THE GOLDEN RULE OF HABIT CHANGE – Why Transformation Occurs – Part 2

To understand how a coach’s focus on changing habits could remake a team, it’s necessary to look outside the world of sports. Way outside, to a dingy basement on the Lower East Side of New York City in 1934, where one of the largest and most successful attempts at wide-scale habit change was born.

Sitting in the basement was a thirty-nine-year-old alcoholic named Bill Wilson. Years earlier, Wilson had taken his first drink during officers’ training camp in New Bedford, Massachusetts, where he was learning to fire machine guns before getting shipped to France and World War I. Prominent families who lived near the base often invited officers to dinner, and one Sunday night, Wilson attended a party where he was served rarebit and beer. He was twenty-two years old and had never had alcohol before. The only polite thing, it seemed, was to drink the glass served to him. A few weeks later, Wilson was invited to another elegant affair. Men were in tuxedos, women were flirting. A butler came by and put a Bronx cocktail—a combination of gin, dry and sweet vermouth, and orange juice—into Wilson’s hand. He took a sip and felt, he later said, as if he had found “the elixir of life.”

By the mid-1930s, back from Europe, his marriage falling apart and a fortune from selling stocks vaporized, Wilson was consuming three bottles of booze a day. On a cold November afternoon, while he was sitting in the gloom, an old drinking buddy called. Wilson invited him over and mixed a pitcher of pineapple juice and gin. He poured his friend a glass.

His friend handed it back. He’d been sober for two months, he said.

Wilson was astonished. He started describing his own struggles with alcohol, including the fight he’d gotten into at a country club that had cost him his job. He had tried to quit, he said, but couldn’t manage it. He’d been to detox and had taken pills. He’d made promises to his wife and joined abstinence groups. None of it worked. How, Wilson asked, had his friend done it?

“I got religion,” the friend said. He talked about hell and temptation, sin and the devil. “Realize you are licked, admit it, and get willing to turn your life over to God.”

Wilson thought the guy was nuts. “Last summer an alcoholic crackpot; now, I suspected, a little cracked about religion,” he later wrote. When his friend left, Wilson polished off the booze and went to bed.

A month later, in December 1934, Wilson checked into the Charles B. Towns Hospital for Drug and Alcohol Addictions, an upscale Manhattan detox center. A physician started hourly infusions of a hallucinogenic drug called belladonna, then in vogue for the treatment of alcoholism. Wilson floated in and out of consciousness on a bed in a small room.

Then, in an episode that has been described at millions of meetings in cafeterias, union halls, and church basements, Wilson began writhing in agony. For days, he hallucinated. The withdrawal pains made it feel as if insects were crawling across his skin. He was so nauseous he could hardly move, but the pain was too intense to stay still. “If there is a God, let Him show Himself!” Wilson yelled to his empty room. “I am ready to do anything. Anything!” At that moment, he later wrote, a white light filled his room, the pain ceased, and he felt as if he were on a mountaintop, “and that a wind not of air but of spirit was blowing. And then it burst upon me that I was a free man. Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in another world, a new world of consciousness.”

Bill Wilson would never have another drink. For the next thirty-six years, until he died of emphysema in 1971, he would devote himself to founding, building, and spreading Alcoholics Anonymous, until it became the largest, most well-known and successful habit-changing organization in the world.

An estimated 2.1 million people seek help from AA each year, and as many as 10 million alcoholics may have achieved sobriety through the group. AA doesn’t work for everyone—success rates are difficult to measure, because of participants’ anonymity—but millions credit the program with saving their lives. AA’s foundational credo, the famous twelve steps, have become cultural lodestones incorporated into treatment programs for overeating, gambling, debt, sex, drugs, hoarding, self-mutilation, smoking, video game addictions, emotional dependency, and dozens of other destructive behaviors. The group’s techniques offer, in many respects, one of the most powerful formulas for change.

All of which is somewhat unexpected, because AA has almost no grounding in science or most accepted therapeutic methods.

Alcoholism, of course, is more than a habit. It’s a physical addiction with psychological and perhaps genetic roots. What’s interesting about AA, however, is that the program doesn’t directly attack many of the psychiatric or biochemical issues that researchers say are often at the core of why alcoholics drink. In fact, AA’s methods seem to sidestep scientific and medical findings altogether, as well as the types of intervention many psychiatrists say alcoholics really need.

What AA provides instead is a method for attacking the habits that surround alcohol use. AA, in essence, is a giant machine for changing habit loops. And though the habits associated with alcoholism are extreme, the lessons AA provides demonstrate how almost any habit—even the most obstinate— can be changed.

Bill Wilson didn’t read academic journals or consult many doctors before founding AA. A few years after he achieved sobriety, he wrote the now-famous twelve steps in a rush one night while sitting in bed. He chose the number twelve because there were twelve apostles. And some aspects of the program are not just unscientific, they can seem downright strange.

Take, for instance, AA’s insistence that alcoholics attend “ninety meetings in ninety days”—a stretch of time, it appears, chosen at random. Or the program’s intense focus on spirituality, as articulated in step three, which says that alcoholics can achieve sobriety by making “a decision to turn our will and our lives over to the care of God as we understand him.” Seven of the twelve steps mention God or spirituality, which seems odd for a program founded by a onetime agnostic who, throughout his life, was openly hostile toward organized religion. AA meetings don’t have a prescribed schedule or curriculum. Rather, they usually begin with a member telling his or her story, after which other people can chime in. There are no professionals who guide conversations and few rules about how meetings are supposed to function. In the past five decades, as almost every aspect of psychiatry and addiction research has been revolutionized by discoveries in behavioral sciences, pharmacology, and our understanding of the brain, AA has remained frozen in time.

Because of the program’s lack of rigor, academics and researchers have often criticized it. AA’s emphasis on spirituality, some claimed, made it more like a cult than a treatment. In the past fifteen years, however, a reevaluation has begun. Researchers now say the program’s methods offer valuable lessons. Faculty at Harvard, Yale, the University of Chicago, the University of New Mexico, and dozens of other research centers have found a kind of science within AA that is similar to the one Tony Dungy used on the football field. Their findings endorse the Golden Rule of habit change: AA succeeds because it helps alcoholics use the same cues, and get the same reward, but it shifts the routine.

Researchers say that AA works because the program forces people to identify the cues and rewards that encourage their alcoholic habits, and then helps them find new behaviors. When Claude Hopkins was selling Pepsodent, he found a way to create a new habit by triggering a new craving. But to change an old habit, you must address an old craving. You have to keep the same cues and rewards as before, and feed the craving by inserting a new routine.

Take steps four (to make “a searching and fearless inventory of ourselves”) and five (to admit “to God, to ourselves, and to another human being the exact nature of our wrongs”).

“It’s not obvious from the way they’re written, but to complete those steps, someone has to create a list of all the triggers for their alcoholic urges,” said J. Scott Tonigan, a researcher at the University of New Mexico who has studied AA for more than a decade. “When you make a self-inventory, you’re figuring out all the things that make you drink. And admitting to someone else all the bad things you’ve done is a pretty good way of figuring out the moments where everything spiraled out of control.”

Then, AA asks alcoholics to search for the rewards they get from alcohol. What cravings, the program asks, are driving your habit loop? Often, intoxication itself doesn’t make the list. Alcoholics crave a drink because it offers escape, relaxation, companionship, the blunting of anxieties, and an opportunity for emotional release. They might crave a cocktail to forget their worries. But they don’t necessarily crave feeling drunk. The physical effects of alcohol are often one of the least rewarding parts of drinking for addicts.

“There is a hedonistic element to alcohol,” said Ulf Mueller, a German neurologist who has studied brain activity among alcoholics. “But people also use alcohol because they want to forget something or to satisfy other cravings, and these relief cravings occur in totally different parts of the brain than the craving for physical pleasure.”

In order to offer alcoholics the same rewards they get at a bar, AA has built a system of meetings and companionship—the “sponsor” each member works with—that strives to offer as much escape, distraction, and catharsis as a Friday night bender. If someone needs relief, they can get it from talking to their sponsor or attending a group gathering, rather than toasting a drinking buddy.

“AA forces you to create new routines for what to do each night instead of drinking,” said Tonigan. “You can relax and talk through your anxieties at the meetings. The triggers and payoffs stay the same, it’s just the behavior that changes.”

One particularly dramatic demonstration of how alcoholics’ cues and rewards can be transferred to new routines occurred in 2007, when Mueller, the German neurologist, and his colleagues at the University of Magdeburg implanted small electrical devices inside the brains of five alcoholics who had repeatedly tried to give up booze. The alcoholics in the study had each spent at least six months in rehab without success. One of them had been through detox more than sixty times.

The devices implanted in the men’s heads were positioned inside their basal ganglia—the same part of the brain where the MIT researchers found the habit loop—and emitted an electrical charge that interrupted the neurological reward that triggers habitual cravings. After the men recovered from the operations, they were exposed to cues that had once triggered alcoholic urges, such as photos of beer or trips to a bar. Normally, it would have been impossible for them to resist a drink. But the devices inside their brains “overrode” each man’s neurological cravings. They didn’t touch a drop.

“One of them told me the craving disappeared as soon as we turned the electricity on,” Mueller said. “Then, we turned it off, and the craving came back immediately.”

Eradicating the alcoholics’ neurological cravings, however, wasn’t enough to stop their drinking habits. Four of them relapsed soon after the surgery, usually after a stressful event. They picked up a bottle because that’s how they automatically dealt with anxiety. However, once they learned alternate routines for dealing with stress, the drinking stopped for good. One patient, for instance, attended AA meetings. Others went to therapy. And once they incorporated those new routines for coping with stress and anxiety into their lives, the successes were dramatic. The man who had gone to detox sixty times never had another drink. Two other patients had started drinking at twelve, were alcoholics by eighteen, drank every day, and now have been sober for four years.

Notice how closely this study hews to the Golden Rule of habit change: Even when alcoholics’ brains were changed through surgery, it wasn’t enough. The old cues and cravings for rewards were still there, waiting to pounce. The alcoholics only permanently changed once they learned new routines that drew on the old triggers and provided a familiar relief. “Some brains are so addicted to alcohol that only surgery can stop it,” said Mueller. “But those people also need new ways for dealing with life.”

AA provides a similar, though less invasive, system for inserting new routines into old habit loops. As scientists have begun understanding how AA works, they’ve started applying the program’s methods to other habits, such as two-year-olds’ tantrums, sex addictions, and even minor behavioral tics. As AA’s methods have spread, they’ve been refined into therapies that can be used to disrupt almost any pattern.

The counseling center referred Mandy to a doctoral psychology student who was studying a treatment known as “habit reversal training.” The psychologist was well acquainted with the Golden Rule of habit change. He knew that changing Mandy’s nail biting habit required inserting a new routine into her life.

“What do you feel right before you bring your hand up to your mouth to bite your nails?” he asked her

“There’s a little bit of tension in my fingers,” Mandy said. “It hurts a little bit here, at the edge of the nail. Sometimes I’ll run my thumb along, looking for hangnails, and when I feel something catch, I’ll bring it up to my mouth. Then I’ll go finger by finger, biting all the rough edges. Once I start, it feels like I have to do all of them.”

Asking patients to describe what triggers their habitual behavior is called awareness training, and like AA’s insistence on forcing alcoholics to recognize their cues, it’s the first step in habit reversal training. The tension that Mandy felt in her nails cued her nail biting habit.

“Most people’s habits have occurred for so long they don’t pay attention to what causes it anymore,” said Brad Dufrene, who treated Mandy. “I’ve had stutterers come in, and I’ll ask them which words or situations trigger their stuttering, and they won’t know because they stopped noticing so long ago.”

Next, the therapist asked Mandy to describe why she bit her nails. At first, she had trouble coming up with reasons. As they talked, though, it became clear that she bit when she was bored. The therapist put her in some typical situations, such as watching television and doing homework, and she started nibbling. When she had worked through all of the nails, she felt a brief sense of completeness, she said. That was the habit’s reward: a physical stimulation she had come to crave.

At the end of their first session, the therapist sent Mandy home with an assignment: Carry around an index card, and each time you feel the cue—a tension in your fingertips—make a check mark on the card. She came back a week later with twenty-eight checks. She was, by that point, acutely aware of the sensations that preceded her habit. She knew how many times it occurred during class or while watching television.

Then the therapist taught Mandy what is known as a “competing response.” Whenever she felt that tension in her fingertips, he told her, she should immediately put her hands in her pockets or under her legs, or grip a pencil or something else that made it impossible to put her fingers in her mouth. Then Mandy was to search for something that would provide a quick physical stimulation—such as rubbing her arm or rapping her knuckles on a desk— anything that would produce a physical response.

The cues and rewards stayed the same. Only the routine changed.

They practiced in the therapist’s office for about thirty minutes and Mandy was sent home with a new assignment: Continue with the index card, but make a check when you feel the tension in your fingertips and a hash mark when you successfully override the habit.

A week later, Mandy had bitten her nails only three times and had used the competing response seven times. She rewarded herself with a manicure, but kept using the note cards. After a month, the nail-biting habit was gone. The competing routines had become automatic. One habit had replaced another.

“It seems ridiculously simple, but once you’re aware of how your habit works, once you recognize the cues and rewards, you’re halfway to changing it,” Nathan Azrin, one of the developers of habit reversal training, told me. “It seems like it should be more complex. The truth is, the brain can be reprogrammed. You just have to be deliberate about it.”

Today, habit reversal therapy is used to treat verbal and physical tics, depression, smoking, gambling problems, anxiety, bedwetting, procrastination, obsessive-compulsive disorders, and other behavioral problems. And its techniques lay bare one of the fundamental principles of habits: Often, we don’t really understand the cravings driving our behaviors until we look for them. Mandy never realized that a craving for physical stimulation was causing her nail biting, but once she dissected the habit, it became easy to find a new routine that provided the same reward.

Say you want to stop snacking at work. Is the reward you’re seeking to satisfy your hunger? Or is it to interrupt boredom? If you snack for a brief release, you can easily find another routine—such as taking a quick walk, or giving yourself three minutes on the Internet—that provides the same interruption without adding to your waistline.

If you want to stop smoking, ask yourself, do you do it because you love nicotine, or because it provides a burst of stimulation, a structure to your day, a way to socialize? If you smoke because you need stimulation, studies indicate that some caffeine in the afternoon can increase the odds you’ll quit. More than three dozen studies of former smokers have found that identifying the cues and rewards they associate with cigarettes, and then choosing new routines that provide similar payoffs—a piece of Nicorette, a quick series of push-ups, or simply taking a few minutes to stretch and relax—makes it more likely they will quit.

If you identify the cues and rewards, you can change the routine.

At least, most of the time. For some habits, however, there’s one other ingredient that’s necessary: belief.

-Charles Duhigg

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