The talk I gave in Amsterdam had the title, “A Brain Disease or What?” This post is about the or what? But in attempting to define addiction, I come up with three words, rather than one:
Habit
Relationship
Narrative
…and these words have to work together to explain what addiction is.
The idea that addiction is a deeply ingrained habit is relatively simple — at first. In fact that is the default definition generally posed against the disease definition. And habit is no stranger to the mind or the brain. We don’t reinvent our perceptions and 
conceptions; we refine and consolidate them over time. And the brain works by creating circuits which are fundamentally self-reinforcing. It doesn’t seem much of a stretch to see addiction as a habit of seeking an expected reward and going through various motions to obtain it. It’s just that, with high motivation and endless repetition, this habit is deeply ingrained.
But many also see addiction as a relationship, for example between you and your drug, your beer, or your porn collection. That’s almost correct. Except that addiction isn’t a real relationship because it doesn’t consist of two interacting partners. The drug doesn’t adjust to you. You adjust to it. And adjust and adjust until the supposed relationship, in your mind, is locked in. So I’d say that addiction is the concept of a relationship.
That’s not special in itself. The study of child-parent relationships in mainstream psychology has mostly fallen under the banner of attachment theory. Attachment theory is all about the child’s concept of the relationship with, let’s say, the mother. A 
secure attachment means the child expects the mother to be available when needed…emphasis on “expects.” An avoidant attachment means the child expects the mother to be unavailable. It’s not just mother’s behaviour that matters; attachment styles are predicated on child temperament as well as maternal behaviour. It’s children’s expectations that maintain their “attachment status” throughout life. An ambivalent or resistant attachment style means the child needs the mother excessively, expects disappointment, struggles against the need, and pushes away at the same time as pulling. Sound familiar? So if we think of addiction as a concept of a relationship (which I’ll call “relationship” in quotes), it seems to match an ambivalent/resistant attachment style. I want you, I need you, you’re not going to be there for me (about six hours later), you don’t help me enough, there’s no one else I can go to for the help I need.
Let’s put these first two elements, habit and “relationship,” together. “Relationships” are certainly habitual. They build on themselves over time. Many teenage or even adult children continue to berate their parents for not paying enough attention to them or not understanding them or not giving them enough, whether the parent does everything or nothing to change this conceptualization. And habits are relational. My habit of brushing my teeth involves a relationship with my toothbrush, and my dentist. So far so good.
Then what about narrative, the third element of the triad? I’ve written a fair bit about this, especially in the last chapter of my second book on addiction. We are constantly telling ourselves who we are, what we’re like, where we’ve been, where we’re going, etc. The life narrative is very much like what we might call our identity. It is not our personality — our underlying nature — but the way we construe ourselves. I’ve argued that changing one’s narrative is a potent way to move beyond addiction. I act like this because, Omigod, I was really suffering and this was the only solution I could find. So I’m not just a piece of shit; I’m a desperate seeker. But I don’t want to be doing this, and I don’t have to be doing this, and the future is changeable even if the past isn’t. The magical thing about narrative, or story, is that it is told. It doesn’t stay inside; it’s communicated with others, who can help us to hear it, hold onto it, reflect on it…and change it. Changing the narrative allows us to focus on the “relationship” more clearly, and to refashion beliefs about what that relationship entails, especially, what to expect. And it can change our habits, first by unearthing them, exposing them to the light, and then by a determined effort to choose B rather then A in situations we recognize as pivotal.
It may be that our narrative sits on top of our “relationship” (with what we’re addicted to) which rests on a set of habits. A hierarchy? I can see currents of change — deep change, “recovery” — moving down the hierarchy, from narrative to “relationship” to habit, or possibly up the hierarchy. Maybe both directions at the same time.
But there’s something huge missing from this analysis, and that is the role of compulsion. We have to go all the way back to habits and think about them again. Some habits, maybe most habits, are unconscious, and they trigger thoughts and behaviours before we can say “stop!” Compulsion is, for some, the defining feature of addiction. Next post, I’m going to look at how compulsion works and what to do about it.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
You leave me with a very valuable thought Marc, as usual. The intersection between a habit and compulsion is, in my believe, the core of the issue of substance abuse. A habit can be changed, almost always easily at free will, sometimes with quite an effort. I habitually drive a certain route to work every day, but one fine morning I decide to take a completely different route and enjoy it. One day I start sleeping on the other side of the bed. I have my first child and decide that my juvenile partying is over. Compulsion is a very different thing. It is a play when I cannot change my partying ways even though I have become a parent. My case: For many years I suspected that I shouldn’t drink alcohol, I occasionally drank to excess, sometimes to oblivion. It was only when I experienced for the first time, after having taking the decision NOT to buy alcohol on my way home from work but turning the car nevertheless into the parking lot of a liquor store almost in an unconscious daze, that I realized I was an alcoholic. Always looking forward to your blogs – and waiting for the recording of your talk with Nora Volkov.
Hi Marc
Yes! How do I become a complete, happy human being. There is an incorporation of all these elements you mention…to make us feel in control, connected and safe enough to “announce over and over our place in the family of things,” to paraphrase Mary Oliver’s poetic analogy about wild geese. This habit of mind…and body…and relationship is much more complicated than a simple hierarchy. If that were the case, the choice to change our ingrained habitual behaviors would be as simple as deciding what I want for breakfast. I may not be happy with it, but I have to eat and have a limited number of options to choose from. Our inner narrative, the legacy of outcomes of our choices strains logical decision making between the passion of the body, the rationality of our conscience, and our needs for survival. All these elements get thrown into the tumbler of time, shaken and rolled out into our next experience– and add to our “unique” narrative. A narrative that doesn’t exist without other characters… elements in relation to one another that make a story, a life.
On NPR last night I heard that Britain has appointed a new Minister of Loneliness… recognizing the devastating effect loneliness has on the human psyche and body. Disconnection and isolation are bad for humans, and loneliness may be the biggest driver of addiction. Recovery is about reconnection… with other humans and ourselves, not things or activities as proxies for human connection, connection to who we really are.
Great article. I have been sober for about a year and a half. My brain still craves anything ferociously. It can be hand soap with alcohol in it, coke, pills, opiates. I was only hooked on opiates but it is screaming for something else starting to worry me. Why does it keep craving almost two years after sobriety? I don’t know what to do.
Cole, craving is hell. It’s the voice of the addiction calling. You could try objectifying it by calling it in the third person: “There’s Cole’s addiction calling”.
Recognizing it for what it is can provide a little distance and prevent your identifying with it. It takes a while for the brain to reconfigure itself. Best wishes.
It sucks man. It makes me feel something is wrong with me and addiction is a disease because other people don’t have to deal with this.
It doesn’t matter if it is or isn’t. Don’t fight the craving; recognize it for what it is, tell it to go fuck itself, and go get a milkshake – seriously.
Thanks man. I’m not going to fight or give in. It’s just like I’m craving anything and I was only addicted to one thing. The cravings are incredibly strong too and stay with me for hours at a time. But I will be ok. I have been dealing with them a while. It’s just like scary because they come on without warning and I have no control.
Hey Cole, cravings do suck and they are scary, especially as them come on without warning, as you say. You may have no control over that, but you DO have control over how you respond to the cravings. You gotta remember this! It is within your control to go have a milkshake, or go for some exercise, or jump up and down and beat the shit out of it in your imagination. Whatever works.
I think this can work really well. Reframe one’s perspective on the addiction, objectify it, and redirect self-hatred and anger at the addiction itself. In the short term, redirect that negative energy toward the positive goal of stopping, and distract yourself. My problem at the end was that I was just beating the shit out of myself with the behavior, and telling my addiction to f—k off was just amplifying my own self-hatred. I needed to substitute something positive I wanted to attain as my motivation, something that the addiction made impossible. I know it’s all a matter of perspective, what we believe will work for us. But this whole enterprise is about shifting our perspective from desire, from wanting…to aspiration of wanting to be a better person and find my place in the world…what I’m supposed to be doing.
Listen to Nicolas…it takes practice, just like it took practice to get habituated. If you didn’t have any control you wouldn’t be able to stop yourself. Just don’t give up, keep going and eventually the craving will quiet down. Reflect on how far you’ve come from where you’ve been. Progress is hard to measure in this endeavor, and just the fact that you are not going backwards IS progress.
Feel for you Cole. I experience something similar. I think what I seek is relief from longing.
For what its worth Cole; For me,coming to a REALISATION that my drug of choice was slowly killing me and I had to make a life and death choice was easy.I knew the different seasons (spring summer autumn winter) would bring it’s challenges as I adapted to a fresh start without drugs. At the end of the 2nd year I was over that toxic addiction.During that time I MADE A STRONG EFFORT to eat healthy, exercise, rest and sleep and quiet moments. That’s ongoing and gets easier as my body and brain become HEALTHIER and more in SYNC with each other. I allow myself treats as rewards for my progress. All that wasted addiction time is now available for me and others.I sought as much help and advise I could find and grateful for sights like this to help me fine tune my growth. It will happen ! !
It’s 5 years ago for me Cole so forgot to mention that I took great pleasure in telling my imaginary GOLLUM (lord of the ring) to F… OFF if my thoughts drifted to my addiction as happened in the early days of my turn around. It used to make me laugh in that serious moment and reminded me to shift my thoughts to something else.I had that GOTCHA moment and felt good about it. It worked for me and 5 years clean. Just not an issue anymore after many decades of addiction
The more I think about addiction, the more I’m inclined to look at it as a dissociative state that can have a looser or tighter grip on the behavior, tightening as it progresses.
Really enjoyed this Marc, always seeking to find different opinions in this field. I get the habit part so much. Using an example like biting my nails, im not addicted to biting my nails but i find myself driving on a long distance trip and im digging into an already painful nail. i realize what im doing and say to myself, stop now before it starts to bleed. Success, while im actively thinking about it that is.
Moments pass, deep in thought listening to some music and my finger is in my mouth again. this happens 6 or 7 times throughout this leg of the journey and it almost seems like unless im present and thinking about not biting my nails, they are in my mouth getting munched.
If i look at this example multiply it by 1000 and throw in a physical consequences to opiates, i can see something different. Habits are potent.
The narrative frightens me because left to ones own devices….ill leave that up to the reader.
Looking forward to the next post on compulsion.
Thanks so much everyone for the kind words and advice. It’ scares me more than anything that a part of me wants to just use and use. Maybe it is so relentless because I plan on drinking moderately one day when I get this under control. Maybe the addict uses this to stay in a state of anticipation and stay on the surface of my thoughts. I don’t know. Maybe strict sobriety is the only way for me.
Hi Cole
Just a thought…
You sound like you have good intuitions and self-reflective capability. If I’m telling myself that someday I will be able to control a presently uncontrollable compulsion, would you think I might be fooling myself? The only way I will be able to moderate a behavior is if I can stop it at will under any circumstances. That takes a lot of time deflecting and redirecting the compulsion. When you have enough time staying stopped so that you can take it or leave it, then you might reconsider your ability to moderate. When most people get to that point, they recognize it is not worth it, nor are the potential consequences of relapse. The other question you should ask yourself is what does it mean to me to be able to truly moderate? If I can’t realistically imagine delimiting my behavior to one drink at a party, then moderation may be more trouble than it’s worth.
Matt Thank you for your response. I understand what you are staying and it seems to be very spot on. I am starting to realize it is not worth it. My drug of choice were opiates not alcohol. I use to want to try and moderate my opiate use until I realized I couldn’t. Now I am struggling with the thought of trying to moderate drinking on occasions. I have had a few drinks over the past year with success. Setting a limit at two or three drinks and not have any problem. The problem happens a few weeks or month later when I get these damn urges and feelings to get high on anything. So I don’t know. I guess time will tell. The thing that gets me is certain foods and cigarettes are addictive. I smoke on occasion and have been for years. I don’t have a problem with that. I don’t know. Its a learning process. I am trying to figure this addiction thing out.
You’re paying attention and thinking about it, that’s the important thing. It is a learning process, just as addiction is a learning process…a deep learning process as Marc says. You can’t unlearn it, but you can learn new habits to replace it.
I guess it will always be a part of me huh? I don’t attend AA meetings but the one I did they said a pickle cannot go back to being a cucumber. I guess its like that.
I guess it’s like that, although I always found that a somewhat facile metaphor. Neuroplasticity is much more complex, and so is life and habit formation. I would never say it can’t be done, but wouldn’t you rather be putting the huge amount of effort and risk it would take into something more important to you?
I don’t know. Maybe I need to go talk to someone. My whole thing with being able to moderate with alcohol is to prove to myself I am like others who can moderate and drink normally. But I guess Im not. Those people do not wake up at 2:00AM craving drugs and punching the wall because of not being able to act upon these cravings. I just feel stuck and these thoughts of using and relapsing don’t help.
That’s probably what I felt most when I was deep into my addictive behavior….stuck… I wasn’t falling back but wasn’t going forward either. I felt like I was in a hamster wheel spinning in one place not getting anywhere. Perhaps you should go talk with someone, maybe ask about medication for urges (like naltrexone), explore some mindfulness techniques and meditation… There are many techniques, but talking to someone who understands addiction would be a good start…
Good luck, Cole. Never give up! That’s the most important thing…
Thanks man. I will not give up. Just a rough week/month.
I’m finding this pyramid very exciting. The compulsion part of addiction is a bitch and I cant wait to hear your thoughts on it Marc.
Marc, you are the man.
Marc, this is awesome, don’t stop thinking and writing (although if you’re anything like me, stopping thinking is not an option, anyway). I love this definition of (complex or multi-dimensional) addictive-habit formation. The habit is undeniable. The idea that it is relational honors the emotional attachment piece perfectly. But the narrative angle is novel and great as well as it describes the importance and depth of personal identification. Both in staying mired within additive patterns as well as using it to tell a personal story of redemption and recovery (this is the strength and the debilitating weakness of the 12-step approach, I think). Maybe the compulsion piece is part of the larger umbrella discussion of habit?
So how do we change when we really -really want to do something? What accounts for spontaneous change? Why do we struggle so mightily?
One has to reach down and decide on a new direction. That means a new narrative has to be absorbed. A new “You” has to be followed-and that’s pretty scary to folks. It sometimes means getting new friends and a new lifestyle (ouch!). Sometimes huge-sometimes not huge but -there will be change. Let’s face it-sometimes change doesn’t work.
*(Maybe) Compulsion comes from a network of learned checks, behaviors and balances that keep us functioning. Throw a wrench into the spokes (second DUI) and maybe were afraid we can’t get a whole new whole path paved again. Compulsion can be good (going to work every day) and it can be just as bad. Question is why-when it’s obviously so bad for us-do we continue doing a behavior. It’s going to be different for all of us. I think Mate makes a good case that many of us have a brain that is predisposed to addiction. Factor in all the influences-, psychology, culture, poverty, ignorance, biology and genetics and you get a fear to change which in turn drives a compulsion to stay the course. Then the more you buy into your path-the deeper it is learned and-the harder it is to change. I’m starting to sound like George Koob.
I remember when I first learned about Stanton Peale-It was a lightbulb moment for me. I think he got the ball rolling for me because he brought a sense of legitimacy to the table and he provided the drop of confidence I needed to fend off my thoughts that said “Carl –Give up! You’re an alcoholic!” But he also started a chain reaction in me that said “I can do this-I can change!” I changed using my own motivators.
One must find their own Peale. We must be willing to listen to that small voice in all of our voices that says we can change and it’s worth it. Why can’t this be easier??
Why can’t this be easier??……
“Changing the narrative allows us to focus on the “relationship” more clearly, and to refashion beliefs about what that relationship entails, especially, what to expect. And it can change our habits, first by unearthing them, exposing them to the light, and then by a determined effort to choose B rather then A in situations we recognize as pivotal.”
So addiction is a symptom of powerlessness/attachment deficit. in order to change the habit and our relationship to it-we need to expose it and re-create a more effctive narrative.
And when i said I sound like George Koob -I guess I should have said Marc Lewis- in my last post.
One question I frequently ask myself and often challenge others to confront is …
“Just what is it that we’re really medicating”?
I find it useful in addressing all manner of compensatory behavior but only if one truly
has the courage to seek our truth hidden from our view within.
Hi Marc!
Over the last ten years, the United States holds a record for the highest number of most common health problems that can be traced to the rise in drug and substance abuse. There are several factors that are linked to drug addiction. Individuals who grow up with parents who are drug users in an inattentive environment are more likely to engage in drugs at an early age. Garnier and Stein (2002) contend that “parents may effectively establish drug use behaviors, reduce children’s internal restraints of drug use, and, through positive attitudes toward drug use, encourage adolescents to seek affiliations with peers who similarly use drugs” (p. 46). According to Spanagel et al. (2010) there is a long-standing acceptance that there is a “genetic component of vulnerability to addiction” (p. 317). Duncan (2012) took it further explaining that certain psychiatric disorders could trigger a “genetic predisposition” that increases the chances of an individual to abuse drugs (p. 7). Peer pressure is also a common factor of drug abuse, mostly among adolescents who experiment with drugs. There are many social ills associated with drug abuse, such as, cases of homelessness, domestic violence, school dropouts, criminal activities, and incarceration. Unfortunately, cases of incarceration have increased due to use of both illicit and prescription drugs. Many criminal activities are directly linked to substance abuse. Offenders who have had an addiction problem commonly resume to their old ways since imprisonment did not provide proper rehabilitation services.
Most cases of addiction cannot be overcome alone. Drug and substance abuse programs must be set up and available to those seeking treatment. Both drug and substance abuse can be curbed through offering guidance and counseling sessions, treatment and rehabilitation, creating awareness and advocacy programs, and possibly through decriminalization. Hard work, continuous support, and good treatment programs are important ways of reducing addiction within the United States.
References
Duncan, J. R. (2012). Current perspectives on the neurobiology of drug addiction: a focus on genetics and factors regulating gene expression. ISRN Neurology, 2012. doi:10.5402/2012/972607
Garnier, H. E., & Stein, J. A. (2002). An 18-year model of family and peer effects on adolescent alcohol and other drug use outcomes. Journal of Nursing Scholarship, 44(1), 36-44.
Spanagel, R., Bartsch, D., Brors, B., Dahmen, N., Deussing, J., Eils, R.,…Zimmer, A. (2010). An integrated genome research network for studying the genetics of alcohol addiction. Addiction Biology, 15(4), 369-379. doi:10.1111/j.1369-1600.2010.00276.x
Hello Damon,
Intersting information here. And I love that you are advocating for those that are seeking help to get treatment. But with all your stats, I’m surprised that you didn’t find all the ones that point to the fact that about 75% of those in addiction find their way out all by themselves, without any professional help, to include that of AA. So most cases of addiction actually do find their way out.
I fully echo your main point, in that those few that don’t do it on their own or those that haven’t found their own way out, do indeed deserve to only availability to treatment … but “real” treatment. As you point out, solid treatment is needed to help those that are currently ‘stuck’. However, if your area is anything like mine; “real treatment” consists of doctors of over medicate at MAT programs, or simple rehabs which are just glorified detox centers. The closed real treatment program I know of is a few hundred miles away and costs more than I can afford lol.
Thanks for sharing!
Hi Chad. I have often cited the statistics showing that most people recover. In fact it’s sort of a recurring theme for me. It’s just that here I focused on the other side of the coin. I agree that MAT is very limited in what it tries to accomplish and what it succeeds in accomplishing. But it does save lives and helps keep people from sinking into serious despair. So, for that, I think it should be valued.
How about something much simpler that covers everything.
People in chronic pain chronically take pain relievers.
In the US quite a lot of that pain is PTSD from child abuse.
Dr. Lonny Shavelson found that 70% of female heroin addicts had been sexually assaulted in childhood.
Damon Bazil March 1, 2018 at 2:46 pm
Of course it is intergenerational. PTSD is in part genetic.
Hello Marc!
Finally a breath of fresh air, a friendly ship in the storm! I’m was beginning to think I was the only one who didn’t think addiction was a disease lol! I’m surrounded in the bible belt by die hard 12-steppers … addiction is a disease, period.
Anyway, I’ll be following to see what else you bring to the table and I look forward to learning anything and everything I can from you!
Choose to have a wonderful day!
I thought it was interesting how your relationship between you and your addiction isn’t a real relationship because it doesn’t consist of two interacting partners. My sister is addicted to alcohol, and I can see it starting to ruin her relationship with her family. I will talk to her about bringing her into addiction services to help her out.