Addiction, Spirituality, and the Brain: An Interview with Dr. Shanti Rubenstone
Q: Shanti, How did you first become involved in the field of addiction medicine?
SR: I was finishing my medical residency in the mid-1980s, when my husband, who was also a physician, was working at the emergency room at Sequoia Hospital in Redwood City, California. Because of his sensitivity and effectiveness in working with people with substance abuse problems, he was asked if he would be willing to become medical director of a small program the hospital had started.
He agreed and in 1984 he took that position at Sequoia Hospital. A few years later he founded The Sequoia Center, a drug and alcohol treatment center with both residential and outpatient programs. I worked with him from the start, first at the small hospital program and later at The Sequoia Center.
Q: Why were you and your husband drawn to this area of medical practice?
SR: We were drawn to it because addiction medicine is one of the few areas of medicine that incorporates spirituality. Both of us were on the spiritual path, and the prospect of being able to combine spirituality with the practice of medicine was very attractive to us.
Q: You are now medical director of The Sequoia Center?
SR: Yes, I became medical director in 2009 after my husband passed away. I’ve been involved in the field of chemical dependency for over 30 years, both through The Sequoia Center and my private practice.
Q: Can you explain why the spiritual component of The Sequoia Center program is important?
SR: In my opinion there can be no lasting recovery from addiction without a person discovering his or her spiritual path and following it. The natural tendency of the mind is to side with habit and the natural tendency of habit is to be contractive. It takes us back to what we already know.
What I’ve seen is that it doesn’t matter how people think of God, but that being able to look to a Power greater than themselves during difficult times gives people recovering from addiction the strength and understanding to move forward in more expansive ways and not be limited by past habits and conditioning.
Q: At The Sequoia Center, do you ever encounter resistance to the spiritual component?
SR: Yes. The Sequoia Center follows a 12-step format. Some people have concerns when they hear “12-step” because they think they have to be religious or believe in God in a certain way. On the contrary, the 12-step format is not at all dogmatic. If one Googles the phrase, “spirituality, definition,” over one million links appear. There are as many spiritual paths as there are people. The 12 steps help each person attune to his or her own unique path.
For example, last year I worked with a 42-year-old man who was diabetic and a late stage alcoholic, meaning his alcoholism had progressed quite far. He was an avowed atheist and was reluctant to come into a 12-step program. Our program was his third attempt at recovery in a program. For two weeks he did terribly. He was argumentative, acting out against all of the program rules, not doing assignments, complaining that the program was boring, and on and on. He was about to fail for a fourth time, so I decided to spend some time with him. I wanted him to have a chance to succeed. I felt his life depended on it.
I gave him the same advice Swami Kriyananda once gave to an atheist: that whenever he heard the word “God” from me, or in a group discussion, he think of “God” as representing the highest potential he could think of for himself – as representing the very best he could possibly be, which might even be better than anything he’d ever imagined until now. He agreed to try.
Within two weeks he was a leader in the program. This man had found a way to make spirituality work for himself and he was embracing it. He had desperately needed a “container” bigger than himself, something to lean on, and into, and a new understanding of how to be in recovery.
Q: Can you explain what recovery means?
SR: Recovery is often defined as a change in lifestyle and a change in attitude, not simply sobriety. It means working to improve your health and wellness, and to live a meaningful life in a community of your choice, while striving to achieve your full potential.
Q: Was it Alcoholics Anonymous (AA) that introduced spirituality as an essential part of substance abuse recovery?
SR: Yes. Before AA was founded in the 1930s, there was no successful treatment for alcoholism, and no treatment programs. The founders of AA caught people’s attention when they wrote about how engaging a Higher Power, a force greater than themselves, helped them stay sober. The time was right – people listened. The 12-step principles at the core of the AA program were later incorporated into treatment programs for other drug dependencies.
Q: Is there any scientific research confirming that spirituality is an effective aspect of substance abuse treatment?
SR: Yes. A recent survey of the research in this field shows that certain parameters of spirituality, (measured by spiritual experiences, gratitude, tolerance, humility, and other factors), increase during substance abuse treatment programs that incorporate spirituality, and that these newly attained qualities help individuals avoid relapse.*
Q: Assuming a person suffering from addiction sincerely wants to change, are there any unique problems he or she faces because of the addiction?
SR: Yes there are. Addiction is defined as a chronic, relapsing brain disease characterized by chemical and molecular changes in the brain. Scientific research shows that these changes alter the way the brain works and impair a person’s self-control. I regularly see evidence of these kinds of changes in my work.
Q: What happens to the brain from repeated drug use, and how do these changes affect a person’s self-control?
SR: Nearly all drugs of abuse target the brain’s reward system by flooding the circuit with dopamine, a neurotransmitter related to feelings of pleasure. The over stimulation of this system produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior.
The brain adjusts to the overwhelming surges in dopamine by producing less dopamine on its own. As a result, the ability to experience any pleasure is reduced. Because the brain is producing less dopamine, the drug abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought him pleasure. Now, he needs to take drugs just to bring his dopamine function back up to normal. And, he must take larger amounts of the drug than he first did to create the same dopamine high.
Long-term drug-taking leads to profound changes in brain neurons and circuits. Brain-imaging studies from drug-addicted individuals show changes in areas of the brain that are critical for judgment, decision-making, learning and memory, and behavior-control. More often than not, these changes lead to impaired self-control.
Q: Is it because of impaired self-control that addiction is classified as a relapsing disease?
SR: Yes. The brain changes caused by addiction translate into decreased self-control. Even after a person goes through a successful recovery, long-term drug abuse can result in a kind of mental conditioning whereby certain “triggers” associated with the drug experience will cause a person to have sudden uncontrollable cravings, even after years of abstinence.
Q: Have you been successful in working with people with long-term drug dependencies?
SR: Yes. For example, a few years ago I took care of a man who had used methamphetamines (commonly known as “meth”) his whole life. He started at age 8 and I met him at age 56. He had been in jail much of his life and didn’t know one single drug-free person. His drug cravings were like demons and he had no sense of what a “normal” life would even look like. Yet he worked harder at his recovery than almost anyone I have ever seen.
After four months in our program in early recovery, he lived in a Sober Living Environment home for two years. Today he takes antidepressants and mood stabilizing drugs, but otherwise he’s drug-free. He leads regular Bible study classes, goes to 7 to 10 meetings a week for recovering addicts, and is totally dedicated to helping young addicts. One story like this gives me hope for everyone.
Q: Are antidepressants and mood stabilizing drugs a common part of long-term recovery treatment?
SR: Addiction is a treatable disease, but people may be working very hard to live a drug-free life, yet still have cravings or feelings of depression or anxiety even after twelve months of abstinence. To get them through these challenging periods, I might step in with pharmacological support (antidepressants, anti-anxiety drugs, or even anti-craving drugs), and also try to reinforce continued use of their recovery tools (attending meetings, seeing a therapist, spending time with a drug-free support group, etc.)
There are many medications we can use to help the brain feel “normal” again. I use them all the time, and they are very important. But these drugs rarely solve the whole problem. I’ve often said to people, “You have to want this recovery as if your life depends upon it, because it does.”
Q: Are you saying, then, that motivation is the most important factor in a successful long-term recovery?
SR: In my experience, people with substance abuse problems only decide to seek treatment when something very, very painful has happened. Perhaps they’ve lost their spouse, a job, or their relationship with their children. Perhaps they’ve squandered the family savings, or a child’s college money. Maybe this is their third or fourth attempt at recovery. Reaching the point of knowing they have to seek treatment is called “hitting bottom.”
Yet it’s hard to take that first step toward change because there’s nothing about the process that’s easy. So yes, motivation is a very important factor.
Relapse rates for drug abuse are high but the National Institute of Drug Abuse (NIDA)** has found that they are about the same as those for other chronic medical illnesses, such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components.** Treatment of any chronic disease always involves changing deeply imbedded behavioral patterns.
Q: Do you know of successful addiction treatments that don’t incorporate spirituality?
SR: There are many programs for people who will not use the 12-steps; while I don’t know the exact data, I know they work for some people. I have a young man in my outpatient practice who is taking a drug called Suboxone to keep his cravings for opiates down, and he has done well so far with about 9 months of sobriety. He has occasional lapses but he wants no part of any recovery program, and he is not interested in spiritual support.
There are also behavioral health treatment programs and self-help groups. NIDA research suggests that medications plus behavioral therapy can also work but that treatment must always be individualized.
Q: What attitudes or practices help a person stay sober or drug-free after completing a recovery program?
SR: I’ve mentioned a few already: being in the right recovery environment with supportive drug-free people; a commitment to continue working on recovery and spirituality; and serving others in need of recovery support. I would also add: practicing gratitude and forgiveness, and having a good sponsor – someone to turn to when things get rough.
Interestingly, these are some of the same attitudes and practices that keep a person connected to the spiritual path. The challenge for people recovering from addiction is very much the same: to keep going, doing the best they can, and to never give up.
Dr. Shanti Rubenstone is a Lightbearer with the Ananda Palo Alto community. She has been involved with Ananda since the late 1970s. She is also a practicing internist who graduated from Stanford Medical School in 1983. She is currently the Medical Director of The Sequoia Center, a comprehensive drug and alcohol treatment program, and she has a private practice called, “Transformational Medicine,” helping people transform their lives by turning obstacles into opportunities to live a life defined by wellness.
* Click here to see article, “The 12 Steps: Building the Evidence Base, ”by Valerie Slaymaker, Ph.D., in the May 2009 issue of Addiction Professional magazine, reviewing a series of studies supporting the value of spirituality in addiction treatment:
** Click here to see National Institute on Drug Abuse (NIDA) website and publications discussing the effects of drug abuse.
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