I remember the exact moment I decided to write this post. I found myself in the kitchen. I saw myself open a cabinet and grab a bag of butter cookies. I remember thinking, “I really shouldn’t be doing this,” as I next reached for a jar of fig preserves to slather on my cookies. “I’m not even hungry,” I continued my self-talk, as my arm raised the fig-covered cookies into my mouth and as I happily and unhappily munched on them. “This will make it harder to sleep… I will regret this,” I said, wiping crumbs and fig preserves from my mouth.

I felt helpless and possessed. Possessed by whom? I don’t know; maybe the cookie monster. After I consumed three such cookies enriched with fig, I got ahold of myself. Or something. It’s hard to say what happened. I probably reached enough of a full stomach to finally allow my helpless observing self to stop all the other parts of me from eating more.

It was then I decided to write this. I realized we often successfully exert direct control over ourselves, that is, we control our behaviors, what we attend to, and even what we choose to think about. We usually call this direct control willpower. We clinicians, as a group, are probably more successful deployers of willpower than the average person given that we succeeded in attaining our degrees after spending thousands of long and sometimes lonely hours studying and foregoing fun activities over the many years of our education and training. But no matter how successful we are at deploying willpower, it does have its limits, which become evident in both trivial and life-altering ways.

So, my midnight grappling match with butter cookies and fig jam led me to list the additional ways we can control ourselves. These ways are indirect in that they don’t require willpower, or at least they don’t require willpower at times of risk of loss of self-control, like when confronted with unwise but compelling temptations. The following list may be of use to you if you’re making, or considering making, changes in your life, such as, for example, following through on New Year’s resolutions.

Reward and Punishment

Ahh yes, contingency management – setting up consequences to guide behavior. If it’s good enough for our patients, it’s good enough for us, I say. So much about our behavior can be explained by the simple fact that we, and many other creatures in the world, are driven to seek out appetitive stimuli and avoid or escape from aversive stimuli. We can use this basic mammalian machinery to achieve self-control indirectly. We train ourselves to increase beneficial actions while minimizing detrimental ones. Contingency management is simply the systematic application of these behavioral modification principles.

Let’s start with punishment. It comes in two forms: application of aversive stimuli and withdrawal of appetitive stimuli when we engage in behavior we wish to stop. Let’s say you realize that you regularly swear and curse – something you picked up in childhood from the neighborhood you grew up in. You decide to stop this behavior because you believe it makes you look bad, and you’re not proud of it. So, you decide if you ever swear or curse, you will donate $20 to a charity or organization you despise; these are sometimes called anti-charities. If you think this is an effective way of modifying your behavior, you’re right. In fact, there are apps that will allow you to set up such a system.

Let’s now consider rewards. Pick an aversive task you’ve been avoiding that has you feeling chronically burdened, something where the thought of doing it is worse than actually doing it. Catching up on your charting or report-writing is a good example. Resolve to catch up on this paperwork and then treat yourself afterward with dinner, shopping, etc.

I don’t know about you, but the punishment option seems more motivating to me than the reward option. Maybe I already have everything I need in life, so further rewards are not that motivating. I’ll have to try both and I’ll let you know.

Control the Conditions

One of the most effective skills people with addictions learn is how to recognize conditions that place them at risk of relapse. The same principle applies to everyone: if certain people, places, things, and situations put you at risk of engaging in some appetitive but unwise behavior, then avoid those people, places, things, and situations. For example, if I didn’t have cookies in my house, no matter how much I wanted to eat cookies, conditions would not have allowed me to indulge.

Controlling conditions is an effective technique but often requires cooperation among the group sharing a place or situation. For example, you may really not want to eat donuts or bagels, but it’s hard to resist when there’s a box of them in front of you. In this case, speaking with your colleagues at work or family at home to avoid bringing in such food items would be necessary. Of course, once you bring it up, you’ll find many other participants also happy to eliminate these options from the shared environment.

Distract Yourself with Substituted Behaviors

When in an unavoidable situation of risk, it’s important to break the seemingly inevitable path of indulging in appetitive but unwise behavior. You can do this through any behavior that distracts, takes you away from, or substitutes for the behavior you’re trying to avoid. One approach is habit substitution (called, non-intuitively, habit reversal). So, for example, persons with hair-pulling or skin-picking behaviors can snap a rubber band on their wrist when they feel the compulsive urge arising.  For a person trying to quit smoking, taking a jog at the time of day associated with the greatest risk of relapse can interfere with their craving or fulfillment of their craving. The jogging itself may become rewarding, thus becoming a more effective substituted behavior. Or, for me, when feeling the urge to eat cookies at midnight, I could do 20 sit-ups instead, for example. Not only does this break the behavioral path, take me away from the kitchen, and distract me with an alternative behavior, but it directly interferes with the craving. If you’ve ever done sit-ups, you know that repeated abdominal compression tends to eliminate food cravings.

Foresight, Strategies, and Planning

Many of the necessary but aversive behaviors we avoid and the appetitive but unwise behaviors we engage in are in no way unpredictable. We likely face them several times a week or even every day. So, given our entirely predictable risk exposures, behavioral response patterns and habits, and known successful and failed control strategies, we can self-reflect and plan ahead of time strategies we can take to avoid our anticipated behavioral traps.

For example, for persons recovering from alcohol addiction, attending a party at which plenty of alcohol is present increases their risk of relapse. As a clinician, you can help them strategize approaches ahead of time to minimize their risk. For example, they may wish to take a short-term course of disulfiram. They may come up with a cover story that they’re on a medicine that does not allow mixing with alcohol. They may say they have to leave early to avoid the time at which most drinking takes place. They may even attend the event with their sponsor, who serves as their auxiliary frontal lobes. And, of course, they can choose to share their recovery status with the hosts and ask for their help in avoiding risk.

That’s it for now. Let me know your thoughts. Let me know which techniques you use with your patients… and yourself.

Until next time,

Dr. Jack

Language Brief

“What we call our destiny is truly our character and that character can be altered. The knowledge that we are responsible for our actions and attitudes does not need to be discouraging, because it also means that we are free to change this destiny.”
Anais Nin

“He who controls others may be powerful, but he who has mastered himself is mightier still.”
Lao Tsu

“Remember, it is not enough to be hit or insulted to be harmed, you must believe that you are being harmed. If someone succeeds in provoking you, realize that your mind is complicit in the provocation.”
Epictetus

“Not being able to govern events, I govern myself”
Michel de Montaigne

“Refrain to-night;
And that shall lend a kind of easiness
To the next abstinence, the next more easy;
For use almost can change the stamp of nature,
And either master the devil or throw him out
With wondrous potency.”
William Shakespeare