Author: Marc

Hi again. I know I haven’t been posting much lately, but it’s time to get back on that horse. One thing I did in the interim was write a chapter for a volume on addiction. Which led to a strange conundrum…and some soul searching.

But before getting to that, I’ll tell you what inspired me to keep blogging for now. First, I opened Google Analytics and found that I’m still getting 200 hits per day…even after weeks with no new posts. People remain interested in our alternative and progressive approach to addiction. Wonderful! Second: I met Sandy P at my father’s memorial in California last week. And she told me she not only still exists but she follows my blog. Amazing. Sandy was my brother’s girlfriend, and Abbie, her next-door neighbour, was mine, when we were in our late teens. (When I was first getting into drugs, Abbie was my salvation. Until I took off for Asia: no Abbie, lots of drugs.) Thanks, Sandy, for a sweet hit of nostalgia.

Now about that chapter. I’ve had papers rejected by publications lots of times. It’s part of the rat race of being an academic, a researcher, submitting your best work to journals, waiting for the letter from the editor, finally getting that heart-stopping email and reading it and Oh Shit! They’re rejecting it?! Without even a “revise and resubmit!” Damn ignorant asshole editors. Too good for your shitty journal anyway… Then the anger and disappointment start to evaporate and you start thinking about what journal to send it to next. That’s the life of an academic. And that’s one reason I was glad to be done with it, and why, about eight months ago, I swore to myself I was done with academic writing.

But I caved. A colleague in Toronto, an addiction doctor, urged me to write a chapter for a book for addiction doctors, to spell out my learning model of addiction, and how it reconceptualizes the data on brain change in addiction, for the benefit of…well, addiction doctors. Because, even though they’re doctors, they don’t necessarily buy the disease model of addiction. At least they don’t necessarily buy all of it, or maybe they’re uncomfortable with it, or maybe, just maybe, the field is changing. (This particular doctor specializes in ACT for his patients.)

So I wrote the chapter. Took pieces from other work, revised them, wrote some new stuff, trying to make it accessible for all those doctors out there, because they don’t really understand human development very well and they sure don’t understand psychology very well. So, why not give them the benefit of my stratospheric perspective. (LOL) I spent a couple of weeks working pretty hard, sent it in, and soon heard back from the editor. Thank you for submitting your chapter for publication in “A prescriber’s guide to methadone and buprenorphine for opioid use disorder…” Which is when I said to myself, those ignorant editors! They got the wrong book. Or the wrong title. Or something. I can’t write a chapter that urges ditching the medical model for a damn prescriber’s guide!

As mentioned, I’ve had my work rejected by numerous publications. But this was the first time I rejected the publication. Even after I’d done all the work. Even when they said Yes, we want it! I wrote back and said, I’m sorry but I can’t contribute a chapter to a prescriber’s guide, or to anything called a prescriber’s guide. Because if the whole point of the book is to get a better handle on prescribing methadone and buprenorphine, then GO AHEAD AND CALL IT A DISEASE! Why not?

My colleague hadn’t told me that this “book for addiction doctors” would be entitled a prescriber’s guide to anything. Maybe he didn’t know. He emailed me after I withdrew my submission and said: Addiction doctors prescribe opioid substitutes to 95% of their opioid-addicted patients. Like: duh…didn’t I know that? Yes, I knew that, more or less. And I knew that opioid addicts are often in desperate need of opioid substitution therapy (OST). It helps them get off the street and sometimes stay off, it relieves the overwhelming anxiety of withdrawal, and it saves lives. As Maia Szalavitz often reports, it’s the only evidence-based treatment that saves lives. And of course that’s because heroin, especially when it’s laced with or replaced by fentanyl or its analogues, can be deadly.

So why would I avoid being featured in such a book? Maybe I should have just swallowed my whatever and revised the chapter. All those words distinguishing physiological dependency from addiction (which I maintain is a psychological process)…they would have to go. And so would that pep talk about listening to the person, not the diagnosis, and using your counselling skills, your human skills, to reach beyond just prescribing. I’d have to shelve all that. I fully advocate the use of methadone and Suboxone. I agree with other progressive addiction specialists (e.g., Mark Willenbring) that they should be easily available wherever they’re needed, free of cost, free of line-ups, free of stigma. But I’ve got nothing to contribute to that argument. Right?

Can we social-development-oriented “addiction specialists” refute the disease model and still advocate OST?

I told myself I’m trying go avoid an awkward irony: that there’s maybe one good reason to call addiction a disease. In the US and Canada it’s the only way to get addicts their medicine, their heroin substitutes. I’ve thought about this lots. But I remain concerned and confused. Maybe “medicalization” is the best we can do for people who are in a real jam, on the street or close to it, hunting for heroin day by day. Yet it maintains, in fact it strengthens, the premise that these people are sick, and it sidelines all the familial, social, economic, and cultural forces that pushed them into that lifestyle in the first place.

Somehow these two perspectives on opioid addiction have got to come together. At least in the present social climate. But I’m at a loss as to how to help that happen.

Or maybe it’s simple. Maybe we just need one or two catchphrases to merge these two approaches: phrases like “harm reduction,” or maybe “working with the individual where they’re at.” In my next post, I’ll tell you about a treatment program in New York City where that kind of conceptualization governs everything they do. I gave a talk there two weeks ago, met some fabulous people, and learned how the field is changing. Stay tuned.

 

 

 

 

 

 

 

 

 

 

We usually talk about addictions to substances (opiates, alcohol, whatever) or behaviours (gambling, porn, etc). But that misses the point. Addiction is entirely psychological, and I think it describes an attachment to a symbol that goes with the feeling provided by the substance or behaviour. The feeling and the symbol are coupled, bonded, and that’s a big part of what makes addiction so hard to beat.

Forget about “physical” addiction for now. I mean the withdrawal symptoms you get when you quit opiates. That’s not addiction; it’s chemical dependency. You also get withdrawal symptoms going off antidepressants or blood-pressure meds. And you don’t get any withdrawal symptoms quitting coke, meth, alcohol (unless you drink a huge amount) or, obviously, porn, sex, overeating, etc. You get psychological rebound, sure, but that’s not the same thing. It surprises me that people continue to confuse these different (but often overlapping) phenomena.

Once we see that addiction is purely psychological, we can break it down, and the categories most valued by psychologists are “cognition” (perceptions, thoughts, images) and “emotion” (feelings, urges, etc).

For some time now I’ve been thinking that the cognitive aspect of addiction is symbolic — entirely — it’s a representation of something. And the reason that symbol is so attractive, so strongly entrenched, is that it’s coupled with emotions like desire, excitement, pleasure, and relief (relief isn’t really an emotion; rather it’s the reduction of an emotion — generally anxiety). It is ALWAYS the case that cognitions and emotions hold each other in place. You think someone is blocking your goals, you feel anger: the anger highlights the image of this goal-blocking person, this shithead, and that image holds the anger in place. I’ve been writing about cognition-emotion coupling for decades….literally dozens of journal articles. But for now, let’s leave the academic abstractions behind and get down to lived experience.

With addiction, you think this thing, this substance (let’s say a few lines of coke) is valuable and special. And you feel the excitement of anticipation — soon I’m gonna have some. Then you feel the buzz, and doesn’t that feel great? Which strengthens the image, the conception, that coke is valuable and special. See how the thought/image and the feeling (both before and during) fuel each other? Which is why it’s so hard to say No thanks, not tonight.

So what does the addictive substance or act symbolize? To me, that’s the big question. The longer I practice psychotherapy with people in addiction, the more convinced I am that each person constructs his or her own scenario, vignette, drama, diorama — I don’t know what to call it — based on what went wrong or what went missing in childhood or adolescence. I introduced this idea last post, in terms of diving into the child self-narrative. Here I want to get into the details: what’s the narrative about?

Example: Helen says she can’t stop snorting coke. What does the coke mean to her? Through talking and remembering in therapy, we discovered that it means something similar to what cutting meant when she was about 12 years old. Her parents weren’t interested in her as a person. They wanted her to perform, be this charming, cute girl, be quiet and unobtrusive because Mom is trying to sleep — because she’s depressed, as usual. So they dismissed and scorned her spirited, creative, and needy self. Helen submitted to the good-girl role…and she was achingly lonely. But when she went into her closet and cut little red lines in her forearm, she felt free, she felt vital, she was unobserved, she didn’t need or seek permission, she felt defiant, and most of all she felt in control of her own feelings. That’s what the cutting meant to her then. And that’s almost exactly what coke means to her now, decades later. She scampers into the bathroom, leaving the other ladies chatting over wine or coffee, and does a couple of lines. Again, she’s on her own, released, free, defiant, and in control of what she’s feeling. Now take that symbolic scenario she’s created, and graft it onto the feeling of the anticipation and then the feeling of the rush itself. That cognition-emotion linkage has been reinforced thousands of times. It’s not going to go away easily.

Behavioural addictions like gambling and porn are no different. I’m the cocky guy who just might win big tonight, and won’t everyone be impressed. They’ll look at me with boundless envy and admiration (like they should have back in high school) as I strut down the corrdior with my armful of chips. Now couple that image with the sheer excitement of not knowing how the next hand will turn out. (That’s a big deal for gamblers.) The image and the feeling fuse — possibly forever.

By the way: the feelings of excitement, defiance, energy, etc, that I’ve described so far have everything to do with dopamine. Maia Szalavitz calls it the thrill of the hunt. And what’s going on at the brain level is this: your nucleus accumbens and amygdala are stoked up on dopamine, so their connections with “association cortex,” where memories converge into vignettes and fantasies, form deep ruts…and those connections get strengthened every single time they get reactivated.

A couple of my clients have combined drugs, sex or sexting, and/or porn into this incredibly artful (what else to call it?) ritual — a scenario in which they are desirable, desired, potent, free, and safe. The experience they’re addicted to is basically a fantasy of being both very good and very bad, nasty and safe at the same time — the dream fantasy of a child or young teenager. But here’s the thing: the components — the coke and the porn for example — are only valuable in how they contribute to this symbolic amalgam. What each offers, without that symbolic currency, is almost nothing at all.

I’ll end with one last example: my own. I recently developed a painful condition called sciatica, and I’ll probably need lumbar spine surgery in a couple of months to carve away the bone that’s squeezing my sciatic nerve. Don’t worry about me: this surgery is extremely low-risk and has very high success rates. I look forward to getting it done. But meanwhile the pain is…well…painful.

So I’ve got a prescription for some pretty powerful opioids. And as soon as I pop one or two, the whole symbolic vignette from my days of addiction returns. I get to make myself warm and safe, I get to be taken care of, like when I was sick as a child — come here, Mommy, I need you — and I get to control all that with these little objects — the pills — which are mine! (particularly handy if Mom isn’t feeling very connected). That symbolism is so much more powerful than the feeling the drug provides. Yet the drug does provide a feeling…a warmth in my stomach, a vague but familiar sense of pleasure. What I’m saying is that this feeling is pretty nice (though I know it will collapse into boredom soon enough), but its power lies in how it holds the symbolic scenario in place.

I’m not worried about becoming addicted again. I’ve had three surgeries in the last decade (I’m actually incredibly old and held together by screws and picture wire). I went on and then off painkillers each time. I recognize the childhood fantasy, tailored, perfected, by years of efficient drug use. I recognize the feeling. Nice, but, as feelings go, if there were nothing else to it, I might prefer a back rub or foot massage. And I’m pretty much past being a slave to my attractions. I’ve had nearly forty years free of addiction.

But man, do I ever get what it’s like, for my addicted clients, and for almost anyone fighting that so-powerful amalgam of thought and feeling: the fabricated scene, the sense of completeness, the revised reality, and the control you take (or at least hope for) — an entrenched (but fantasized) improvement over what it was really like to be young and scared, alone and helpless.

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Please think of attending this one-day conference on novel and progressive ways to conceptualize addiction, highlighting harm reduction (and, in general, compassionate) approaches. It’s called Shifting the Addiction Paradigm. It will be presented by The Center for Optimal Living and partners, at the New School, New York City, June 7th. I’ll be a keynote speaker.

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ALSO PLEASE NOTE: The bug that was trashing some of your comments is now fixed. Please comment!

 

 

 

 

 

 

 

 

 

 

 

 

I continue to be obsessed with this problem of incompatible self-narratives. So, permit me one more rant on the subject. In this post I want to tell you about the dissociation I experienced myself, during my days of addiction, and the child-like freedom it brought me. I also want to compare what I experienced then to what I’m hearing from my psychotherapy clients now.

In re-reading my last two posts, I still see value in recognizing that we have discrepant versions of ourselves, discrepant self-narratives. And that trying to mash them together into a single coherent self-narrative can be more trouble than it’s worth (even though that’s considered the principal task of growing up). In fact, for addicts, it can be agonizing. It can generate much more stress than it resolves. And that’s simply more fuel for the addiction. Rather, I suggested that we try to accept each self-narrative, e.g., the “addict self” and the “good self,” on its own terms, and allow them to cohere in their own time.

The most extreme version of separate, distinct self-narratives is what psychiatrists call dissociation. And the most extreme form of dissociation is a bonafide multiple personality syndrome. While multiple personality is very rare, dissociation is not. It can be quite common for people with addictions.

When I was seriously addicted (during my 20s) I had two distinct selves — I can only call them that. By day I was an industrious graduate student in psychology. I was attentive in seminars and determined to excel — which I generally did. Then as the day drew to a close, my anxiety grew. Things were not working out in my marriage — my wife and I had radically different needs and expectations. I’d anticipate going home, dismissing my own needs, and catering to hers. Really I was going back to my “false self” — a term borrowed from psychoanalytic theory — which means being fake and imagining that the fake you is the real you. I tried being sensitive, solicitous, responsible, accommodating. I felt trapped in this role — a third self-narrative? I couldn’t see a way out. So I managed to change selves. I’d get those first glimmerings…why don’t I get some drugs and get high and of course hide it, not only from my wife but from everyone. It will be my secret — it’s always been my secret. Except when things went really wrong, like the time I woke up on a sofa in the student union lounge suffocating on what seemed poison gas. That unholy smell was burning upholstery. The sofa was on fire from the cigarette I’d dropped while nodding out. Or the times I got busted, fired, or kicked out of school.

So much for war stories. You often pay tenfold for whatever freedom your addiction earns. I did. But the solution isn’t to ignore what it’s telling you — about yourself…or your selves.

Here’s my point: when I switched to my drug-taking self, everything changed in my emotional world. I felt free and I felt real. I knew that I was in deep shit in my life, in my marriage, in every index of adult functioning. But! In this self-narrative, I was a bad boy who would get away with something, as I had before, as I would again, until…maybe until I got caught or until the rules changed. I willingly went after the freedom I gained from “being bad” — which is pretty much the label I attached to my drug-seeking.

People dispute whether addictive drug-taking is a choice or a disease. For me, as you know, it’s a choice, but it’s not a rational choice. It can certainly be a compulsive choice. It can be a very effortful choice to stop, which means it can be a relatively easy choice not to stop. (Choice is momentary. Anyone who’s ever been addicted knows the feeling of surrendering to the impulse — the relief of it. But the fact of that relief does not contradict the fact that you’ve just made a choice.)  So what are we choosing when we choose to get high? Not just the feeling of the drug (or activity — as in porn, sex addiction and gambling) or the excitement of anticipation. We’re choosing freedom from the restraints of being who we’re supposed to be. We’re choosing to become the child and throw off the sense of being judged and held accountable.

There’s a lot more to say about this choice. We know that most addicts had difficult childhoods of one kind or another; they could not be the children (or teens) they really were yet fit the world of adult expectations. In the dissociation of self-narratives that comes with addiction, we become those unruly children once again.

I’ve got roughly 10 clients in online psychotherapy right now — all of them struggling with addiction or moving beyond it. For perhaps every one of them, the addiction is a portal into a revamped childhood. They each give up the “self-imposed” rule of abstinence for the release of using (or doing). Several are coke addicts for whom coke is the thrilling invincibility of the rebellious child. Two are porn addicts who find in porn a secret world where they can watch the forbidden and desirable…and pretend. Two are heroin users who give up the loneliness and boredom of adult life for the cookie jar of pure pleasure, stolen rather than earned. For another, it’s food. Why should I have to stop eating? Why should I obey?! For all these people — and they are people I like and respect — addiction isn’t primarily about the substance or activity. It’s a portal to another world, where they can be another self. And here’s the crux: that other self feels more real, at least for a while — I mean more authentic, more pure — than the obedient, responsible self they return to afterward.

I wonder whether the “addict self” and the “good self” can only converge thoroughly, peacefully, when we allow ourselves to be greedy and selfish and needy or defiant, day to day, moment to moment, honouring the child who still lives inside us, at our core. When we grow to that stage (maybe with a little help from our “uber self” or our therapist or mindfulness meditation), when we achieve that degree of self-acceptance, then we won’t have to go to such lengths to feel comfortable in our own skin.

 

Hi all. I’ve been trying to write a post to follow up on the self-narrative post I put up last. I’ve found that a certain paradox stands in my way. The pull toward a coherent self-narrative is so strong. Partly because, from the outside, we look like a single person. And where do we learn how to see ourselves? From the outside. From the perspective of others. From our parents and caregivers, while growing up, starting in earliest infancy. Oh, isn’t he cute! (Not aren’t they cute!) These others who love me, they see me as a single person. So that must be what I am. Also, we feel like unified beings in the sense that we have one body. Just one. When any part of me is in pain, it’s my pain. It belongs to a unitary me. When I die, it’s all of me that dies.

Yet the reality looks different from inside. There’s so much going on in “me”. Last post I observed that there seem to be multiple self-narratives. This is especially obvious, and maybe especially extreme, in addiction. The classic version is “the addict self” versus “the good self” or “caring self” or…what have you. When I was an addict, it was pretty straightforward. I was a good student by day, then I’d become Robin Hood when it got dark, stealing from the rich and giving to the poor — i.e., me! Each part had its own history, its own motives, and its own — highly contradictory — goals.

Should we think of these as incompatible self-narratives, and view each as separate, with a sort of life of its own, yet worthy of acceptance and compassion? Should we stop trying so hard to unify them? Because sometimes…you just can’t. They simply don’t fit. And the effort to weld them together can be overwhelming, soul-destroying, can leave us feeling more fragmented than we already were. The infamous “dry drunk” is one victim of this misguided struggle.

That’s what I suggested last post…along with an “uber-self” who’s pretty hard to define. Yet I’m not sure it’s right. Maybe we have just one, or just one main, self-narrative — this is who I am, this is who I was, this is who I want to become.

Or who I expect to become — a very different way to frame a future self!

Maybe the project is indeed (as the psychologists and philosophers claim) to make that self-narrative coherent. Maybe that’s the job. It’s just that there are aspects of the self, parts of the self, that don’t fit. Wanting to get high, choosing to get high, being determined, being defiant about getting high. (Even in the world of “normies,” there are parts that don’t fit the narrative.) Maybe it’s best so see these as strands of the self-story that truly aren’t compatible with the rest. Maybe they are “clips” (when we actually bother to see them at all), but not self-stories per se. In fact, maybe their incompleteness reflects this. Maybe those strands are “doomed” to remain incomplete.

(By the way, if you doubt the diversity of self-images, cover one half of the face above, then cover the other half. Did you see the same person? Think about the two halves of your brain — they process things very differently.)

 

Anyway, I’ve been thinking about this and trying to come up with something like a resolution. (I’ve always liked to create theories or models, but they have to be — guess what? — coherent.) I’ll let you know if I get any closer.

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Meanwhile, Isabel sent me this powerful and beautiful poem, so I (we) want to share it with you. It seems to show that desire, in reaching too far for completion, finds that which cannot cohere.

Letting the Emptiness Become My Government Within me, the sipped, iced bourbon enacts the sense of a slow, April rain blurring and nurturing a landscape. Decades I’ve been pipe-dreaming of finding a life as concise as a wartime telegram. Ultimately, I’ve ended up compiling an archive of miscommunication and the faded receipts of secondary disgraces. In third grade, a friend’s uncle stole the two dollars from my pocket as I slept on their couch, and later he must’ve hurried into the night toward a flat in the nearby building where a newly minted narcotic promised to evict the misgivings from all riled souls. I told no one of the theft, letting the emptiness become my government, my friend’s mother counting her food stamps while we walked the late-morning blocks to a bustling grocery, within which she eventually smacked the hopeful face of my friend as he reached again for too costly a thing.   by Marcus Jackson

Here come two posts, the first one is more of an idea, the second a suggestion for practicing what the idea is about. My question for today: How can we (who struggle with addiction) reconcile our radically different self-narratives, some of which seem so ugly, and arrive at self-acceptance and self-compassion?

We know that self-anger, self-disgust, shame, and the accompanying frustration and depression are among the greatest challenges to overcoming addiction. We feel fragmented, made of pieces that can’t possibly fit together. We crave, we choose to use, we take care of ourselves at the expense of others, and we lie (without hesitation) to protect our habit. Yet we can’t let go of the sense that we are also good, or at least have been good. We are caring, and generous, and smart, and very often responsible. How can we possibly fit these views of ourselves together?

According to thinkers and researchers in developmental psychology and adolescent development, we just lost the game of growing up. In fact philosophers and writers down through the ages have come to the same conclusion. The main task of growing up is to create a coherent narrative about who we are. A coherent self-narrative. Yet that seems to be very difficult for addicts.

A big part of our sense of self, our identity, the “me” we show others, is in fact a narrative, a story. This is who I am. This is where I came from. This is what happened to me. That caused me to do such and such. And then this happened. And now, this is where I am, this is who I am, and — most important — this is where I’m going.

I’ve written (especially in The Biology of Desire, last chapter) about how difficult it is for addicts to create and hold onto a coherent self-narrative. I’ve suggested that addicts can be helped, or can help themselves, by solidifying that narrative and (most important) extending it into the past and the future. Because of the pull of the present moment (“now appeal” — e.g., wanting only to get high today and forgetting about tomorrow) it’s crucial to stretch the time-line. We should try to extend the narrative into the past, to understand how we got to be this way, and into the future, so we can begin to imagine being someone different, someone freer and happier, and aim ourselves there deliberately. I’ve suggested that scaffolding (by therapists, friends, loved ones) can help create and maintain this extended narrative. It’s too hard to do it alone.

But it’s damn hard to do even with the best of help! Here’s why. What most of the experts miss is that we are made up of more than one narrative. We often have two or three or four going at the same time. Psychologists sometimes talk about parallel identities: e.g., I’m a parent, but I’m also an American, or I’m also a plumber, or I’m also hot! Okay, but that stuff is easy. Multiple self-narratives are particularly challenging for addicts, because they fit together so poorly. There’s the self that often gets called the “addict self.” There’s this me who was abused, or thrown out, or traumatized in adolescence, and all I could find to feel better was this or that drug, so that’s what I go after. That’s one “addict self.” There are others that aren’t so benign. There’s the “I’m such a loser” version — very common, very hard to shake. Or its close cousin: “I’m just a teenage dirt-bag.” In other words, a piece of shit. When I (Marc, personally) was addicted, I saw myself as sneaky and determined and defiant, all of which fit into one narrative…which didn’t resolve for years.

But addicts also have self-narratives that are positive, even admirable. We may see ourselves as nurturing and compassionate, especially if we are parents (or lovers). Those are real narratives too: I had this baby and I learned to take care of her and I love her so much and I’ll continue to do anything for her. We may have self-narratives in which we are heroes or rebels, not beholden to others. Or simply victims.

The point is that these narrative threads really don’t cohere. They don’t jibe, they don’t reconcile. They are just too different to blend into a single story line. So we get torn apart by the tension between one self-narrative and another. From an email I recently received: How can I have gone back to meth, when I know that I’ll never get custody of my child now! Not ever! I hate myself so much. Or: How can I steal money from my own mother and still see myself as loving her and caring for her?! How can I be worthy of being drug-free when I’m so indulgent, so weak?! These stories cannot be merged. They are too discrepant.

So here’s what I want to suggest. Bump up a level. Recognize that you do contain distinct, incompatible self-narratives. Create an uber-narrative that allows for each component narrative and doesn’t have to shut any of them down. Now you can let yourself get to know each of these self-narratives. Make each one conscious, talk it out, recount the plot-line, to yourself or others, write about it. But realize that they will not blend into one nice story. Bump up a level to a more insightful, wiser self who recognizes each of these radically different story lines as real…and lets them coexist.

Try it. Pull yourself up to the level of the overseer. Be a real author, a real choreographer, who can shift from one plot-line to another and accept that they are not ready to be stitched together. Not yet.

I think there are at least two benefits to be had. Number 1: When you stop trying to reconcile your “addict self” with, say, your “caring self,” you release yourself from an enormous amount of tension and frustration. You are both of these. Accept them both. Number 2: By accepting each of these self-narratives as real and maybe even inevitable, and by making them conscious, you provide a space for true self-acceptance. Self-compassion. Even self-love.

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Next post: how this “retelling” might relate to that squishy idea we hear so much about — mindfulness.