My thoughts on the "two arrow" model of pain vs. suffering from DBT.
I had a hard time deciding what to write about this week.
I have an informal editorial calendar with seventy-something items on it, so I started there; I surveyed the options, then began writing the first few paragraphs for one topic.
Dissatisfied with how it was going, I switched to another topic, which I wrote about a thousand words on before abandoning it, deciding on a wildcard topic, and beginning yet again.
Before I got too far into my third first draft, though, I stopped myself. My writing was crap, I realized, and it was crap because my heart wasn't in it.
I felt pressured to produce something, but I couldn't summon my usual rush of enthusiasm.
Maybe I should just take a week off, I thought. I've written at least one article per week for over 40 weeks now; it's not like I've been shirking my commitment.
Before that particular thought even finished flowing across the teleprompter in my mind:
You can't do that. Not when you're so close to the blog's one-year anniversary, when you've worked so hard to write a blog that you're (reasonably) proud of every single week.
I felt an all-too-familiar spike of anxiety as I began brainstorming an outline for my fourth first draft.
***
This is what I do.
You want to know what happens when I get back in shape?
I start with a slow, six-mile run, which has been my go-to length for 20 years.
At first, I run those six miles every other day.
It feels so good, though. The calm that arrives after I've exhausted myself physically makes me feel like maybe, just maybe, I can handle being Brian for the day.
By the second week, I'm running every single day.
I tell myself that I should take at least one day off each week. I know that every exercise physiologist on Earth extols the benefits of a recovery day.
But I can't fucking help myself. So, I begin running every single day.
I know that I should cross-train, too, but I can't stand the thought of giving up that breath-focused, meditative cardio state or the rare peace that follows.
By the third week, I throw in two "long run" days of 12 miles each. After all, I've got to challenge myself somehow, right?
By the fourth, fifth, six weeks, I'm running 12 miles a day without a single day off.
During my 20s, before I'd had treatment to help me rein in some of my psycho tendencies, there was one period during which I was running two to two and a half hours (14 to 20 miles) every single day for months on end.
I ran until I got stress fractures on my shins that were so bad that I had to go up and down the stairs sideways, like a crab. When I woke up to use the bathroom in the middle of the night, I collapsed onto the floor as soon as I put weight on my legs; the pain was that sharp, powerful, and surprising.
Running feels good, of course: The runner's endorphin high is a very real phenomenon, which helps to explain why so many people in recovery become avid distance runners.
However, sticking to these outrageous running regimens had less to do with feeling good and more to do with the intrusive thoughts and malaise that would plague me if I didn't get on the treadmill at my usual time. I'd feel a generalized, visceral anxiety build up, which was punctuated by worries that I was going to start slipping in my routine and wouldn't be able to turn it around, that I'd lose everything I'd been working toward.
This is why I emphasize the shared qualities of addiction, eating disorders, and Obsessive Compulsive Disorder. The commonalities vis-à-vis anxiety, compulsion, ritual, and reward are striking, and the neuroprofiles of the disorders are similar enough that a Deep Brain Stimulation (DBS) treatment used for OCD has also been used to treat severe addiction (article here).
***
It's not just running, of course.
These obsessive tendencies played a significant role in my academic success (although in many ways they were self-defeating, too, especially as I entered an ultra-competitive collegiate world where perfection in every assignment and exam simply wasn't attainable anymore).
When people talk about addictive personalities - man, I've got one.
I have absolutely no doubt that there is a strong genetic component in my case. On my mother's side of the family, every single male for two generations has had a substance abuse problem, and many of the women have struggled, too. We're kind, bright, decently accomplished people, but we seem to pick up chemical habits much more easily and permanently than other people do.
I'll get obsessive about friends and partners sometimes, too. Not in a scary, Investigation / Discovery way, but in the sense that I'll replay a (possibly negative) comment from someone that I care about hundreds of times in my head. Sometimes, even more bafflingly, the possibly negative comment will come from someone that I don't care about.
Even my hobbies can become forced and joyless under the influence of this obsessiveness. I started with one DuoLingo lesson per day, then increased it to two, then three, then four, then I never wanted to complete less than four, then I added a reading exercise, then I never wanted to miss a reading exercise...
I'm sure that it sounds like a joke, but if you think about what it's actually like to inhabit a mind that forces this sort of pattern of escalation onto every part of life, it's not so much funny as it is scary. It's a lot like running on a treadmill whose speed is increased and increased and increased.
Unfortunately, a lot of addiction treatment is pretty narrowly focused on stopping drugs*.
*Addiction used to be considered a secondary diagnosis, meaning that it resulted from an underlying psychiatric problem. It is now considered a primary diagnosis, meaning that there doesn't have to be anything else wrong with you for you to become an addict, and treatment focuses on stopping substance use first and foremost. There are advantages to this approach, but in general, I believe that drug and alcohol use is usually a symptom of a deeper dysfunction around anxiety, depression, trauma, pain, dysfunctional relationships, and many other issues.
Nevertheless, through the years, I have picked up some skills that have helped me counteract my obsessive and perfectionist tendencies.
Cognitive Behavioral Therapy has taught me to spot globalization, catastrophization, and other maladaptive thought patterns.
It's not that helpful just to recognize them, though; you've got to have a way to talk yourself away from the edge.
For me, questioning the implicit assumptions that are producing these negative thought patterns often does the trick.
If I skip writing a blog for one week, what's going to happen? I ask myself.
You'll do it every week. Except that people, including me, who take vacations typically return to work when they're over. A break is just that - not a resignation.
You'll lose / disappoint your dedicated readers. Almost every content creator takes a break for a vacation or other personal event once in a while, and they still maintain their followings. It's a mental health blog, for God's sake; do I really think that my readers won't understand me taking a week off?
Your blog will fail. Does it really matter? I don't need this blog to survive, after all, and while I enjoy connecting with my readers, this is hardly the only way to connect with other addicts and indulge my creative side.
I know how simple this sounds, but if you have a mind like mine, which sometimes moves bewilderingly quickly, getting this all out, especially by writing it down on paper, is a gamechanger.
The next time that these thoughts and anxieties arise, it's almost like they're short-circuited by the healthy realizations I've arrived at. The cognitive and behavioral loops are broken because the replacement thoughts have taken root.
Most helpful of all has been DBT (Dialectical Behavioral Therapy); I believe that every addict would benefit from this set of treatment techniques*.
*I wrote an overview of CBT, DBT, psychodynamic therapy, and Eye Movement Desensitization and Reprocessing (EMDR) therapy, which is structured around four key questions to ask yourself to help determine which therapeutic approach you will likely benefit from most. If you're unfamiliar with the alphabet soup of therapy types, I would start there.
DBT consists of three components: mindfulness, emotional regulation / distress tolerance, and interpersonal effectiveness / communication, which overlap, complement, and synergize with each other.
Some DBT techniques are physio hacks, such as submerging your face in ice water to calm your heart rate, which slows your body down and thereby tricks your mind into chilling out, too.
Much of DBT is founded on radical acceptance of one's internal and external circumstances and learning to focus on only those aspects within one's locus of control - no matter how unfair, limited, or contextless this approach seems at first. In the end, radical acceptance - which is also stressed in 12-Step programs, incidentally - is incredibly freeing; we accept what we cannot change while working on what we can, which unlocks a powerful formula for health and success.
I have been practicing mindfulness meditation every single day lately. The relief that I get during those few thoughtless seconds when I occupy my mind and body with full presence is profound. In fact, it almost feels like a high.
The other day, as my body was contending with the effects of a recent 10-mg drop in my methadone dosage, I felt super wound-up and uncomfortable around 2 a.m. My 5:30 a.m. dosing time seemed so far away, and I knew that it would be a slog to work a full day after another sleepless night.
All of the familiar opioid withdrawal symptoms were there: Hot flashes and shocking sensations; muscle aches and Restless Leg Syndrome; rapid heart rate, anxiety, and sneezing / watery eyes. There were some methadone specials, too, including full-body cramps, a diffuse, mild headache, and a feeling that - on a quantum level - something was just not fucking right.
I forced myself to do a 10-minute mindfulness meditation, and you know what? At the end of the meditation, those symptoms were still there and mostly undiminished.
However, as I re-analyzed how I was feeling, I suddenly realized that there were positive aspects of the state that I was in, too.
I felt a surging energy that was almost manic, full of verve and possibility.
My emotions were in overdrive as I listened to a favorite British band called Shady Bard. The emotional depth / texture of the lyrics and the melody, overlaid on the memories that I had on replay, was so rich that I felt a bit like I was coming up on E.
My soul is waking up, I realized suddenly.
It was the same exact state that I had been in 10 minutes before. The only thing that had changed was my perspective and the way that I interpreted my symptoms.
***
I recently came across a DBT concept called the "two arrow" model, which helps to explain this experience.
The first arrow that pierces us, this model holds, is some physical or emotional pain - from a physical injury to a breakup to the discomfort of methadone withdrawal.
This first pain is limited and often unavoidable.
The second arrow that injures us is the suffering that comes from perseverating on that first injury - from allowing it to grow and dominate our inner experience; from returning to revisit it time and again; from giving that pain permission to project forward in time, tainting the future with its memory and the fear of its recurrence.
With opioid withdrawal, the second-arrow effect is powerful, indeed.
The amount of trauma and anxiety that result from a single episode of opioid withdrawal is substantial. When you're someone like me, who has spent years of his life dopesick, the dread associated with coming off of opioids is almost unbearable.
In terms of the science of the second-arrow factor, there is a neurological kindling effect involved: Essentially, the brain experiences some of a set of sensations that it has experienced previously; it recognizes from context what is causing them and anticipates what the result will be based on previous experience, at which point it tends to fast-forward and produce the full, expected outcome even when the sensations are being triggered only to a small degree and sometimes even when that outcome isn't actually reasonable or proportionate.
The kindling in this example is the brain's memories of previous instances of opioid withdrawal, which are triggered by minor withdrawal symptoms. They set off a much greater blaze that is only possible because the brain knows what to expect and has decided to produce that output regardless of the strength of the inputs.
The more times that you have experienced a given uncomfortable state, the more powerful the kindling effect becomes.
Thus, relatively mild withdrawal can be transformed into catastrophic sickness because the brain produces the symptoms that it has learned to view as appropriate given a certain set of conditions. It's a maladaptive, anticipatory effect. It amplifies pain that would likely be manageable into suffering that feels unbearable.
A similar effect likely plays a role in Post-Acute Withdrawal Symptoms (PAWS), which can occur weeks or months after acute withdrawal is over. PAWS can be triggered by stress, lack of sleep, and many other factors.
Significantly, many addicts experience their most intense bouts of PAWS when they are sick with a cold or the flu. The brain experiences symptoms that are similar to those caused by opioid withdrawal, and - even though these symptoms are being triggered by an entirely different cause - the kindling effect takes hold and the symptoms intensify into what feels like full-blown opioid withdrawal.
The severity of PAWS often shocks people in early recovery, who feel like they have time-traveled back to the first hours without their drugs of choice.
One way to counteract the kindling effect is to use mindfulness. When we tap into our mind and body in the purest, most present way possible, we experience where they truly are rather than where our past experiences lead us to fear that they should and will be.
Registering the reality of our physical and mental state, in turn, takes away from the power of the second-arrow suffering. It throws water on the kindling before that kindling can set off a forest fire.
***
This post is my compromise, I suppose.
It isn't my most structured, robust, elegantly worded, or well-researched blog, but it's short, sincere, and shows me practicing the skills that I'm writing about.
It's good enough for me, and I hope that it's good enough for you, too.
Take care of yourselves -
Brian
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