My blogging days may be winding down. But if they do, as they do, I want to put more energy into methods for helping beat addiction than ideas for explaining it. It’s critical to understand addiction in depth, and I still believe that linking neuroscience with lived experience provides a potent frame of reference. But lately I’ve been moving on, thinking almost exclusively about treatment. Is there a connection from brain parts to mind parts to effective methods for helping people? Let’s see.
I started this blog with an emphasis on addiction neuroscience. I can sum up most of that brain stuff in a few simple conclusions, but I’m going to add some points of clarification:
-even though brains change with addiction, addiction is not a brain disease, as often claimed. The brain changes with any and all learning, and the more emotional and repetitive the learning events, the greater and more enduring the resulting brain changes.
-habits are inscribed in synaptic networks (networks of connections among neurons). Those networks become the hardware for processing new information: “What fires together wires together.” Thus, novelty gets sidelined by habitual patterns of thought, feeling, and behaviour. That’s the case with love, politics, religion, and yes, addiction.
-the “narrowing” of synaptic networks is mirrored by a narrowing of the social world. Friends, family, finances, legal circumstances all become more limited, more “narrow,” for the person who finds fewer neural avenues for pursuing rewards. You’ve heard that life imitates art? It’s also the case that social change imitates brain change. (See my review article here.)
-the “narrowing” metaphor suggests that the connections between different brain parts become more entrenched, less open to change. But that doesn’t mean that diverse neural regions become fused in some way. The brain retains its functional components (e.g., frontal regions underlying conscious attention versus limbic structures in charge of automatic behaviour) and those components are designed to compete.
So now what? With all we know about the science and psychology of addiction, how do we put it all together? How do we help?
The neuropsychology of addiction is important! It exposes us to many critical concepts, like the biological embedding of habit formation. Yet we don’t generally treat addiction, either in ourselves or others, by altering the brain. At least not directly. We don’t perform lobotomies or lobectomies, nor is it common to use deep-brain stimulation or transcranial magnetic stimulation to help people recover. No, when it’s time to turn from thinking to helping, we turn to talk, often in the form of psychotherapy.
Talk is social behaviour. So the goal is to free up addicted people by expanding their social world, especially the social world they carry around in their minds — the way they talk to themselves, the way they interpret messages from others. At that point the neuropsychology of addiction takes a back seat, as an aid to our clinical intuitions and our capacity to listen. Once again, lived experience, both that of the client and of the therapist, becomes the needed partner for our scientific theories.
Now if both the brain and the social world “shrink” in tandem, then we should be able to “grow” the brain (the realm of synaptic possibilities) by “growing” social-psychological flexibility. How can this be achieved?
(There is one method of acting on the brain directly, bypassing all that messy talk stuff. We can give the addicted person drugs that directly affect their neurophysiology and/or how they think and feel. Antidepressants and antianxiety drugs to target underlying mood states, methadone or naltrexone to nudge drug-soaked synapses out of their ruts. But in my view, psychotherapy — if it works — goes deeper, induces changes that last longer, and provides a sense of well-being that no drug can mimic.)
I find Internal Family Systems (IFS) therapy to be the most effective form of talk therapy available. You’ve heard me rave about it over the last few posts. I’ll end today by pointing out that IFS brings to the table a fundamental experience that most addicts find exhaustingly familiar. For them (and of course I include myself) the internal social world, the voices in our heads, are most conspicuous because they are at war with each other. The internal critic tells you that your wishes and goals are reprehensible. But the childish wishes don’t go away. In fact, they get stronger, fueled by defiance against the internal critic and desperation to meet needs that are hunted down and locked away.
By recognizing this internal duality, this multiplicity of conflicting part-selves, IFS brings empathy and clinical intuition to bear on what neuroscientists already know but never think about. Brains are composed of components that are designed (by evolution) to compete with each other. Frontal inhibition (lateral prefrontal cortex) versus learned habits (striatum), future oriented action tendencies (dorsal cortical circuits) versus preoccupation with threats (ventral cortex and amygdala). These tendencies are supposed to compete. That’s what gives humans their incredible capacity for choice and intelligent action.
How did we psychologists forget that when going about devising treatment strategies?
So, here’s the breath of fresh air provided by IFS. Conventional methods of treating addiction involve training people to “just say No.” That doesn’t work. Mounds of disappointing outcome stats make that clear. Why doesn’t it work? Because it ignores the lived experience of people in addiction and it ignores the way brains actually work. In contrast, IFS trains people to listen to the voices or “parts” that occupy their minds and accept them, welcome them, soothe them, without trying to shut them down. In that sense, it respects the idea that the mind — as well as the brain — is multiple, and it is composed of competing functions.
But that’s enough for today. In my next post I want to be very explicit about the IFS alternative to “Just say No.”
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
I’d be curious to know what you think about throwing in some somatic components to addiction treatment, to assist with dysregulation/regulation while the IFS process is unfolding. The brain/CNS is attracted to comfort, ease and pleasure, so slow relaxed, low-effort movements could be an extremely powerful adjunct. Feldenkrais lessons and derived mini-movements from those lessons might show the brain/mind what pleasant feelings can be generated by one’s own body. Also, being led in such movements by an attentive and watchful teacher might be an important component, though these movements can be learned and performed independently.
Hi Robin! Good to hear from you. Did you know that we’re back in Toronto? If the lockdown ever lets up, let’s have lunch.
The somatic components you speak will indeed be helpful. Trauma-oriented therapy seems to be moving in this direction in leaps and bounds. Here in Toronto, Jan Winhall uses body work to free up trapped physiological patterns, as guided by Porges’ Polyvagal Theory. Since most addicted people have trauma in their backgrounds, this added ingredient is a no-brainer (ha-ha). Thanks for mentioning it.
Sign me up for your blog, please.
Thank you!
Peter
Chicago
Hi Peter. There’s a “subscribe” link near the top on the right side of the page. Welcome aboard!
Hello Marc,
Your work is helping so many and will forever give hope and understanding. Thank you for being a bearer of the light.
I wholeheartedly agree with Janet. I understand you may be winding down on posting, but just know of all the things that inundate my Inbox – I savor yours. And these most recent IFS posts have brought me to a place of calm and understanding. Thank you.
Thank YOU! I’m really grateful to hear how all this is affecting my readers. Choosing one school of therapy to focus on runs the risk of becoming partisan or jaundiced, so I’ve avoided being a card-carrying member of…anything. But there is something inspirational about IFS. I think that’s because its premise is both radical and intuitively valid. Our minds aren’t meant to be unified or coherent. That’s a cultural overlay. The nature of the mind is to negotiate…with itself! Because our various goals simply don’t hang together, however much we might wish that they did. Where addiction is concerned, the goal of being in control and the goal of being free of control are so diametrically opposed. That’s why this perspective takes on such potency when the lens is focused on addiction.
Still haven’t decided whether to go on blogging or not. But your comment surely helps me see blogging as a useful way to connect with thoughtful people.
I agree with Kevi. Your posts Marc have increased my understanding and wellbeing.
Great post, thanks. I’d been hoping you’d write something about the relationship between your enthusiasm for IFS and your earlier writings focussing on the neurophysiology of addiction. Looking forward to the next part. It would be helpful if you also had suggestions for those of us in small countries (I’m in NZ) where the range of treatment options is limited at est, and tends to be concentrated in a few small currently fashionable range of options.
Hi Marc, it’s been quite some time since I read your blog, though I’m grateful I did today! Looking forward to reading more about IFS. Always interested in the science of the brain as well, although from a very simplistic space.
Cheers, Jo.
Hi Marc, I just completed your book and started following your blog. I’ve struggled with sex/porn addiciton for 2 decades.Three years of IFS therapy have helped me get to a place where I can relax a bit. Took me a while to access that part which isn’t a part – my core self. Also found a group several months ago (not 12 step) that focuses less on “lust management” and more on past stories that shaped my attraction to porn and futility/anger/deprivation that feeds it in the present. No badges given out, yet I’ve acheived my longest stretches of sobriety – seemingly just by expanding my social network.
You’re probably already familiar with IFS therapist Cece Sykes. If not, she has some terrific material about IFS and addiciton on her own website.Thanks very much for your help.
Hi Thom. Yes, I do know Cece Sykes. In fact I just finished a week-long training workshop with her as leader, sponsored by the UK branch of the IFS network. Thanks for piping in on this and for your courageous honesty.
Cece is terrific. She has developed her model, using IFS principles and techniques for therapy specifically tuned to people struggling with addiction. I’ll highlight and discuss some of her ideas in my next post.
Finally, thanks for an example of “expansion” as applied to social networks. Expanding one’s social network can mean many things, but it seems that increased flexibility would be a good place to start. Meaning….not more outlets or more contacts but more WAYS of engaging with…other people.
Marc,
Your commitment to focus on treatment is laudatory and this post makes so much sense. In the past you have talked about synaptic pruning where the brain increasingly focuses on the addiction. The present description of the ‘narrowing’ synaptic network and the corresponding shrinking of the social network is what happens in addictive disorders. Successful recovery therefore, involves utilizing appropriate anticraving medication like methadone, buprenorphine or naltrexone to protect the healing drug-soaked synapses from falling back into the rut of drug use.
Now that the ‘wheels’ are secured, the real work of rewiring the brain begins and helping the patient back into the right social orbit. I describe this process as putting humpty dumpty back together. The patient has multi-dimensional needs – housing, legal, financial, relational etc. Most often, the first priority is getting the patient out of the toxic living environment. Ever since we started offering housing to patients, the recovery rates have soared. Patients at the ARCA clinics see a psychiatrist, internist, nurse, peer support specialist etc. 2-3 times a week. The more I read about IFS, the more I am impressed and I am encouraging my therapists to get trained on this modality.
The treatment and other services offered should be attractive to the patient. One weakness we observed was many patients were not walking four blocks to fill their prescriptions. We solved the problem by opening a pharmacy onsite. The patient sees the provider, walks across the hall and the prescriptions are filled within 15 minutes. We are also working on opening an ‘urgicare,’ walk in clinic. There are dozens and dozens of urgicare clinics in St Louis for all sorts of ailments but none for patients in withdrawal from drugs or alcohol. We hope to open the walk in clinic in early February. This is a sorely needed service all over the US.
The pandemic has created unprecedented opportunities for patients to seek help. We have established a robust telemedicine platform for patients to be seen by a provider remotely and receive medical and psychiatric services. The two physical clinics and 35 telemedicine sites has allowed us to treat in excess of 2400 patients a month!
I hope when things settle down in the next year or so you can spend a day or two at the clinics, meet the staff, meet patients living in the recovery houses and other patients coming to the clinic.
Our staff will be thrilled to meet the scientist who has devoted many years to explaining the neuropsychology of addiction and now treatment.
Thanks for the update on what’s happening at your clinic, Percy. You seem very attuned to your patients/clients, and of course that is a great boon to them…and a rare commodity.
What is especially noteworthy in your comment is that the pandemic creates opportunities for innovation and perspective. It isn’t all bad. That’s something that is rarely considered.
Percy :
Do you have a safe consumption site attached ?
No. We are a safe treatment site. There is a lot of noise about starting one in the US but none so far. The city of Philadelphia approved one for Kensington, PA but it has run into all sorts of delays.
The Canadian Province of British Columbia even has a minister of addiction and they are running into challenges. Here is the link to the new article.
https://thetyee.ca/News/2020/12/10/BC-New-Addictions-Minister/
Patients come to the ARCA clinic for treatment of addictive disorders and other wrap around services. All patients are given the naloxone nasal spray with instructions on how to use it.
Percy :
I live in Vancouver , BC and have been a supporter of “Insite/Onsite” (North Americas first safe ingection site” since before in actual creation and opening in 2003 . What many don’t know is that Insite is the safe injection site and Onsite is a detox and treatment center in the same building . Vancouver , specifically , the downtown east side has a long history of covert safe injection sites back to the 90’s thanks to V.A.D.U ( Vancouver area of network drug users ) and a wonderful woman named Anne Livingston , look her up , she a hero .
Now and for the last 4-5 years organizers just open sites using tents and volinteers where needed and just wait to be supported by the Goverment . Many , many lives have been saved .
The greatest resistance to new injection sites is N.I.M.B.Yism ( Not in my backyard } its a hard sell to many neighbourhoods outside the DTES. I would try and explain the East side but I’ll leave that for another day .
My point being that Insite is a wrap around service , welcome people to a safe place to do drugs and if they want to kick there is a detox and treatment center in the same building . I don’t really like the term “Meeting people where they are at ” but all the safe injection sites are doing just that .Might be time to make a lot more noise .
NIMBY is a huge obstacle in opening a treatment center. There is considerable resistance on the part of the community to open methadone clinics, residential places for people in recovery etc. I was determined to open my outpatient treatment center in a medical building. The landlord was very skeptical about allowing a ‘drug’ treatment center in a medical building housing internists, cardiologists, dentists etc. The big concern was our patients discarding used syringes and drinking in the parking lot! I assured the landlord that would not happen and he reluctantly leased me space and we remained in the building for almost 15 years.
At this particular facility we treated mostly working professionals who demanded a high level of confidentiality. They felt comfortable coming to a medical building. We expanded our services and started seeing patients from the criminal justice population and street addicts and the usual issues arose and we were asked to leave the building and we moved to a location where the landlord was a lot more accommodating, We do have our challenges of patients occasionally using drugs and overdosing, patients selling drugs in the waiting area etc. The vast majority of ARCA patients are seeking treatment.
I am not familiar with Canada, but in the US, most methadone clinics are located in rather indiscreet locations and they have the same challenge of drug dealers hovering around the clinics.
I personally feel it is impractical to have a safe injection facility and a detox facility in the same building. Insite/Onsite has made it work, but I am going to stick to my safe treatment facility which has worked very well for over 20 years.
i couldn’t agree more about the summary in your first couple of paragraphs here Marc – its far less about biology and (disease) and far more about ‘connection’ – can they make an anti loneliness pill – well they do – its called Ice or Cocaine or Alcohol (well the later not a pill ..) – and this all questions the very notion of ‘treating’ people – i think its time for a real shift to occur – legalize illicit drugs (because they do work and they are a great temporary fix – the main word – temporary) and then take a completely different path – improve peoples social world and give them meaning through connection to society through education and work – but as Bruce Alexander might suggest – is that possible – is it too late to go back? reconnection works directly against the free market ideals of individualism and competiveness and the ongoing deliberate creation of anxiety across the globe by monster companies that exploit our habitual natures – I fear we have gone to far – the epidemic is not drugs it is loneliness
Hi Terry. This emphasis on connection, as an antidote to loneliness, is a hugely influential concept. I think that Hari’s book, Chasing the Scream, made that point very effectively when it came out, what was it? 8-10 years ago. Followed by his book on depression. I don’t know anyone in the throes of addiction who isn’t quite depressed, and loneliness is ALWAYS the front door to depression, in my view.
Is it too late? I hope not. I see free-market capitalism as a serious obstacle to connection, as you do, but it’s not a conspiracy, just a stage in the evolution of human economics. I doubt whether it’s the last stage. There’s a lot of really optimistic stuff happening on/via the web as well. Millions of people using meditation apps, all kinds of virtual gatherings to share feelings, ideas, experiences. Who knew that digital technology would serve to help us connect as well as compete?
And by the way, your solution, legalize and then deal with social disconnection, is exactly what’s recommended by Hari. If you haven’t read that book, or seen his TED talk, I suggest you check it out!
Thank you again Marc, for all the information. Though my brain only understands some of it, it is refreshing you read your research and ways to treat addiction, OTHER THAN 12 step programs and behavior therapy. My clean date remains s September 25, 2020. Thw latest very big problem was Methamphetamine. That was a real tough one. Still is somedays. To “just say no” as has been said. I have been seeing a $3/hr therapist (state) for other issues. The other day I admitted to lying to her over past year about being clean. Wow, huh. She had me answer a bundle of questions, going back to 13yrs old (the facility has my hx mind you). I guess it was easier to have me tell her. I left feeling shame, and low. I don’t like talking about the past drug use, arrests, and failures. I come from a mid to upper class family, put myself thru RN school, had a dream princess wedding I’ll never forget. Then, I pissed all that away. Life is different now. I’ve learned drugs helped me to run. Away from thoughts and facing reality. This therapist offered me outpatient services for addiction and medication. I declined. 1st, I don’t want medication, 2nd, Been there done that with 12 step. That’s what facility uses. I believe submitting crimetips to cops has helped me stay away thos time.
It sounds like your therapist is pretty committed — what a boon to get that kind of attention for $3/hour! Why don’t you ask her if you can keep on talking with her without getting on medication. Why not? Lying and shame are such familiar companions to addiction. You’re far from alone. Maybe see my post about Authenticity, about 5-6 posts ago. it’s not the usual approach of course.
Hey Marc,
We have spent hours talking about all of the things you neatly summarise here. Just a brief comment:
Unfortunately, there are those people who believe in taking the direct and reductionistic approach by damaging people’s brains in an unethical and misguided attempt to ‘cut out’ addiction:
1. Stanford’s Adler, has used a laser scalpel to destroy areas of the brain in a Chinese study. 60 opioid-dependent patients in mainland China were followed up 5 years after ablative surgery. 47,4% were seen to be abstinent and memory deficits were seen in 21%, motivational loss in 18% and some changes in personality in 53%.
Despite the negative outcomes, the paper concludes: “The bilateral ablation of NAc by stereotactic neurosurgery was a feasible method for alleviating psychological dependence on opiate drugs and preventing a relapse. Long-term follow-up suggested that surgery can improve the personality and psychopathological profile of opiate addicts with a trend towards normal levels, provided persistent abstinence can be maintained; relapse, on the other hand, may ruin this effect.“ (1)
2. There are currently trials using dopamine-attenuating agents to reduce the “reward” attached to dependent drug use. This is incredibly misguided, considering the failures of the dopamine theory of dependent use (See David Nutt’s summary). The NIH supervisors of the trial call it the “demotivation pill”.
My point is: You cannot stop “addiction” by blocking it or cutting it out – to do that is to impact on what it is to be human. If there is a capacity for relationship and learning, there is a capacity for habituated dependent drug use. Remove the capacity for dependent drug use, and you impact the capacity for relationship and learning.
A far better way of limiting or resetting the default mode network is through learning something new that rewires the established synaptic paths. That change is facilitated by an emotional connection and the feeling of increased integration. Talk-therapies and an empathetic therapist can go a long way to achieving new behaviours that become hard-wired into the DMN.
In my opinion, we don’t ‘treat’ addiction and people don’t ‘recover’. Rather, we assist someone to resolve their habituated default dependence on drugs. To quote my favourite ‘addiction’ author: “What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place — while they reach toward it.” [2]
Or there are psychedelics….
But that is another story.
[1] Ge S, Chang C, Adler J, R, Zhao H, Chang X, Gao L, Wu H, Wang J, Li N, Wang X, Gao G, Long-Term Changes in the Personality and Psychopathological Profile of Opiate Addicts after Nucleus Accumbens Ablative Surgery Are Associated with Treatment Outcome. Stereotact Funct Neurosurg 2013;91:30-44
[2] M Lewis The Biology of Desire
Very interesting. Thanks for your input here. I myself have no interest in taking a medication to help me stop using, or wanting drugs. I’m always open for ideas from my therapist to reroute my energy and time toward more healthy activities. It will be a lifelong of keeping myself in check. I’m always looking and reading more information to combat this monster. ADDICTION.
HI Shaun. What can I say? This is a fascinating review. The ablation study sounds insanely suspect in all kinds of ways, especially when the conclusion is qualified by “provided persistent abstinence can be maintained; relapse, on the other hand, may ruin this effect.“ Doesn’t that overwrite any possible advantages? And dopamine-dulling drugs…I wonder if they’d be in the same camp as naltrexone, because they subdue something so human as the attraction to reward.
You and I have always seen eye to eye on addiction. Yes, “stopping” addiction by invasive techniques is a form of dehumanization, I agree. And I agree that the addictive substance or activity has to be replaced by a “reward” that also offers warmth, comfort, and/or plain old happinesss. Yup, scaffolding is what it’s all about in therapy, (and I appreciate your quote). First you help the person find that “something else”, and then you have to, really have to, help them reach for it repeatedly until the pathway become sufficiently entrenched to stand up against cravings for the “sure-fire” solution of drugs.
The way IFS does this is simple and almost magical. You find the parts of yourself that are frightened, lonely, ashamed, and/or angry, and you reach out to those parts to befriend and comfort them. Reach out from where? From the Self that’s not a part. Sounds so woo-woo, but it actually works. The premise is that those parts, including the “fire-fighter” who leaps for the drug to put out the fire, and leaves the clean-up for other parts…those parts are continuously rejected. We disown and hate them. So they — those parts of ourselves — remain hived off, lonely, and often desperate. When you give these parts acceptance and love, you feel a rush of peace and comfort. And to my mind, it’s that, and only that, which is powerful enough to serve as an alternative goal that *feels* attractive enough to compete. It feels good! And isn’t that what it’s all about?
Hey Marc,
There is something mystical and magical about talk therapies when done right and in the right circumstances. The results are sometimes just, well, miraculous.
I think of the way Narrative Exposure Therapy for child soldiers and others with multiple and complex trauma simply makes the implicit explicit ad helps the person make some coherent narrative sense of it all.
https://www.vivo.org/wp-content/uploads/2015/09/Narrative_Exposure_Therapy.pdf
It sounds like IFS is similarly amazing.
Lots to think about in your post, as there always is.
Hi Marc!
So enjoying your parts work writing and insights. I hope you’ll keep sharing it, and your overarching message, too.
This thought – above – from you is what brought me to your work, and I think it bears repeating (and repeating;)
“Even though brains change with addiction… the brain changes with any and all learning, and the more emotional and repetitive the learning events, the greater and more enduring the resulting brain changes.”
I want you to know, every time I think that thought, I feel more hopeful, joyful and committed to my own growth and healing, and to my teaching, too.
Too many still believe that only addiction and trauma can change the brain as they do.
The power of mindfulness, of intentional practices, and connection with supportive, meaningful, growth-oriented community… these and more are gradually transforming my life, including my neurophysiology. I’m grateful, and that, too, is transformative!
HI Joanna. I’m glad that this message resonates so fully with you and with your practice. The repetition, entrenchment, rewiring….it’s just a brain’s-eye view of what we understand about habit formation. But it is indeed crucial. Please look at Shaun’s message above and my reply to it. I think that this form of scaffolding-repetition, and the IFS operationalization of it, provide a novel and powerful way to link the psychotherapeutic community with the spiritual/contemplative community. What could be better?
Marc, attachment theory is at the base of most addiction issues and severe CPTSD & PTSD are the others. I know you are part of the Addiction Theory Network as I am. We have a chance to share what we know with the new administration that would reduce the grip on the BDMA held by NIDA/DEA. We have enough scientific data to make the case that we actually know to effectively treat addiction. If we can have some dialogue with whoever the new admin selects we could possibly get someone other than the Surgeon Generals who blindly follow NIH & NIDA.
It would be great if such a dialogue took shape, almost too good to be true. The Addiction Theory Network, for those who don’t know, is a Google-group of several hundred addiction researchers and clinicians who are unified by their opposition to the “brain-disease model of addiction”, referred to as the BDMA in the above comment. As most of you know, the proposition that addiction results because drugs have somehow “hijacked” the brain is still the dominant orthodoxy in the US. Organizations like ours try to gather and disseminate findings that show that, no, in fact addiction is the result of social-developmental factors (e.g., attachment problems, developmental trauma) that have gone seriously awry.
Marc,
Thank you so much for your blog, a voice in the wilderness.
Thank you for providing a platform for connecting such a knowledgeable readership.
A humble shout to remind everyone how yoga (like the afore mentioned Feldenkrais) can be a powerful component …the breath allowing for soothing mediation between competing parts of the brain.
Here’s to the survival of our species!
Melia
Hi Marc! I loved your book, and I just wanna sign up for the blog!