Self-Medicating for Depression?

Dear Cliff,

I need info on self-medicating for depression following brain surgery for acoustic neuroma. Following surgery, upon removal of steroids for brain surgery, husband became depressed and began using cocaine powder and now crack. Please e-mail any info.

Sincerely, S.

Dear S.

"Self-medication" is not an accurate way to describe a cocaine problem. In my experience, cocaine CAUSES depression and other psychoses. I hate to quote Rush Limbaugh, but "words mean things." The words you use (semantics) affect how you see things, and how you see things (your beliefs) strongly affect your ability to respond and to act (change). For a better chance at a solution, call the problem what it is: getting loaded.

No addicted person will take action in solving a drug problem until he or she wants to solve the problem. Until then, increasing one's awareness is about the only option.

Meanwhile, the problem is probably affecting the lives of the family members. A loved one can either sit on the sidelines and watch (i.e., do nothing); or a loved one can confront the person with the problem and force her or him to make a choice and take some action -- knowing full well that the person might just choose the drugs (i.e., work for change); or a loved one can leave. These are your choices as the spouse of a problem drug user -- and neither of them are any fun. The third choice isn't much fun either: Get the hell out of dodge!

Using benign descriptions like "self-medication" not only won't make the problem go away, it may just blind both of you into a state where you won't take any action to solve your problem. Pay attention to my careful choice of words, here; I didn't say "get help." Getting help may be one of many actions you take to solve your problem -- but it may end up being a very minor player. The major player is the drug user: without drastic action on his or her part, nothing will change. No matter what you do, the person quitting the drugs is the major player.


Do not get taken in by a crafty drug addict. An addicted person's thoughts and goals are "centered around getting and using and finding ways and means to get more" (Narcotics Anonymous, page 3). In many cases, the priorities become reversed and getting drugs becomes more important than being honest, etc. Often, the addicted individual eventually comes to believe that the drugs are more powerful than the person, and sometimes the addicted person quits trying to control him- or herself.

Rational Recovery:

We start working the Rational Recovery program by asking ourselves "Is it in my best self-interest to stop using (or drinking)?" I tell people to people divide a page into four quarters: one square is called "Advantages of Drinking and Using"; another is called "Disadvantages (or Costs) of Drinking and Using"; the third is called "Advantages of Staying Clean and Sober"; and the last is called "Disadvantages (or Costs) of Staying Clean and Sober."

Work this exercise at least a dozen times over the course of two weeks; the idea is to come up with a consensus of what you really want to do. In most cases the answer is a "no-brainer." The first time you work the exercise, the solution is obvious: Quit now!

Still, work the exercise several times anyway. You want to have it down on paper -- from your own pencil -- what you really want. We begin to think of it as what the self -- "the real you" -- wants, because we are going to play a little head game with ourselves, called AVRT (pronounced "avert"). In AVRT (Addictive Voice Recognition Technique), I use all of my mind's facilities to decide what is in my best self--interest and what I really need to do about my drug problem. If it is obvious that I need to quit, I then make the decision to quit.

And then I listen.

(this is where the head game begins)

I start listening to that voice in my head that is telling me to get loaded. And believe me, if I, as an addict, say to myself "I will never use (or drink) again," that voice will object very loudly in my mind: "What? Never!? Wait a minute! You don't mean never, do you?"

Now, if I've decided that it is in my best interests to quit, and I've decided that I can and will do whatever it takes to get and stay clean and sober, then who is talking in my mind, telling me to get loaded? I want to stay clean! Am I crazy or something? I want to stay clean, but I hear myself -- my mind's voice -- telling me that I want to get loaded.

What is going on in here?

If you don't understand the questions I'm raising here, you've probably never been addicted to anything. Try this experiment: Hold your breath for three minutes. Don't just think about it, go ahead. Try it. You may not think you can do it at first; if so, you're playing right into my point. Keep holding your breath as that unique discomfort that I call "start breathing" sets in. A small part of your brain is sending messages to you -- the real you, the rest of you -- urging you to start breathing.

(don't do this if you think you may hurt yourself doing it)

Still holding your breath? Starting to get nervous? uncomfortable? Beginning to doubt you can make it for the full three minutes? Sit down on a couch or a bed or the floor. You don't want to hurt yourself in case anything happens.

Still there? Is this starting to get downright scary? Do you think it just might not be worth the pain, effort and risk to actually see for yourself the point I'm trying to make? Keep at it. You can make it. (Perhaps...)

Has that state of outright panic snuck up from behind and tightened its hands around your throat? Good. I've felt that very same way about the prospect of running out of drugs. Panic. Sheer panic. Some smokers feel that way in the middle of the night when they are down to three cigarettes. (I know I did!) We believe it is a similar mind function as that which produces hunger, thirst, and the sex drive. We think the addicted person's urge for drugs is mixed up with this simple, natural brain function.

As powerful as those urges seem to you, they are coming from a small, very simple part of your brain, called the midbrain. Some people call it the limbic system, others call it the reptilian brain; in RR, when it calls out for drugs or alcohol, we call it the Beast. The Beast is probably associated with what many of us call the Appetite Center. The Beast cannot look abstractly to the future and predict the consequences of certain actions (like the results of remaining addicted). The Beast cannot remember the past and be reminded of how certain actions always produced the same results (like the consequences of remaining addicted). The Beast is oblivious to these principles of cause and effect. The Appetite Center can only think in the most simple of terms: "Want food." "Want fluids." "Want sex." "Start breathing -- now!" The Beast is that part which screams out: "Want drugs; want booze!"

It's probably more complex than that, but you should be able to use this model to successfully fight the urge to get loaded. Remember, this model is deliberately imprecise.

In early Rational Recovery, the Beast was, by definition, any thought or image in your mind urging you to get loaded. The acronym B-E-A-S-T stands for: Boozing opportunity; Enemy voice recognition; Accuse the voice of malice; Self-control and self-worth reminders; Treasure your sobriety -- a lot is at stake. Now, there is more to AVRT than just an acronym and a role-playing game. It is still, nonetheless, a head game that you play with yourself to restructure how you see yourself; how you see drugs and alcohol, and how you see what role drugs and alcohol play in your life.

In Rational Recovery, you don't need to take this model literally in order to work with it. You can think of the Beast as a literal section of your brain, as a brain function, or simply as a role-playing game.

The goal of AVRT is twofold: (1) Become aware of your self-talk -- especially as you advocate the use of drugs or alcohol in your mind. This is the "recognition" part of Addictive Voice Recognition Technique. Start to recognize the thoughts, imagery, and sensations that begin the urge cycle, and nip them in the bud before they grow into a full-blown craving. AVRT is a game of "Gotcha!" If the thoughts are extremely powerful, slap your thigh real hard and shout "No!" or "Stop!" -- two very ancient words in your memory. Probably two of the first five or six words you learned as a baby. Shouting these words will reach deep down into your mind.

The other part of the AVRT goal is (2) to dissociate yourself (the "real" you) from the part of you that is advocating "self-medication" (or whatever lame excuse works the best or is floating around in your brain at the moment). The voice will say, "I need a drink!" Add a "t" to the "I" and tell the voice the truth: "IT wants a drink; I'm fine, thank you!" Then the voice may start saying, "Let's get loaded!" You say to the voice, "Are you trying to say, 'let US'? What is this 'US' business?"

You see, I filled out that Advantages/Disadvantages chart (a Cost/Benefit Analysis, if you're a business type) and it came up an absolute no-brainer. I've already decided that getting loaded is definitely out. But this voice keeps pestering me about getting some more drugs. Even though it is me thinking these ideas (it's my brain, isn't it?) , they are not really my ideas because the ideas are not in my best interest.

It's me, but it's not ME. See the difference? If you can see that the urges and thoughts are coming from a very small, simple part of your mind, you can use your rational mind (your "self") to override your appetites. In time, both "I" and "it" will understand who is boss: "Me" -- not "it." Remember, the arm muscles are controlled to the self -- "Me" -- not the appetite center. "It" must appeal to me in order to have its way with me. It does this by enticing me with a promise of pleasure and by threatening me with impending pain. "It" is also more likely to get its way if "I" think that "its" ideas are really "My" ideas.