caught between two sets of socially reinforced absolutes: fellow addicts pressurising them to join the addiction and the rest of society, often including close relatives and friends, urging them to give up the addiction. Such a conflict can only be overcome by reframing and seeing recovery as good for both oneself and others. But others might very well doubt the sincerity of the move towards recovery. Practice over a period of time shows integrated intentions and build up our capacity to avoid both extremes in any practice of the Middle Way. For the addict, ‘making amends’ (i.e. presumably exerting practical effort to create the basis of better relationships) could be the evidence that others need of actually being able to stay in the middle, no longer oscillating between the grip of addiction and merely willful attempts to give up.

I like your contextualizing here, for most their addiction will have had quite a profound impact on, not only themselves, but their loved ones and wider community. Like you’ve said it’s kind of like the butterfly effect in chaos theory, the addict may find themselves caught between lots of sets of, what are often, very fragile, “socially reinforced absolutes.” The whole thing collapsing as their addiction progresses, a process that often escapes their sense of accountability and responsibility. In order to, as you say, “reframe” this, we need to develop an empathic prospective, by learning to understand the impact the behaviour has on others, and open the self up to the objectivity that this will hopefully entail. Lots of people, including myself, have experienced OCD almost autistic-like thoughts and behaviours well before taking any drugs. OCD/autism being very much about control, absolutes and life threatening fear of the unknown. The steps, and especially step 4 onwards, help to create a less black and white/either or/absolute landscape and begin to give the person the confidence, capacity, support network and competence to inhabit it without needing substances.

It is very much a middle way position aiming to create an absolutes free landscape where risks can be taken, mistakes can be made and, when necessary amends can be given.

Making a list and subsequently making amends is a set of actions designed to put right wrongs you have caused. I always say to sponsees that they have created loads of you shaped holes in the universe that they will need to go back and repair. Staying clean and sober is an amend within itself and quite a lot of people I have made amends to have said as much. Making amends is really really powerful and often ends in tears in one way or another. I believe it helps us in the process of becoming forgivable and it also gives the people around us an opportunity to say to us what it was like for them.

Maybe amends are also a kind of rite of passage in the growing up journey of recovery. It’s the new non-using grown up identity I’m claiming becoming a responsible citizen and declaring the old self dead. Once you’ve started to make amends it’s going to be really difficult to go back.

  1. Continued to take personal inventory, and when we were wrong, promptly admitted it.

The ‘inventory’ mentioned in step 4 obviously needs to be maintained if the recovery is to be integrated. Integration is largely achieved over time, and involves the recognition that our states vary but that the goals they represent can be fulfilled better in a wider and more consistent set of purposes. One needs to keep that set of purposes clear.

The need to admit when we are wrong is a key element of Middle Way practice, and the main way in which we avoid absolutisation. Admitting we are wrong allows alternative views to come into our awareness – ones that we might have repressed ore rejected up to that point. By doing this we gain the ability to reach new understandings of ourselves and others and thus move beyond the narrow assumptions that characterise addiction.

10 is steps 8&9 in practice on a daily basis. It’s the acknowledgement that we are human after all and we will continue to make mistakes. The key will be to make and keep each 24 hours as manageable as possible. We don’t want to be carrying things over and we want to learn to shine the light on our mistakes and do something about them as soon as possible. It keeps our house clean, stops things building up and cuts down any reasons we may pick up to use.

It helps to maintain the social scaffolding and recovery oriented inner/outer landscape necessary for the changes taking place to move into and become unconscious behaviour and thinking patterns. One does indeed “need to keep this new set of purposes clear”, but they will also need to use daily inventory taking to help with the continued transition from a world of dependency towards autonomy. In many ways they will be growing up probably for the first time, at least since adolescence, and learning how to master the new, and much more acceptable, human being and life they are trying to create.

  1. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

This step returns to the recognition of God in steps 3, 5, 6 & 7, but seems to be making the point that the greater open awareness represented by God here is not just a tool for overcoming addiction. Rather it needs to be the basis of a lifetime’s practice if a slide back into the addictive mind-set is to be avoided. Again, the ‘as we understood him’ emphasises God as an experience or as an archetype rather than as a supernatural being issuing revelations. We gain our power to carry on and sustain recovery from integration with those otherwise repressed elements of our own experience.

This need to switch to a longer-term mode again reflects a necessary element in any Middle Way practice. It is quite possible to move into what you at first think is the Middle Way, but turns out on closer inspection to have further dogmatic elements, so that you need to maneuver yourself a bit more to get off the sandbanks and back into midstream. It’s only as our awareness is allowed to become a bit more subtle and attuned that we might become aware of assumptions we were making that might still, in the longer-term, have taken us back in the direction of the extremes we were avoiding. In the case of a recovering addict, that need for further maneuvering in the light of gathering self-awareness may be particularly acute, as the polarising effects of addiction can be so deeply rooted and socially reinforced.

I really like your observation here where you talk about god as an experience rather than a supernatural being dispensing revelations. Although, for some, the higher power will be more supernatural it will involve revelations being revealed, for me it’s much more experiential and proactive. As I’ve said, I’m not a particular fan of god, either as a word or in the very loaded context it’s used far too often. For me “god or godliness/the divine, etc.” is in everything and everywhere. Because, by now, I’ve changed pretty much everything about me, I see and experience things very differently. Probably since childhood, almost everything I’ve done has been on the basis of me and what can I get out of it. My modus operandi was all about control and, as you say, this was very much deep rooted and socially reinforced. If we’re not careful and, I suppose, aren’t embracing a middle way philosophy, the steps and the programme can and often will become a further extension of dependency involving just as much fundamentalism and dogma as any extreme religious belief or addiction to substances. Prayer and, for me more importantly, meditation enable us to continually centre ourselves, stay humble and open ourselves up to a broader horizon.

11 keeps us spirit centred. It emphasises the need for discipline, self reflection, meditation and prayer/continued contemplation. I also believe it encourages us to become seekers of wisdom and spirituality and recognises that beliefs, faith and attachments can change. All the steps have prepared us for this point and the transition to step 12

  1. Having had a spiritual awakening as the result of these steps, we tried to carry this message to other alcoholics, and to practice these principles in all our affairs.

Given my Christian background, the wording of this step reminds me rather of the Acts of the Apostles, but it also seems important to try to put aside such associations and try to imagine what they mean to someone recovering from addiction. Given the sheer enormous difficulty of recovering from a serious addiction, and the amount of reframing involved, to describe recovery (or the transformation of attitudes that allowed recovery) as a spiritual awakening is probably no exaggeration. Carrying the message to other addicts does not necessarily mean evangelisation in the gross forms we may associate with some forms of Christianity, but rather may be motivated by a genuine urge to help others whom we know, from our own experience, to be suffering.

“To practice these principles in all our affairs” again makes it clear that the 12 steps do not merely imply a method for overcoming addiction, but draw on a larger view of life. This view of life seems close to the Middle Way in all sorts of ways, even though one has to imagine the principles of the 12 steps in practice to draw out those Middle Way elements. The language seems clunky, but one has to bear in mind that the first creators and users of the 12 steps probably had no better language available to them with which to express their practical insights than the language of Protestant Christianity.

Everything has prepared the person for this point which, I believe, is all about becoming of service and maintaining yourself to carry on. Over the years I’ve come to see “the addict/alcoholic” in just about everyone I come across so I always try to be in a position where I can be of service should the need arise. This does involve “practising these principles in all my affairs” because I want the service I offer to be authentic, attractive, empathic and engaging. Otherwise it will be controlling, fake and far from appealing.

Although for many, and especially in early recovery, step 12 does take on an urgency and can become very evangelical. It can also give some people permission and ammunition to become very closed minded, authoritarian and arrogant as they develop an “it’s the only way” type message. I think that’s why one of the traditions talks about attraction rather than promotion, after all we do tend to move towards things we find attractive and either rebel against or move away from things that are rammed down our throats.

This, in my humble opinion, is what I call modelling recovery and does have a definitive middle way air about it.


As Marc Lewis explains in ‘The Biology of Desire’, addiction consists in a set of feedback loops between the striatum in our lower brains and the frontal cortex. These loops link our representation of our goals and of the state of affairs around us to dopamine rewards that reinforce behaviour that addresses certain conditions. These are entirely normal loops that emerge in the course of learning and adapting to our environment, but in the case of addiction, the loops become deeply entrenched and gradually automatised, excluding other possible modes of behaviour. We then lose the flexibility that we need to continue responding to changes in our environment. Lewis’s account thus highlights how we are all addicts to some extent – just some more than others. We all have entrenched habits linked to rigid beliefs about our goals and conditions: it’s just a matter of how much. Those rigid beliefs form the extremes on either side of the Middle Way, the positive and the negative absolutisations.

Purely by virtue of their track record as ways of effectively addressing addiction, the 12 steps must offer a way of addressing these entrenched habits and beliefs. Thus it seems that we can all benefit from them, whether we regard ourselves as ‘addicts’ in any sense or not. Wherever we find rigid thinking or unhelpful habits in ourselves we can adopt the basic procedure that it seems the 12 steps are pointing at: reframe, realise it’s not just a matter of wanting to change or being unable to change, be receptive, reconsider your assumptions, face up to the full difficulties, develop and clarify sustainable goals, address the issues in your relationships with others, and commit yourself to continuing to do this in the long term. The 12 steps seem to have a great deal to teach us, and this seems to be rooted in much wider insights than might first appear.

I do believe that everyone could benefit from the 12 steps especially in these days of consumerism, selfhood, reductionism and instant gratification. Maybe the language needs changing, after all they were written 70-80 years ago in very different times with very different social circumstances. Personally I would like to find an alternative to god/higher power because of the sheer amount of people I see who just cannot get used to it.

Marc Lewis and people like Bruce Alexander and Maia Szalavitz are beginning to challenge some of our long held shibboleths around the abnormalisation of the human condition and, in particular, learning/neuroplasticity. Unfortunately it has become a diametrically opposed argument where a middle way has yet to evolve. Personally I do believe that both camps are far from incompatible, both probably have far more in common than they have differences. Yes looking at things as diseases is pretty much absolutist and you can’t really go anywhere with a religious interpretation of god/higher power. But, and this a big but, there are lots of things within the fellowships and the 12 steps that could be contextualized within the new thinking. All agree that things like connection, giving, learning, taking notice and keeping active are the essential components of recovery, no matter what it is we are recovering from.

My major concern around 12 step ideology is how it has been and continues to be corrupted by people marketing it as an evidence based “treatment”. My view is that it should never involve money. If you are going to invest in any kind of treatment system there are loads out there to choose from. It should have no part in treatment except to offer access to meetings. It should have no part in the politics of substance use treatment politics and/or commissioning and should be left well alone to do what it does best through peer support and self help.

Picture: Annie Besant ‘Greed for Alcohol’