5 tips for helping patients reach their `aha` moment

Addiction clinicians often face the problem of their patients getting stuck and being unable to progress further in treatment. Addiction Professional recently spoke with licensed counselor Courtney Armstrong, MEd, author of The Therapeutic “Aha!”: 10 Strategies for Getting your Clients Unstuck, (W.W. Norton & Company, Inc.) who offered five pieces of advice when it comes to helping clients overcome this hurdle.

Armstrong says that there are two overarching principles that enhance the effectiveness of all therapeutic strategies: presentation and timing.

She also explains that clients often logically know that something is bad for them and continue to do it anyway—whether it’s drug use, certain relationship patterns, or other habits. The problem stems from the fact that habit in procedural learning takes place in the subcortical level or mid-level of the brain, or what she calls the “emotional brain,” which can easily override conscious intentions.

“Ninety-five percent of anything we think, do or feel at any moment is coming from the emotional brain, and it’s controlling our responses,” she says. “Only 5% is controlled by our conscious mind or prefrontal cortex.”

1. Harness the emotional brain

Armstrong explains that in order to reverse negative habits or addictions, it’s imperative to appeal to someone’s emotional mind. For example, having clients make a list of all the bad things that have happened when using won’t be effective because they already know those things and it’s likely that all logic will go out the window when they experience craving.

“When they’re seeking the drug, they just want to feel better. That’s all it’s about. The emotional brain has learned this particular thing makes me feel better,” she says. “All emotion is a request for action … and their [emotional] mind doesn’t give a crap about what has happened [in the past].”

2. It’s all about experience, association and repetition

Armstrong says that the emotional brain learns from experience, association and repetition rather than logic. In order to get the emotional brain to do something different, clinicians must create an experience during sessions that teaches it new associations and a new pattern and then repeat it.

First, she advises to think about the situation that needs to change, and then decide how to present an experience that immediately gives the client a negative emotional association.

3. Memory reconsolidation is the name of the game

The above components are the building blocks of memory reconsolidation, a technique that has been elucidated only in the last 10 years, but Armstrong swears by its effectiveness. While neuroscience literature has been all over this phenomenon, she says therapists haven’t quite gotten it yet.

Armstrong contrasts memory reconsolidation with the traditional practice of extinction—bringing up a craving and withholding the substance. She says extinction teaches the brain that there are two pathways: one where they can think about the substance and not get any in contrast to the original pathway of wanting it, getting it and being able to feel good.

“This creates two pathways that compete for expression,” she says. “If we want to update the original learning—the original neuropathway where that pattern got learned—we have to bring up the memory of that craving and allow them to access it; whatever you have to do really to turn it on.”

Then, once the pathway is opened, Armstrong says waiting 10 minutes allows the pathway to become malleable. Then one must juxtapose the craving side-by-side with something that’s soothing, comforting and positive—being at the beach, for example—which allows the brain to learn a new association or alternative to the substance use.

“Take them into a five to 10 minute experience of using their own mind to calm themselves down,” she says. “It needs to be an experiential thing that shifts their feelings emotionally.”

After a break, the process is then repeated and paired with something aversive from the client’s past. For example, ask the client to remember how they felt when they were arrested for a DUI—how being in jail smelled, how it looked, and how scared they were.

“Figure out the most awful part of the thing that they hated, but get them to feel it because the emotional brain learns through feelings, not words,” she says. “Then I hold them in that until they can tell me that they’re not craving the alcohol anymore.”

Taking a short break in between, Armstrong then returns clients to the positive imagery. When it’s time to return to the aversive imagery again, sometimes Armstrong increases the unpleasantness or brings up another negative event that will help the client continue to connect emotionally. And she tells clients to immediately flash that awful image anytime they have a craving outside of the session.

“By pairing the craving with something awful that they can vividly recall and feel elicits the feeling of disgust, associating disgust with the drug use,” she says. “You’re showing the mind where it’s going and it’s a complete turn-off; but I also give them the positive image so that they have a way to feel better, because that’s really all they’re looking for.”

Armstrong has found that sometimes, within one session—depending on how long someone has been using and how deeply embedded the habit is—clients will tell her they have no desire to have whatever substance they’re recovering from. Other times, she says it’s not enough and it’s important for the client to be practicing these techniques and learning other recovery skills outside of her office, such as through 12-Step participation. 

“If I get someone who hasn’t been using for that long, we can definitely get it in one session. For someone who has been using for years, they’ve also got to be repeating that on their own in between sessions,” she says.  

Armstrong says there are a few studies that show positive outcomes using similar methods. In one study, 66 formerly heroin-dependent males were shown a five-minute video of people using the drug. After a 10-minute wait, the extinction training was carried out and the substance was simply withheld until cravings disappeared. This process was repeated over and over until, eventually, the males were given actual needles and paraphernalia to hold.

Outcomes showed a significant decrease in drug cravings among the males, as opposed to the control group that was shown the video but didn’t have extinction training until six hours later. When tested again a year later, the test group held their changes. 

“What the research has found is that we have a window [spanning] 10 minutes and five hours before memory consolidation closes,” Armstrong says. “[In this] study, they didn’t do anything aversive, so that can work too, but my clients tell me the aversive [juxtaposition] really helps them make that connection.”

4. Use music, mindfulness and humor to your advantage

Armstrong says music, humor, mindfulness are all ways to help create an experience. Although imagery can be really powerful, some people might struggle with getting a clear image—that’s where these techniques come in. 

Music helps clients feel emotions quickly, Armstrong says, so she often has clients listen to songs that they associate with partying or using and then have them brainstorm a series of songs that will instead incite desired feelings of recovery and strength. 

She also plays a mindfulness game with clients when bringing up a craving, called “Whatever.” In the game she purposely asks clients about things they won’t care about and their job is to respond with “Whatever.”

“We’re trying to teach [clients] to be indifferent to sensations in the body and thoughts in the mind,” she says. “What I try to do is to get them to start laughing because that immediately reduces anxiety and puts them in a positive state. It also gets them to start to make an association like, 'So what, I’m having a craving; big deal.'” 

5. Find unresolved trauma and clear it

Clients can also get stuck during treatment or recovery if they have an unresolved traumatic experience, which is often at the root of substance abuse and acts as a trigger, Armstrong says.

“For clearing trauma I use a similar [memory reconsolidation] process because their desire to use is often related to some negative belief about themselves,” she says. “What I do is go back to an event from their past that brought up that feeling, and create an image of what’s desired to diffuse that whole belief pattern.”

Trained in cognitive-behavioral therapy, Armstrong has found that it has many limitations, which is why she initially set out to do research on memory reconsolidation.

“[The strategies] are easy and not hard or painful; it keeps therapists from burning out; and people tell me that they get a lot of referrals,” she adds. “It takes things to another level.”