Your Cerebral Cortex Can't Overcome Your Nucleus Accumbens...

...or so a physician friend tells me. The point he was making is that we--practitioners treating addictive disorders or individuals experiencing them--cannot change addictive behavior with information and knowledge alone. True, information can be useful in motivating an individual to move from a pre-contemplative stage of readiness to change to a contemplative stage, but this is movement as regards "readiness to change" and does not directly translate into change per se.

It is true that one will never move from a point of seeing alcohol or other drug use as a solution to a life problem until and unless able to recognize his or her substance use as a problem--the cost of continuing is greater than the cost of changing. It is likewise true that the first step in this metamorphosis is beginning to question the substance use as a "solution" to one's life problems. This happens as individuals step back and can see the bigger picture, thereby beginning to recognize that, "what cause a problem is a problem because it causes a problem."

The cerebral cortex is that part of the brain responsible for much of the higher functioning that separates us humans from other creatures in the animal kingdom. It is our ability to think and reason, to problem solve and to learn as the result of our experience that builds the bridge from the past through the present to the future where change can take place. This earns us our cherished position at the top of the evolutionary ladder. But the physiological and neurochemical rewards that are associated with substance use, rewards that can be connected to a much more primitive but nonetheless necessary function of the human brain, that helps explain addiction.

Once addicted, there is a demonstrable process by which the use of substances results in the activation of a "pleasure pathway" of sorts, and the nucleus accumbens is an integral part of that pathway. Once activated, mere information and knowledge about addiction, substance use disorders and/or consequences associated with the continued use of my drugs of choice are not going to supersede the physiological rewards associated with continued substance use.

To be succinct, logic and reason are no match for the physiology of addiction or, to reiterate my friend's quip, "your cerebral cortex can't overcome your nucleus accumbens." That said, the prevention of substance use disorders requires a concerted effort that addresses a number of factors. As individuals with addictions are able to move along the continuum of readiness to change from a pre-contemplative stage of readiness where the substance use is actually perceived to be a solution to life's problems to the next stage on the continuum, "contemplation," where change is not yet a perceived option, but the use is no longer viewed as a solution. It is this ambivalence that is actually welcomed by those practicing motivational interviewing rather than viewed with disdain and attacked as indicative of denial.

This movement along the continuum of readiness to change comes as practitioners resist the temptation to confront the user, which historically has been predicated upon the belief that a refusal to change behavior, even when willing to change perspective, is tantamount to denial. The traditional approach to counseling addicted individuals, even in a contemplative stage of readiness to change, has been to confront the user directly in an attempt to "break through" the denial and, as William Miller, the father of Motivational Interviewing has written, "wrestle" the addicted individual into submission. This is tantamount to the bully on the playground that engages his adversary and does not stop until the victim cry, "uncle!"

Miller goes on to suggest that counselors therefore have two choices when engaging an addicted individual: (1) to wrestle with that client in an adversarial relationship where counseling’s success necessitates client failure, or (2) to dance with the client. Notice the difference in these two metaphors; both clearly cast the counselor in the lead position, but as any ballroom dancer will tell you, the pair collaborate in a symbiotic relationship built on mutual respect for the other and his or her role in accomplishing the end goal..

To return to my opening admonishment; knowledge may appeal to the cerebral cortex, but it does not hold sway over the nucleus accumbens. Yet historically, prevention programs have been heavily if not exclusively steeped in delivering information in the misguided belief that rational beings will make good choices, avoiding high-risk and dangerous behaviors, if only they are given the information and knowledge on which to base those decisions. And as if this placement of all the prevention eggs in the knowledge enhancement basket were not enough, the information presented has tended to be at the same time negative--"this is your brain...this is your brain on drugs..." and steeped in scare tactics, as if the combination of knowledge and fear would be sufficient to void the activation of the pleasure pathway in the brain.

So the next time you are tempted to intervene in the high-risk behavior of a client, acquaintance, or loved one with a lecture or information about the risks and consequences associated with substance use, remember, "Your cerebral cortex can't overcome your nucleus accumbens."

What do you think?

Robert