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| The Marshak Method: Merging Traditional 12-Step and Holistic Methods |
| Feature Articles - Treatment Strategies or Protocols | ||||||||
| Written by Dr. Jacob Marshak | ||||||||
| Tuesday, 22 July 2008 | ||||||||
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In the early 1990s, after the break-up of the Union of Soviet Socialist
Republics (USSR), the newly established Russian Federation faced a fast
growing heroin epidemic, created by two factors: veterans returning
from the war in Afghanistan; and the dramatic impact of a diet that
consisted primarily of high-glycemic processed foods and fast foods,
rich in sugars and corn syrup. In the USSR alcohol and drug abuse was
officially minimized by the government, and addicts were neglected —
the worst addicts, mainly alcoholics, were sent to forced labor camps. Only after Mikhail Gorbachev’s 1986 economic restructuring, known as perestroika, were U.S. activists allowed to introduce 12-Step philosophy to Russia for the first time. I was personally invited to spend a year in the United States as a guest of American addiction professionals. When I returned to Russia as a certified addiction professional, I opened the country’s first private practice specializing in addiction medicine in 1991. My practice began with six heroin addicts. I combined the 12-Step program with a methodology I had personally developed 10 years earlier to stop myself from drinking. It is a holistic method, which allows an addict to quickly achieve sobriety without the help of pharmaceutical medications, and to rapidly improve his or her mood, so as to remain happy, positive and sober long term. A few years later the Marshak alumni “club” included about 30 sober, happy and creative members. In 1996, together with some of my former clients, I founded The Marshak Clinic, Russia’s first private drug rehabilitation center. The clinic rapidly became known as the most successful rehabilitation center in the former Soviet Union. By 2007, more than 2,000 alcoholics and drug addicts had completed our residential program, and as the two clinic follow-up surveys demonstrated, about 70 percent of our alumni still enjoyed continued sobriety two years after completing treatment. Many were able to improve the quality of their lives. About addiction I believe that pathological addictions have the same structure as what I call “healthy addictions.” These “healthy addictions” are instinctive behaviors that activate the reward system, which exists in the brain of all animals. They include breathing, food and water consumption, waste elimination, sleep and reproduction. These behaviors support our life and survival, both as individuals and as a species, and have two important qualities similar to those of pathological addictions: • When we abstain from using the instinctive behaviors for a long enough period, we experience a growing discomfort, which at some point, becomes intolerable. • Each time we resume the instinctive behavior, we experience a feeling of instant gratification or relief. A simple illustration of these two principles is shown in an experiment that relates to breathing, hunger or thirst. Attempting to delay the normal cycle of any of the above behaviors will negatively impact your mood, whereas resumption will alleviate your “distress.” Try not breathing for one minute; you will experience intense discomfort. Now, inhale; instant relief. The behavior pattern is supported biologically by pain/pleasure neurotransmitters in your brain. Addicted persons who abstain from drugs feel a similar pain and sense of despair. When an addicted person uses again, he or she will have a similar feeling of instant gratification and relief, as compared to what you felt when you resumed breathing. I believe that all animals live according to two basic rules that determine their behavior patterns throughout life. The Rule of Intolerable Pain. When an animal or human suffers physical or mental discomfort, the period of time that suffering can be tolerated decreases as the pain increases. If the suffering — either physical or mental — becomes too great, people chose to end their suffering and commit suicide. The Rule of Behavioral Imprinting. If an animal or human suffers physical or mental discomfort and then engages in behavior that results in instant gratification, such behavior will be recognized by the brain’s reward system as highly valuable. It will be imprinted into the neural pathways and added to the list of the “SOS tools” that we use in times of trouble. The faster an SOS tool allows us to transition from “dysphoria” to “euphoria,” the higher its ranking on the list. That is why smoking crack cocaine is more addictive than snorting cocaine — the resulting gratification is achieved more instantly. After using a new SOS tool that successfully and instantly alleviates discomfort several times, this behavior pattern becomes instinctive, and from then on, is extremely difficult to control. The interesting thing is that we most love those behaviors that cause an instant transition from dysphoria to euphoria. When they become imprinted in our brain they stay with us for eternity. “Healthy” people who live mostly in a pleasurable state of well-being may occasionally also use recreational drugs. For these people, the drugs further enhance their already positive state of mind. In these cases, a fondness is created for the substance, but it does not become addictive. Social drinkers are an example of this, as they enjoy having a drink and often do so in social settings. Social drinkers are able to control their drinking and have the capacity to avoid using alcohol, if necessary. Historically, the appearance of pathological addictions (as opposed to “healthy addictions”) has been a result of the human race’s constant quest for new means of instant gratification. Pathological addictions are behavioral skills that give instant gratification, but at the same time, impair mood regulation and have harmful consequences to the addicted individual and those around him. People with pathological addictions have different goals than non-addicted people. Attaining the drug of choice becomes a central goal of their lives, and every behavioral skill is used to attain possession of the drug. To restore an addict’s long term sobriety, we need to use either the first or second rule of addiction. Examples of the second rule, The Rule of Behavioral Imprinting, include treatments like aversion therapy and hypnosis. The second rule also would include stereotactic neurosurgery, which is performed on some areas of the brain’s reward system in an attempt to erase the pleasurable memory of the drug use. Unfortunately, these methods have not had significant impact. One of the reasons is that despite modern science’s many efforts, it is difficult to selectively inactivate drug-associated memories. Additionally, even if the person “forgets” the pleasant memory of the quick fix he or she gets from a drug, that person still remains in a state of depression and discomfort. This discomfort will lead that person to seek other forms of self-medication to numb the discomfort. The Marshak Method is based on the first rule of addiction, The Rule of Intolerable Pain, and uses two complimentary strategies, biological and psychological, to quickly normalize the brain’s reward system. First, a biological approach is used to achieve and maintain a baseline state of pleasurable well-being. When the addicted individual experiences internal comfort, his or her craving for drugs substantially decreases and becomes controllable. Once an addicted person achieves a steady state of internal comfort, his or her whole personality changes. If all of the addict’s previous behaviors were devoted to drug use, in order to achieve short episodes of feeling good, his or her behavioral skills will now be turned extensively to protecting this newly achieved internal comfort. The biological component includes: • A special exercise regimen, derived from Hatha and Kundalini Yoga, which over the years, I have personally designed to enhance the mood of my clients and help them sustain the resulting sense of well-being • Bioactive nutritional supplements that compliment the exercise regimen and enhance the ability of the exercises to elevate the mood • A recovery diet, which is designed to minimize mood swings and elevate energy levels • Genetic testing that identifies variations in a number of genes which can predict predisposition to addiction Guided by the results of the genetic testing, both the exercise program and the bio-active nutrition supplements are individually tailored to the client’s needs. Second, psychological guidance and assistance is used to help the addict make the transition from an “unhappy” to “happy” personality. This includes group therapy, individual therapy and working a 12-Step program. The psychological component of the Marshak Method is based on the principles of the 12-Step Program and includes daily group and individual sessions with therapists and counselors. Exercise program — why yoga? The practice of yoga began 4,000 to 8,000 years ago and continues today. Many different types of yoga coexist in ancient India and in the modern world, each practicing its unique way to achieve the ultimate goal. In Sat Chit Ananda, “Sat” means existence or experience of truth and essence of life; “Chit” is consciousness or the comprehension of causal relationships of events; and “Ananda” means bliss. The different schools of yoga each have their own methods of achieving the internal feeling of “Ananda,” a very high level of euphoria. This also is the Marshak Method’s goal: to have our clients achieve a high state of well-being. I have been practicing yoga for 37 years, and studying the effects of various yoga styles and exercises on mood regulation. To help addicts attain sobriety and maintain sobriety long term, I have carefully selected those exercises that most quickly elevate the mood. There are three groups of exercises that I use to achieve mood regulation. The first group of exercises helps a person to feel invigorated and energized throughout the day, and when practiced each morning, puts him or her in a joyful state through which he or she achieves reward from daily activities, such as work. The second group of exercises, usually practiced in the evening, help a person efficiently achieve deep relaxation and tranquility, and then rest, without using tranquilizers such as alcohol, benzodiazepines or opiates. The third group of exercises are designed to relieve and control anxiety. These exercises consist of alternating anxiety-provoking and anxiety-calming exercises that train certain areas of the brain to inhibit endogenous anxiety. Our experience at the Marshak Clinic in Moscow (now in its 11th year) shows that alumni who continue for two years after completion of treatment, to practice Marshak exercises daily for at least 60 minutes; take their prescribed food supplements; and follow a low glycemic diet; will maintain the elevated state of well-being they have achieved, which is a condition for long-term sobriety. Apparently, two years is enough to stabilize the neurochemistry of the brain’s reward regulation system at the new higher level achieved during residential treatment, even if they then stop the daily routine. Brain building While working to make the Marshak Method more efficient, I discovered that combining bioactive food supplements with the exercise program significantly increases the mood enhancing effects of the exercises. I call this phenomenon “brain building.” It is analogous to bodybuilding. To maximize muscle growth, bodybuilders combine special muscle training with specialized nutritional products that support the increased demand of muscle cells for protein and energy. To maximize brain building, we have a special exercise program which stimulates neuronal pathways that provide a feeling of reward. When combined with specialized nutritional products — amino acids, fatty acids, vitamin and mineral “feeds” — we maximize reward system performance by providing these neuronal pathways with precursors and facilitators of neurotransmitter synthesis. For example, amino acid l-tyrosine is a precursor for the neurotransmitters, dopamine and norepinephrine, which both are important mediators in the reward system. In order to be converted into dopamine or norepinephrine, amino acid l-tyrosine has first to be modified in a neuron by an enzyme called tyrosine hydroxylase. Tyrosine hydroxylase is a slow working enzyme and the speed of this enzyme determines how much dopamine and norepinephrine will be produced. L-tyrosine is often prescribed as an antidepressant, a stimulator of alertness and mental arousal. However, l-tyrosine supplementation alone will lead only to a very moderate increase in dopamine and norepinephrine production due to a slow rate of tyrosine hydroxylase. The Marshak exercise program increases the firing rate of neurons in the reward areas of the brain. Neuronal activity in its turn speeds the activity of the tyrosine hydroxylase enzyme (Cooper et al, 2003). When exercises are combined with the l-tyrosine supplementation, the production of dopamine and norepinephrine in the reward system is greatly enhanced. Different sets of Marshak exercises stimulate different areas of the brain. Knowledge of brain biochemistry has allowed us to formulate food supplement cocktails which, in combination with the exercises, greatly enhance brain performance. Recovery diet Every individual habitually eats foods for which he or she has developed a “liking.” The choice is largely determined by the culture in which one lives, as well as family traditions. Food satisfies the physiological needs of our body, and at the same time, provides feelings of relief and satisfaction by taking away the unpleasant state of hunger while promoting a feeling of contentment. The history of the modern high-glycemic diet started 10,000 years ago, when humans first discovered that fire could heat previously inedible starchy grains and make them edible. Starch provided humans with a rich source of glucose — the fuel for the neocortex, our organ of adaptation and survival. Before fire was used for cooking, humans ate mostly the seeds of perennial plants, which contained large amounts of fatty acids (Harris & Hillman, 1989). New glucose-rich diets allowed the human brain to work more efficiently, ultimately leading civilization to progress. However, the ability to process starchy foods had another important consequence. Eating glucose-rich food became pleasurable. Rapid elevation of glucose in the bloodstream leads to rapid increase in serotonin levels in the brain, which in turn mediates activation of the reward system. In about 30 minutes this short lasting state of comfort changes to a prolonged state of dysphoria, which triggers another craving for sweet food. Instead of satisfying our hunger we start satisfying our appetite. The faster and stronger the elevation of glucose, the more addictive food becomes. This addiction has pushed, and is continuing to push food manufacturers to develop increasingly sweeter foods. When sugar cane arrived in Europe at the beginning of the 18th Century, the average British person consumed three pounds of sugar per year. Development of cheap beet sugar production increased sugar consumption 20 times. In 1830, an average British citizen consumed 60 pounds of sugar per year. Now, the sugar consumption of the average American is as high as 140 pounds per year (Atkins, 1989). The modern high-glycemic diet has led to development of such 20th Century diseases as diabetes, obesity, atherosclerosis, stroke, heart attacks and gastrointestinal diseases, as well as pathology of male and female sexual organs. Along with contributing to the spread of disease in our bodies, our addiction to “tranquilizing,” soothing sugary foods has also created problems in the mood regulation system. Sugar both disregulates the serotonin and cathecholamines function and provokes reactive hypoglycemia, manifesting itself as “sugar blues,” bipolar depression, ADHD, various psychoses and substance abuse. So why can we not just stop eating sugars and return to a healthier diet? Many dietitians recommend diets that are physiologically sound, but do not result in a feeling of “reward,” or satisfaction after eating. Consequently, most people can only follow such diets for a few weeks, and soon afterward, revert to their previous methods of obtaining the feelings of satisfaction from their favorite foods and their habitual lifestyle. There are two kinds of “rewarding” or “satisfying” feelings that human beings can experience. The first rewarding feeling is “relaxation.” You feel soothed and satisfied. The “relaxation reward” allows us to enjoy times when we are resting. The second rewarding feeling is “stimulatory.” You feel active, energetic and excited. The “stimulatory reward” allows us to enjoy the times when we are active. People use “downers” and “uppers” to increase the pleasure or reward they derive from these feelings. The foods we eat can, in the same manner, affect our mood, in a “relaxing” or “stimulating” manner. While high-glycemic foods induce a soothing state of “relaxation,” protein-rich foods induce a stimulatory reward. Therefore, after meals, nomadic hunter-gatherers and pastoral peoples would initiate dances, skill and strength competitions, while sedentary farmers would enjoy a siesta after eating sugary soothing meals (Arutyunov, 2004). Based on this knowledge, we have developed a special recovery diet. This diet is rich in protein, contains a variety of special spices and does not incorporate sugars, white flours and other high-glycemic products. The recovery diet serves two major goals. First, it promotes healthy body and reduces “mood swings,” which are so dangerous for those suffering from addiction. Second, this recovery diet provides people with a stimulatory reward after meals. Weekly cooking classes demystify the principles of the diet and teach clients how to easily prepare “stimulatory” meals at home. The 28 days of the residential program are usually enough to lessen our client’s addiction to sweet tranquilizing food and habituate them to enjoy stimulatory meals. Genetic testing There is very little doubt today that addiction has a strong genetic component. Family, twin and adoption studies suggest strong genetic contributions to the development of drug and alcohol dependency (True et al., 1999; Kreek et al., 2004). The first gene linked to alcoholism was described in 1990 by Kenneth Blum and his colleagues (Blum et al., 1990). This gene encodes for the dopamine D2 receptor, one of the receptors involved in producing pleasurable feelings in the reward system. Certain variants (polymorphisms) in the dopamine D2 receptor gene have been associated with reduced levels of the dopamine receptors in “reward pathways” (Klein, 2007) and increased severity of alcohol dependence (Noble, 2003; Konnor, 2007). Since 1990, numerous scientific studies were dedicated to identifying a growing number of gene variants that predispose people to addiction. A deviation in these genes can cause a shift in one of the many biochemical reactions in the brain that are responsible for regulation of mood and behavior. The resulting biochemical imbalance can lead to chronic dysphoria and vulnerability to stressful environmental factors, which may result in a person searching for relief and seeking drugs to alleviate the emotional pain. In our clinic, when a new client arrives, my daughter, Sonia Marshak, MD, PhD, immediately evaluates a number of genes that are shown to be risk factors for the development of addiction. The results of the confidential genetic testing provide information about whether each individual client carries gene variants that can cause mood dysregulation. Knowledge of the client’s genetic profile allows us to identify biochemical or neurological pathways that might be compromised due to genetic factors. We tailor supplement and exercise regimens for each client, to optimally and efficiently restore his or her mood regulation system. Six years of testing at our Moscow Clinic demonstrate that understanding the genetic makeup of addiction-prone genes significantly increases positive outcome with the Marshak Treatment. Psychological support The life of an addicted individual is centered around his or her drug of choice. An addict depends on his or her drug to function and feel good. If the drug is not readily available when needed, a person experiences severe dysphoria and anxiety. Every time an addict feels uncomfortable, he or she depends on the drug to regain the feeling of comfort, just to lose it again when the effects of the drug wear off. The addict becomes a seeker of instant gratification. All of his or her feelings, thoughts and behavioral strategies are aimed at grasping a short-lived state of comfort. Many addicts don’t generally care about the moral principles by which normal people live. For instance, many drug addicts lie easily. In general, healthy people define “lying” as “not telling the truth,” whereas many addicts perceive “lying” as a way to creatively use their intelligence to obtain the desired reward. Just as easily, many addicts offend and threaten other people. Some of them can easily steal without thinking twice and can even harm or kill another person in order to alleviate the despair. Many addicts don’t regret their amoral behavior. That’s why drug addiction is also called a “disease of frozen feelings.” The personality of a healthy individual is structured quite differently. Healthy people live in a relatively stable state of internal comfort and have a variety of tools to enhance their state of well-being. The healthy person’s feelings, thoughts and behavioral strategies are aimed at protecting that stable state of internal comfort. Healthy people develop feelings of self dignity, conscience and honor, and the internal moral law generally prohibits healthy individuals from lying, offending and doing harm to others, because these behaviors will throw them out of their comfort zone. When addicted people transit from an unhappy to happy state of well-being, their personalities change. This transition can be dangerous, especially if it happens fast, as it does during a 28-day residential program at the Marshak Clinic. As an addicted person attains a higher level of well-being, he or she will begin to remember any of the immoral acts committed in the throes of addiction. This can result in powerful surges of guilt, shame, remorse and repentance. Consequently, these memories can bring back the depression, which in turn, may provoke drug or alcohol cravings. This is why psychological support is so important during residential treatment, and for 30 to 60 days after clients complete treatment. We help those “emotionally thawing” clients to dissociate themselves from the things they did while using. We explain to them that what they did was not their real nature, but the nature of their disease, in the same way that fever is a symptom of the flu. We base our psychological support system on the 12-Step program, which I believe has three important features that assist addicts as they transition to and learn to maintain a sober lifestyle. First, the 12-Step program provides great tools for an addict to safely go through the process of remembering his past and dissociating his previous immoral behavior from the concept of self. Second, the 12-Step program teaches skills of sober behavior; educates addicts in how to recognize early triggers of relapse; and provides aid at times of dysphoria and craving. It also provides an individual with a strong social support group in the form of a sponsor and peers. The third and most important feature of the 12-Step program is that it engages its members in an emotionally rewarding life style. The Marshak Clinic has found that there are eight behavioral practices in the 12-Step program that increase our client’s state of well-being: practicing religious feelings and prayer; avoiding the instant gratification that comes with offending others; forming friendships; experiencing insight from understanding and relating to the experiences of peers; getting intellectual pleasure from analyzing and understanding life experiences; sharing and experiencing relief from confession; experiencing reward from doing good deeds; and zealousness. We at Marshak Clinic believe that the deep and detailed explanation of the benefits of the 12-Step program greatly increases the participation and involvement of our clients in the clinic’s program, and thus, enhances the chance that our alumni will go on to live joyful and sober lives. Dr. Jacob Marshak is the founder and program director of the new Marshak Clinic for alcohol and drug rehabilitation in Malibu, Calif., and scientific director of Moscow’s renowned Marshak Clinic. He earned his medical degree from Moscow State Medical University, and was one of the first Soviet doctors brought to the United States to learn 12-Step methodology. Dr. Marshak became a Certified Addiction Professional in 1989 after six months of training at Florida’s Heritage Health Treatment Center. For information about the Marshak Clinic visit www.marshakclinic.com or call 1-800-366-8101. References Arutyunov, S.A. (2004) Cultural anthropology. Russian, Moscow Press. Atkins, R. (1989). Dr. Atkins’ health revolution: how complementary medicine can extend your life. Houghton Mifflin Company, Boston, Mass. Blum, K., Noble, E.P., Sheridan, P.J., Montgomery, A., Ritchie, T., Jagadeeswaran, P., Nogami, H., Briggs, A.H., Cohn, J.B. (1990). Allelic association of human dopamine D2 receptor gene in alcoholism. JAMA, 263:2055-60. Connor, J.P., Young, R.M., Lawford, B.R., Saunders, J.B., Ritchie, T.L., Noble, E.P. (2007). Heavy nicotine and alcohol use in alcohol dependence is associated with D2 dopamine receptor (DRD2) polymorphism. Addict Behav. 32:310-19. Cooper, J.R., Bloom, F.E. & Roth, R.H. (2003). The biochemical basis of neuropharmacology, Oxford University Press. Harris, D.R. & Hillman, G.C. (1989). Foraging and farming: evolution of plant exploitation. One World Archeology. Klein, T.A., Neumann, J., Reuter, M., Hennig, J., von Cramon, D.Y., Ullsperger, M. (2007). Genetically determined differences in learning from errors. Science, 318:1642-5. Kreek, M.J., Nielsen, D.A., LaForge, K.S. (2004). Genes associated with addiction: alcoholism, opiate, and cocaine addiction. Neuromolecular Med., 5:85-108. Noble, E. P. (2003). D2 dopamine receptor gene in psychiatric and neurologic disorders and its phenotypes. American Journal of Medical Genetics, 116B:103—125. True, W.R., Xian, H., Scherrer, J.F., Madden, P.A., Bucholz, K.K., Heath, A.C., Eisen, A.C., Lyons, M.J., Goldberg, J., Tsuang, M. (1999). Common genetic vulnerability for nicotine and alcohol dependence in men. Arch Gen Psychiatry,56:655-61.
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