Rabbit Holes, Rest, and Relapse: that was Groucho, this is Karl

Bootzin & Epstein, 2000, Stimulus Control

I must say, though I already knew that behavioral treatment for Insomnia were apparently effective, these findings still really wowed me. Seeing the incremental effectiveness Stimulus Control (both on its own and as part of a larger treatment package) has over pharmacological interventions (and, in some cases, even over combined behavioral/pharmacological treatments) makes me wonder about the already-suspect motives of drug companies in pushing these meds. Is the book essentially closed on treatments for sleep disorders – the problem already largely solved? Do articles in the journal SLEEP about treatments amount to the academic equivalent of the very Nick-at-Nite reruns their subjects were once ensnared by in the wee hours? I find it telling, though, that such strong effectiveness findings for behavioral treatments seem to present themselves in the arena of more unitary, nomothetic, reactive, and instrumental disorders, while they are more contentious (at best) with regard to more potentially complex, behaviorally aggregate, usually ipsatively-deduced disorders (such depression, autism, personality disorders, etc).

That said, there were a few areas of the Bootzin and Epstein paper that caught my interest and led to several questions:

-On the first page of the article, the authors note that in the 60’s and 70’s, “programs for weight reduction that focused on SC were found to be highly effective” (p. 168). What happened to these “highly effective” programs, though? Were they overtaken by more cognitively-based approaches, discarded for some methodological reason, or simply lost to history for no good reason?

-The authors note that their preferred method, the “small-group format,” (p.171) had some evidence for its specific effectiveness (although, near the end of the article, they seemed to note that there was some evidence to the contrary). I’m wondering, then, if there has been any mechanisms of change work examining the potential “common factor” in this condition. Specifically, what, if anything, might the role of normalizing sleep disturbances be in reducing the stigma (and consequent anxiety) surrounding them? I imagine there might be a differential effect (that could be easily testable with an intervention group, plus wait-list control and a support-group control conditions), though I’d be curious to find out if such a thing exists.

-On p. 177, the authors note that “older adults usually take longer to fall asleep than younger persons.” Though I’ve certainly seen this phenomenon in action, it seems counter-intuitive to me. Young, spry individuals seem more likely to have an excess of wakeful energy to keep them up at night. Is this not the case?

-Finally, among the treatment instructions, Bootzin & Epstein note that “SC should be followed at the time of the final awakening.” However, they don’t say what to do in the event of finding oneself very sick with a cold or flu. In these situations, staying in bed can be healthy and necessarily (not to mention medically indicated), and could certainly circumvent the effectiveness of a SC protocol. I imagine that the authors would allow for this as an exceptional circumstance, though I wonder what their preferred method of response might be (e.g. get up and be sick on the couch instead). Additionally, does this response change when a mental illness such as depression is involved? Are there intermediary interventions to break the cycle of exhaustion and depression that can be so self-reinforcing in depressed individuals?

Sleep Hygiene Handout

I guess my main reaction to the Sleep Hygiene handout was simple: how, if at all, does Sleep Hygiene (programmatically) differentiate itself from the Stimulus Control method outlined by Bootzin & Epstein? It seems to just incorporate it as the manualized component of a larger battery of recommendations around, well, healthy sleep. Is that all?

-Also, is the nightmare component of sleep Hygiene simply a variant on systematic desensitization? If so, I wonder if augmenting the “change” component of it with humor or absurdity (e.g. “put a bow on the snake,” or “you fall… into a big pile of tapioca pudding”) might increase its reliable effectiveness.

Witkiewitz & Marlatt, 2004, Relapse Prevention for Alcohol & Drug Problems: That was Zen, this is Tao

I found myself perplexed by my response to this article. Though the model and systems (and, importantly, the article’s subtitle) should have been fascinating to me, I had a lot of trouble getting into it. In any case, I came up with a couple of thoughts:

-After much ado, on p. 229-230, Witkiewitz & Marlatt present their Dynamic Model of Relapse. This model is fascinating in its complexity, modernity (it’s awfully hip), and comprehensiveness. Not being extremely well-versed in the literature, I don’t really feel qualified to take serious issue with any component of it, though, importantly, the authors themselves do note that the model “needs to be empirically tested and replicated across drug classes and with a variety of distinct substance-using populations” (p. 232). An interesting factor that they touch upon only briefly is the role of neural mechanisms & correlates of additions. Specifically, I’m curious as to whether the authors would conceptualize them as more “phasic” or “tonic,” as the implications for “hard-wiring” learning and thereby neurologically protecting relapse seem to be great.

-Also, I’m not entirely clear how the Dynamic Model of Relapse directly speaks to treatment. Though it “depends on clinicians’ ability to gather detailed information about an individual’s background, substance use history, personality, coping skills, self-efficacy, and affective states,” (p. 231) I’m not sure how, given the necessarily immense complexity of the relationship of these factors as they relate to the Dynamic Model, it can give direction to a clinician. Put simply: it’s just too much information to effectively synthesize; indeed, the comparison to chaos & catastrophe theories, whose models can only be analyzed and plotted using the most cutting-edge computing hardware, seems apt. If a clinician is to use the model, it should inform either a) how s/he should intervene, or b) when is the most optimal time to apply specific interventions. As it stands now, the Dynamic Model seems to provide meaningful direction for either of these questions, but it certainly does hold immense promise.

Voelker, 2006, Stress, Sleep Loss, and Substance Abuse Create Potent Recipe for College Depression

The findings reported in Voelker’s article are striking indeed! It is really quite amazing to see how mutable the brain and its structures are. That socially-activated adrenocorticotropic hormones “have the potential to remodel the brain” (p. 2177) at the genetic level says a tremendous amount about the importance of our ability to process and regulate social information – and about the fragility of the brain’s architecture in the first place. Though I don’t believe that anyone really thinks of humans as nothing more than walking bags of blood & neurons & hormones that just bump into different environmental factors (or, as Greenberg put it more eloquently in our first reading, we are beings “orchestrated by ion channels and neural pathways and axonal projections… deep in the grips of [our] chemicals”), the findings reported in this article are pretty persuasive in that direction. Though the finding the “brain change that defines addiction” may take us beyond the “metaphor of the frying pan,” I daresay that it may take is into the fire. If we find that all this neurobiological information is knowable, and all that we are is changeable, then the only field with more infinite promise than psycho(pharmaco)therapy is… bio-psycho-totalitarianism.

FIN