Tomorrow, for my last publicity event in Toronto, I’m giving a talk at a Harm Reduction group. I don’t know that much about harm reduction as a philosophy or practice. I do know that I like the idea that there are many and varied paths to recovery, or maintenance, or whatever you want to call a relatively harm-free solution to addiction. I also recently found out that the Harm Reduction folks don’t even like the word addict. I think I get their point. The tension here seems to resolve to the ongoing debate, both in science and in clinical practice, about whether addiction is a disease or a choice. Here’s what I think.
It’s a false dichotomy. Addiction is not a disease like cancer or diabetes. No way. It’s hard to get rid of, which makes it like a disease, but that’s really just an analogy. The resemblance stops there.You can’t catch it. It’s not communicable. And you can’t cure it according to some specific formula. This idea is very much at odds with the pronouncements of the American Society of Addiction Medicine, the high church of addiction, as it were. So is addiction a choice, is it just bad behaviour, is it the result of a genetic predisposition to self-indulgence or a low tolerance to psychological pain? All of these other definitions fall short as well. Addiction has an incredibly powerful, self-propelling momentum that takes it beyond the realm of “normal” choice or “normal” bad behaviour. If addiction is neither a choice nor a disease, then the choice vs. disease dichotomy is useless. It creates havoc and argument, it’s confusing, and it takes our minds off the more important issue. Such as: What is addiction really?
The disease camp assumes that the brain is important for understanding addiction. Addiction, they claim, is a brain disease. But the choice people paint themselves into the opposite corner. They claim that the brain is not important for understanding addiction. Rather we need to understand how difficult circumstances — trauma, rejection, economic hardship, and so on — affect substance-taking behaviour. What’s that got to do with the brain?
It’s got everything to do with it! Choices are not some magical puff of our spirit selves. Choices come from the brain. And the choice to take drugs, or booze, or cigarettes, again and again, comes from a brain that has been altered by a series of similar choices in the past. It just takes a moment of reflection to realize that choices are rarely “free”. And while philosophers debate the very existence of free will, we can be much more practical about it. Choices involve an exchange between the part of your brain that wants something (the ventral striatum and related areas) and the part of your brain that thinks about consequences and directs behaviour accordingly (dorsal and lateral regions of the prefrontal cortex). That exchange takes place in the synapses (connections) that join these regions. And those connections are altered by so many aspects of experience: hardship, success, self-image, trauma, and very clearly by the spiralling of wanting and relief that results from substance-taking itself. No two people have the same brain to work with, but there are features of addicts’ brains that neuroscientists can describe in detail: high levels of dopamine continue to strengthen the feelings of craving that spring from the striatum, while the satisfaction of those pernicious goals continue to reinforce the circuits that give substances their meaning and value. And the regions responsible for self-control are themselves weakened by excessive demands for impulse control. So their connections to the regions of craving shrivel because they’ve lost their potency.
Understanding the brain is essential for making sense of the kinds of choices that addicts repeatedly make. But that doesn’t make addiction a brain disease. It makes it an aspect of the biology of being a sensitive human being in an often difficult world.
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
Hi Mark,
Your explanation of what the animal called “addiction” is, makes the most sense to me – that from looking at myself and my own struggles.
Looking forward to reading your book.
Best regards,
Susan
Thanks. It’s good to hear that this explanation is making sense to people. I hope you’ll continue to be in touch, especially once you’ve read the book. There may be other aspects of my model that will make sense and promote insight into this difficult subject!
Dear Marc,
I was in the audience at your talk yesterday, second row luckily, it was packed! Thank you for speaking in such a humane way about a subject that can be intimidating to non scientists. I’m a psychodynamic therapist, not trained in drug or alcohol treatment at all, but I am fascinated with your work and believe this information about addiction mechanisms could also translate into treatment for addictions/compulsions to negative thoughts, beliefs, behaviours that cause such suffering.
I look forward to studying your book and a fruitful dialogue on your blog.
All the best,
Susan
Thank you, Susan. I wonder if I could put a face to the name…If you feel like it, please send me a picture.
I agree that the approach I take could have wider clinical applications. For example, rumination–a big part of depression–is very much like addictive thinking in that it is compulsive in nature. It involves an ongoing cycle or feedback loop, from negative interpretations about oneself to actual actions of self-harm. And they don’t have to be physical actions, like hacking up one’s arm with a razor blade. They may simply be hostile “voicings” in which one attacks oneself with scornful words or thoughts that remain on the inside. As with addiction, the loop from interpretation to seeking/doing and back to (now reinforced) interpretations… is powered by dopamine. In other words, there is a neurophysiological thrust or lunging of self-attack, a narrowing of focus that excludes other possible goals, and then something akin to satisfaction when you beat yourself up. And then further growth and proliferation of the synapses that comprise the network of depressive imagery–a view of the self as unworthy and deserving of punishment or blame.
I’ve thought about the compulsive nature of depression (at least certain forms of depression) as well as anxiety disorders, including OCD, in very much the same terms as I use to think about addiction. And it all boils down to feedback cycles in which negative pursuits build on themselves and reinforce themselves, regardless of our conscious attempts to turn them off. I also think, as you seem to, that insight therapy can be a way into this tragic and destructive process…..though of course it doesn’t always work, and it’s probably not the right approach for everybody.
Thanks for sharing your perspective and opening up the dialogue.
Marc
Hi Marc,
I could not see a way to upload a photo here, so I tried replying to marc@memoirsofanaddictedbrain.com, let me know if you receive it, or if not which email address I should use. Perhaps as things heat up on this blog, as I can see more people are starting to write in…. you will enable thumbnails in the i.d.line.
All the best,
Susan
Hi Susan,
Yes, sorry, I didn’t mean that you should post your pic to the blog! I meant to send it to me privately. Which you did, and I got it. (sorry, I’m retaking etiquette 101) I assumed it was the “you” I thought it was, but it was such a busy day…I wasn’t sure.
And thanks for the idea of thumbnails. It sure makes sense.
Cheers,
Marc
Timing is everything. Change (healing) often erupts after an emotionally significant experience. My years working with people in the throws of addiction has taught me much, but the insights I have gained looking through a neurobiological lens have added some missing pieces to that puzzle. I think about long and short alelles on the 17 chromosome, the impact of trauma (ever so slight) on a sensitive soul, the importance of epigenetics……….Sometimes its about trying to survive the rawness of life – the only way some people can do it is to seek solice in a chemical. It is about survival at times. Marc this has been a facinating read for me in so many ways (just finished the book). Its not about disease vs choice, I agree.
Thanks, Jan! (Jan took two courses with me, at least one of which focused on the neuroscience of emotion and emotional development.) You really do get the sensitivity angle, and yes some degree of emotional sensitivity is innate. Different alleles (different “versions”) of a gene — especially a gene that helps build brain structure — can have quite massive effects on dimensions of personality: one’s tolerance to separation anxiety, one’s capacity for self-control, one’s resistance to psychological pain. So genes influence our tendency (and I do mean tendency — our fates are not determined by our genes) to become an addict, or at least to have to struggle with addiction. Problems get their foothold when those tendencies are amplified by environmental events that are universally difficult. When you lose a partner, or a job, or a parent, life is rough for a while, regardless of who you are. But if that loss compounds a genetic tendency to be sensitive to loss, then you are really in the danger zone.
I’ve generally assumed that I was sensitive temperamentally and THEN got smacked by those years in boarding school, and then, oh yeah, I landed in Berkeley in the heyday of the drug movement. That mix of genes and experiences was a perfect recipe for me to become an addict.