View Full Version : "The Four Steps, Plus One" -Gabor Mate M.D.

04-14-14, 02:28 PM

"The Four Steps, Plus One"

This chapter outlines a specific method that I view as promising for behavioural addictions--for example, shopping, gambling and eating compulsions--for

anyone wishing to disengage from maladaptive habits of thinking or acting.

Its other value is that it sheds further light on the nature of the addicted brain and mind.

These steps are not a comprehensive treatment for addiction, but can serve as an adjunct to Twelve-Step programs or to the approaches recommended in the

preceding and following chapters.

They will not work if done mechanically, but require regular practice with conscious awareness.

The ability of conscious attention to transform the automatic mind and its physiology substrates in the brain has been successfully applied at UCLA to the

treatment of obsessive-compulsive disorder.

As we have noted, OCD has a similarity to addiction in the driven nature of its behaviours.

They are both impulse-control disorders.

Deeper that that they are both based in anxiety.

The person with OCD believes that something catastrophic may happen if she doesn't perform a particular activity a precise number of times and in a particular way.

The addict's behaviour or substance use is also meant to calm anxiety--an unease about life itself, or about a sense of insufficient self.

And, we recall, OCD and addiction seem to share the phenomenon Dr.Jeffery Schwartz has described as "brain lock"--the stuck neurological gears that cause

thought to be acted out before the action can be stopped, because the brain's transmission mechanism cannot be put into "neutral".

When the obsessive or addictive thought occurs, obsessive or addictive action follows.

There are further parallels on the biochemical level, with disturbances in neurotransmitter systems involving serotonin, for example.

The method Dr.Schwartz and his colleagues have developed applies conscious attention in a systematic, four-step fashion.

On brain scans they have shown that the locked circuitry of OCD undergoes a change after a relatively brief period of consistent and disciplined practice by

obsessive-compulsive patients.

The demonstrate "brain lock" opens up, and the person is freed from the nonsensical thoughts that formerly compelled her behaviour.

Can the same four steps be applied to addiction?

"I haven't worked extensively with addictions," Dr. Schwartz told me, "but given that addiction also involves problems with intrusive urges and repetitive behaviours,

there is good reason to think that the four steps could be useful in its treatment."

What follows, then, with Dr.Schwartz's kind permission, is my adaptation of the four steps to the healing of addiction.*

There is no clinical evidence to support this specific application, but there are excellent theoretical grounds for anticipating its value.

The method is consistent with tradition Twelve-Step approaches, although it is not intended to replace them.

Addiction physicians elsewhere have also expressed interest in adapting this technique to their work.

If a personal testimony is of interest, I'm glad to offer mine: it has made a difference for me.


The program devised at the UCLA School of Medicine for the treatment of OCD is formally called the Four-Step Self-Treatment Method.

*The UCLA four-step method is detailed in Dr.Schwartz's first book, Brain Lock.

This slim volume, meant for the general reader, deals with OCD, but it does contain the suggestion that its recommendations may also be used in conditions

characterized by the addiction process, including overeating, sexual addiction, pathological gambling and substance abuse.

Needless to stay, it depends on a high level of motivation for its success.

As I pointed out earlier, motivation is generally higher in the case of OCD, where, unlike in addiction, the patient's experience of her symptoms is intrinsically unpleasant.

For the substance or behaviour addict there is at least an initial promise of delight that flows from the activation of the brain's incentive-motivation and

attachment-reward circuits.

The suffering is delayed, rather than immediate.

There is no bypassing the first step suggested at the end of the previous chapter--that is, before we can usefully apply UCLA's four steps, we have to take the

First Step of acknowledging the full impact of the addiction, and we have to resolve to confront its power over our mind.

The Four-Step program is based on the perspective that makes the best sense of disorders like OCD and addiction: that they are rooted in malfunctioning

brain circuits and in implicit stories and beliefs that do not match reality.

That, as we have seen, is the core problem in addiction because the development of the brain and the mind was negatively affected by adverse early circumstances.

The first two steps place the maladaptive behaviours in their proper context of brain dysfunction.

The third directs the brain to a more positive focus.

With the time and mental space granted by the first three, the fourth step then reminds the addict of what motivates her to get over her habit.

To support that process, I've added a fifth step that I have found helpful.

The four steps should be practiced daily at least once, but also whenever an addictive impulse pulls you so strongly that you are tempted to act it out.

Find a place to sit and write--preferably a quiet place--but even a bus stop will do if that's where you happen to be when the addictive urge arises.

You'll want to keep a journal of this process, so carrying a small notebook with you is an excellent aid.

A warning about possible pitfalls.

I have a tendency, typical in ADD, of beginning projects with enthusiasm and a sense of commitment, only to abandon them after some lapse or failure.

"I've tried that," I'll then say, "but it doesn't work for me."

That attitude is also typical of self-recovery practices in addiction, since, by definition, addiction is characterized by relapses.

I have to get that there is no "it" to work or not work.

"It" doesn't have to work.

I am the one who has to work.

And what is commitment?

Commitment is sticking with something not because "it works" or because I enjoy it, but because I have an intention that overrides momentary feelings or opinions.

So, too with the Four-Step program.

You don't have to feel or believe that it's working for you: you just have to do it and to understand that if you have lapsed, it doesn't mean that you have failed.

It's an opportunity to begin anew.

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 353-356.

04-14-14, 02:31 PM

Step I: Re-label

In Step I you label the addictive thought or urge exactly for what it is, not mistaking it for reality.

I may feel, for example, that I must leave off whatever I'm doing right now and go to the classical music store.

The feeling takes on the quality of a need, of an imperative that must immediately be satisfied.

Another person will say that she needs to have a chocolate bar immediately or needs to do this or that, depending on the object of the addiction.

When we re-label, we give up the language of need.

I say to myself: "I don't need to purchase anything now or to eat anything now; I'm only having an obsessive thought that I have such a need.

It's not a real, objective need but a false belief.

I may have a feeling of urgency, but there is actually nothing urgent going on"

Essential to the first step, as to all the steps, is conscious awareness.

It is conscious intention and attention, not just just rote repetition that will result in beneficial changes to brain patterns, thoughts and behaviours.

Be fully aware of the sense of urgency that attends the impulse and keep labelling it as a manifestation of addiction, rather than any reality that you must act upon.

"In Re-labelling," writes Dr.Schwartz, "you bring into play the Impartial Spectator, a concept that Adam Smith used as the central feature

of his book The Theory of Moral Sentiments.

He defined the Impartial Spectator as the capacity to stand outside yourself and watch yourself in action, which is essentially the same mental action as the

ancient Buddhist concept of mindful awareness."(*1)

The point of re-labelling is not to make the addictive urge disappear--it's not going to, at least not for a long time, since it was wired into the brain long ago.

It is strengthened every time you give in to it and everytime you try to suppress it forcibly.

The point is to observe it with conscious attention without assigning the habitual meaning to it.

It is no longer a "need", only a dysfunctional thought.

Rest assured, the urge will come back--and again you will re-label it with determination and mindful awareness.

"Conscious attention must be paid," Jeffery Schwartz emphasizes.

"Therein lies the key.

Physical changes in the brain depend for their creation on a mental state in the mind--the state called attention.

Paying attention matters."(*2)

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 356-357.

04-14-14, 02:32 PM

Step 2: Re-attribute

"In Re-attribute you learn to place the blame squarely on your brain.

This is my brain sending me a false message." (*3)

This step is designed to assign the re-labelled addictive urge to its proper source.

In Step 1 you recognize that the compulsion to engage in the addictive behaviour does not express a real need or anything that "must" happen; it's only a belief.

In Step 2 you state very clearly where that urge originated: in neurological circuits that were programmed into your brain long ago, when you were a child.

It represents a dopamine or endorphin "hunger" on the part of brain systems that, early in your life, lacked the necessary conditions for their full development.

It also represents emotional needs that went unsatisfied

Re-attribution is directly linked with compassionate curiosity toward the self.

Instead of blaming yourself for having addictive thoughts or desires, you calmly ask why these desires have exercised such a powerful hold over you.

"Because they are deeply ingrained in my brain and because they are easily triggered whenever I'm stressed or fatigued or unhappy or bored."

The addictive compulsion says nothing about you as a person.

It is not a moral failure or a character weakness; it is just the effect of circumstances over which you had no control.

What you do have some control over is how you respond to the compulsion in the present.

You were not responsible for the stressful circumstances that shaped your brain and worldview, but you can take responsibility now.

Re-attribution helps you put addictive drive into perspective: it's no more significant than, say, a momentary ringing in your ear.

Just as there is no "bell" that causes the ringing, so there is no real need that the addictive urge will satisfy.

It is only a thought, an attitude, a belief, a feeling arising from an automatic brain mechanism.

You can observe it consciously, with attention.

And you can let it go.

There are better sources of dopamine or endorphins in the world, and more satisfying ways to have your needs for vitality and intimacy met.

Once more, don't allow yourself to be frustrated when what you have let go returns.

It will--probably soon.

When it does, you will re-label it and re-attribute it: "Hello, old brain circuits," you say.

"I see you're still active.

Well, so am I."

If you change how you respond to those old circuits, you will eventually weaken them.

They will persist for a long time--perhaps even all your life, but only as shadows of themselves.

They will no longer have the weight, the gravitational pull or the appeal they once boasted.

You will no longer be their marionette.

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 357-358.

04-14-14, 02:33 PM

Step 3: Re-focus

In the Re-focus step you buy yourself time.

Although the compulsion to open the bag of cookies or turn on the TV or drive to the store or the casino is powerful, its shelf life is not permanent.

Being a mind-phantom, it will pass, and you have to give it time to pass.

The key principle here, as Dr. Schwartz points out, is this: "It's not how you feel that counts; it's what you do"

Rather than engage in the addictive activity, find something else to do.

Your initial goal is modest: buy yourself just fifteen minutes.

Choose something that you enjoy and that will keep you active: preferably something healthy and creative, but anything that will please you

without causing greater harm.

Instead of giving in to the siren call of addiction, go for a walk.

If you "need" to drive to the casino, turn on the T.V.

If you "need" need to watch television, put on some music.

If you "need" to buy music, get on your exercise bike.

Whatever gets you through the night--or at least through the next fifteen minutes.

"Early in therapy," advises Jeffrey Schwartz, "physical activity seems to be especially helpful.

But the important thing is that whatever activity you choose, it must be something you enjoy doing."(*4)

The purpose of Re-focus is to teach your brain that it doesn't have to obey the addictive call.

It can exercise the "free won't."

It can choose something else.

Perhaps in the beginning you can't even hold out for fifteen minutes--fine.

Make it five, and record it in a journal as a success.

Next time, try for six minutes, or sixteen.

This is not a hundred-metre dash but a solo marathon you are training for.

Success will come in increments.

As you perform the alternative activity, stay aware of what you are doing.

You are doing something difficult.

No matter how simple it may seem to others who do not have to live with your particular brain, you know that holding out for even

a short period of time is an achievement.

You are teaching your old brain new tricks.

Unlike the case with old dog's, no one can tell you it can't be done.

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 358-359.

04-14-14, 02:34 PM

Step 4: Re-value

This step should really be called De-value.

Its purpose is to help you drive into your own thick skull just what has been the real impact of the addictive urge in your life: disaster.

You know this already, and that is why you are engaged in these four steps.

It's because of the negative impact that you've taken yourself by the scruff of the neck and delayed acting on the impulse while you've re-labelled

and re-attributed it and while you have re-focused on some healthier activity.

In this Re-value step you will remind your-self why you've gone to all this trouble.

The more clearly you see how things are, the more liberated you will be.

We know that the addicted brain assigns a falsely high value to the addictive object, substance, substance or behaviour,

the process called salience attribution.

The addicted mind has been fooled into making the object of your addiction the highest priority.

Addiction has moved in and taken over your attachment-reward and incentive-motivation circuits.

Where love and vitality should be, addiction roosts.

The distored brain circuits, including the orbitofrontal cortex, are making you believe that experiences that can come authentically only from genuine intimacy,

creativity or honest endeavour will be yours for the taking through addiction.

In the Re-value step you de-value the false gold.

You assign to it its proper worth: less than nothing.

What has this addictive urge done for me? you will ask.

It has caused me to spend money heedlessly or to stuff myself when I wasn't hungry or to be absent from the ones I love or to expend my energies

on activities I later regretted.

It has wasted my time.

It has led me to lie and to cheat and to pretend--first to myself and then to everyone close to me.

It has left me feeling ashamed and isolated.

It promised joy and delivered bitterness.

Such has been its real value to me; such has been the effect of my allowing some disordered brain circuits to run my life.

The real "value" of my addictive compulsion has been that it has caused me to betray my true values and disregard my true goals.

Be conscious as you write out this fourth step--and do write it out, several times a day if necessary.

Be specific: What has been the value of the urge in your relationship with your wife? your husband? your partner, your best friend, your children, your boss,

your employees, your co-workers?

What happened yesterday when you allowed the urge to rule you?

What happened last week?

What will happen today?

Pay close attention to what you feel when you recall these events and when you forsee what's ahead if you persist in permitting the compulsion to overpower you.

Be aware. That awareness will be your guardian.

Do all this without judging yourself.

You are gathering information, not conducting a criminal trial against yourself.

Jesus said: "If you bring forth what is within you, what you will have will save you." (-The Gospel of Thomas)

That is true in so many ways.

Within you is knowledge of the real value of the impulses you have obeyed until now.

To quote and paraphrase Dr. Schwartz, the more consciously and actively you come to re-value the addictive drive in light of its pernicious influence on your

life, " the more quickly and smoothly you can perform the Re-label, Re-attribute and Re-focus steps and the more steadily your brain's 'automatic transmission'

function returns.

Re-valuing helps you shift the behavioral gears!"(*5)

Dr. Schwartz introduces what he calls the two A's: Anticipate and Accept.

To anticipate is to know that the compulsive drive to engage in addictive behaviour will return.

There is no final victory--every moment the urge is turned away is a triumph.

What is certain is that with time the addictive drive will be drained of energy if you continue to apply the four steps and also take care of the internal and external

environments in the ways suggested in these chapters.

If there are times when it reappears with new force, there is no reason to be disappointed or shocked by that.

And accept that the addiction exists not because of yourself, but in spite of yourself.

You did not come into life asking to be programmed this way.

It's not personal to you--millions of others with similar experiences have developed the same mechanisms.

What is personal to you is how you respond to it in the present.

Keep close to your impartial observer.

I take the liberty of suggesting a fifth step to be added to the Four-Step Self-Treatment Method, at least in the context of addiction.

I call it Re-create.

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 359-361.

04-14-14, 02:34 PM

Step 5: Re-create

Life, until now, has created you.

You've been acting according to ingrained mechanisms wired into your brain before you had a choice in the matter, and it's out of those automatic mechanisms that

you've created the life you now have.

It is time to re-create: to choose a different life.

You have values.

You have passions.

You have intention, talent, capability.

In your heart their is love, and you want to connect that with love in the world, in the universe.

As you re-label, re-attribute, re-focus and re-value, you are releasing patterns that have held you and that you have held on to.

In place of a life blighted by your addictive need for acquisition, self-soothing, admiration, oblivion, meaningless activity, what is the life you really want?

What do you choose to create?

Consider, too, what activities you can engage in to express the universal human need to be creative.

Mindfully honouring our creativity helps us transcend the feeling of deficient emptiness that drives addiciton.

Not to express our creative needs is itself a source of stress.

I permit myself here to quote from the final pages of When the Body Says No, my book on illness, stress and mind-body unity:

For many years after becoming a doctor I was too caught up in my workaholism to pay attention to myself or to my deepest urges.

In the rare moments I permitted any stillness, I noted a small fluttering at the pit of my belly, a barely perceptible disturbance.

The faint whisper of a word would sound in my head: writting.

At first I could not say whether it was heartburn or inspiration.

The more I listened, the louder the message became: I need to write, to express myself through written language not only so that others might hear me but

so that I could hear myself.

The gods, we are taught, created humankind in their own image.

Everyone has an urge to create.

Its expression may flow through many channels: through writing, art or music or through the inventiveness of work or in any number of ways unique to all of us,

whether it be cooking, gardening or the art of social discourse.

The point is to honour the urge.

To do so is healing for ourselves and for others; not to do so deadens our bodies and our spirits.

When I did not write, I suffocated in silence.

"What is in us must out," wrote the great Canadian stress researcher, Dr. Hans Selye, "otherwise we may explode at the wrong places or become

hopelessly hemmed in by frustrations.

The great art is to express our vitality through the particular channels and at the particular speed Nature foresaw for us."

Write down your values and intentions and, one more time, do it with conscious awareness.

Envision yourself living with integrity, creative and present, being able to look people in the eye with compassion for them--and for yourself.

The road to hell is not paved with good intentions.

It is paved with lack of intention.


Are you afraid you will stumble?

Of course you will: that's called being a human being.

And then you will take the four steps--plus one--again.

-Gabor Mate M.D., "In The Realm Of Hungry Ghosts", (The Four Steps, Plus One), Page 361-362.