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Some people say that addiction is not a choice, it’s a disease. As you know, I’m not one of them. But even those of us who believe in choice ask how much volition (intention or will) is involved in the choice to use or not. I think that choice is a lot more complicated than most people think. For now, I’ll skip the philosophical objections to the idea of “free choice.” Sticking to brass tacks, I think that volition interacts with many other factors when we make choices — especially choices about addiction.

Choices are based on appraisals (interpretations) of situations. People with addictions choose whether to get high or abstain based on appraisals of the quality of the high, the consequences of indulging, the proximity of other people who might approve or disapprove, and so forth. Since our appraisals are determined by factors outside our volition or awareness, especially in a complex situation changing moment by moment, the choice we make in that situation is less determined by our volition and more determined by luck and circumstance.

Appraisals are also strongly affected by internal variables: mood states, present emotions, beliefs, (biased) recollections of previous events. But this list doesn’t yet scratch the surface. There is my sense of emptiness and dislocation at this moment, compared with how I think I’ll feel after getting high, compared with how much drug I possess or can afford, in the context of building excitement and/or building anxiety and shame. These “internal state variables,” as psychologists call them, are highly complex and they change from moment to moment. Since that mix of factors will certainly affect one’s choice (e.g., to use or abstain), I can’t see how the choice can be entirely voluntary, entirely an expression of “free will.”

Over the time scale of development, habits evolve and consolidate, creating a spiral of increasingly strong predispositions to seek addictive rewards while alternative rewards become less meaningful. Is there any voluntary choice left after those habits congeal? Yes, I believe there is. Which is how people can slow down or quit. Recovery involves choice, and choice cannot suddenly be imported into a system that has none. Changes in appraisal, emotion, and social factors strongly influence volition, which influences actions, all of which alters one’s belief in oneself — one’s self-efficacy. That’s why self-talk and help from other people (friends, partners, books, stories, podcasts) can be so important. Once addicts tune into the possibility of volitional choices, the mechanism underlying volition itself grows in strength and availability.

In my book and elsewhere, I emphasize how synaptic networks can compete with each other, but when any of these networks is activated repeatedly, it becomes stronger, more likely to win the competition. This is the case when addiction arises in development, but also when it declines, replaced by the desire for and belief in alternative outcomes. I also think that addicts temporarily lose the capacity — or at least belief in the capacity — to make reflective judgments, and that loss is underpinned by a loss of connectivity between the prefrontal cortex (“the bridge of the ship”) and the striatum (“the engine of desire”). Then this connectivity can return, gradually, as people recover. Now newly forged connections between these neural systems allow desire and decision-making to work together in the service of future-oriented goals. To put it simply, I see this as the resurgence of volition in a system overwhelmed by habit.

There are many other goads, nudges, constraints, and impacts on volition — the voluntary component of choice. Most important are the psychological mechanisms of “now appeal” and ego fatigue. The passage of time also has enormous impact on volitional choice. Also critical are the roles of impulsive and compulsive action tendencies. How much volition is available during the impulsive phase of addiction, as one’s imagined future slides down a sort of chute into the “now”? Some, I think, but not much. Once the compulsive stage of addiction is reached, how much volition is present? Now action is put in motion before one is even aware of making a choice. Still, compulsion is not abnormal or pathological. When we examine more mundane decisions, like whether to check that the stove is turned off, it’s clear that volition and compulsion mix together, competing and cooperating, as we make choices. It’s not mandatory to recheck the stove.

According to a developmental-learning model (like mine, or that of Maia Szalavitz), interpersonal, social, emotional, and personality factors all contribute to a developmental trajectory that continues to adjust itself, to consolidate itself. So we don’t have to waste another moment conceiving of addiction as a disease. Using personal reports, psychological research, and neurobiological findings as our sources, we can achieve a far more detailed understanding of choice in the context of development, with its phases of relative stuckness and relative flexibility. We can also study the links between brain changes and environmental forces, to increase our knowledge of how addiction develops and how it can be overcome.

Hi again. My work was recently criticized (politely) by a respected philosopher — Owen Flanagan — who specializes in the study of addiction. Here is a very nice article of his, on the topic of addiction and shame. His point was that the word “addiction” is an umbrella term used to refer to many distinct and diverse phenomena, and it is therefore unhelpful and should be replaced. If he’s right, then obviously I’m not the only perpetrator. Most of us in this field use the term “addiction” to describe what we see as a holistic phenomenon. But that doesn’t mean he’s wrong.

I’ve had to take a break from blogging because I’ve been so busy writing pieces for a journal called Neuroethics. I sent them a fairly dense article about a year ago, basically a summary of my book. I vowed to myself that this would be my final piece of academic writing. I much prefer writing “pop science” these days. Surprised? Anyway, I was told that my piece would be followed by several commentaries, and half a year later the total came to 15 — shock! — many from well-known researchers and journalists, including Kent Berridge, George Ainslie, Maia Szalavitz, and Sally Satel. The punchline for me was that I had to write replies to each of these commentaries, to be printed along with them in the journal. And let me tell you, these were sculpted pieces of academic writing — some of them many pages in length — so I’ve had to sweat blood to reply to them. And I’ve still got more than half left to do.

Enough whining?

So let me share with you a few paragraphs from my reply to Flanagan — edited as a brief stand-alone: my answer to the claim that “addiction” is too general a term, given all the distinctions it tries to cover.

According to Flanagan, we should recognize that different attractions to different substances or behaviors really are distinct, and that the umbrella term “addiction” does the field a disservice by lumping them all together. So, he said, it’s a good thing that the DSM has dropped “addiction” (almost) from its vocabulary. Just like the phrase “nervous breakdowns” has disappeared from the popular lexicon: it’s about time we got rid of the outmoded term “addiction.” The culprit, for him, is imprecision. Addiction is an imprecise term, and worse, it brings with it “many problematic accretions and connotations” — no doubt he means accusations of blame, self-indulgence, moral decay, and the resultant stigmatization of addicts.

So Flanagan replaces the word “phenomenon” with “phenomena.” But what are these distinct entities? To me this is like trying to describe and differentiate the various species included under the label “birds” — so that we can do away with the term “bird” altogether. Is that a good idea?

It may seem surprising but Flanagan and I agree on the value of finer distinctions in talking about the phenomena comprising what we’re in the habit of calling “addiction.” The variations in personality factors, the diversity of negative feelings that fuel addictive tendencies, and the nature of the substances or behaviours themselves…altogether provide a cornucopia of distinctions that I think we should discuss and analyze in far greater detail. Here’s just one example:

I have long believed that the kinds of feelings and personality patterns that attract some people to psychostimulants are fundamentally different from those that attract others to opiates. I think that people who get addicted to meth have tended to feel an absence of power, or commitment, or relevance in their lives. They are most bothered by the flatness of their existence. Whereas people attracted to opiates (like me) are fundamentally afraid of losing warmth, acceptance, and connection with other people. We grow up feeling unsafe because we are hyper-aware of our aloneness, and the soothing quality of opiates eases the hurt.

So, lots of differences — important differences! But in my mind, that doesn’t erase the commonalities — the features that different addictions have in common. Such as the growing magnitude of our attraction to one reward at the expense of all others, the impulsive and then compulsive nature of that attraction, and the way that “now appeal” — a cognitive distortion that overvalues immediate rewards — funnels that attraction into a self-reinforcing cycle of thought and behaviour. In other words, all the stuff I wrote about in my recent book.

I believe that neuroscience can move us forward in specifying and understanding what different addictions have in common. But it can also help us understand the distinctions. Depression looks different from anger on a brain scan, impulse looks different from compulsion, and so forth. Our next step should be to discover the brain pathways that tie these mental states to specific addictive patterns.

As for the term “addiction,” I don’t think replacing it with “substance use disorder” is going to get rid of the “many problematic accretions and connotations” Flanagan worries about. That kind of modernization of terminology doesn’t seem to help alienated or marginalized groups. For example, replacing “retarded” with “delayed” never erased the stigmatization of people who can’t think as quickly as others. So in this case, let’s not throw out the baby or the bathwater. Let’s continue to explore how all addictions embody fundamental changes in how we think, feel and act. But let’s also try to clarify how those changes take different forms, leading to different outcomes, for different people.

…by Lisa Martinovic…

There’ve been times during the life of this blog that the Great 12-Step Snowball Fight has erupted — as is typical for any blog, podcast, or article on addiction. I’m not a fan of AA, but I’m not a 12-step basher either. I like to keep an open mind, and I thought this essay was so good that it’s worth giving the Steppers another think.

……………..

In the thirty-four years since I cleaned up, paths to sobriety have proliferated in tandem with rates of addiction. At last count there were some 14,000 treatment facilities in the US alone. If you have good insurance it might cover a stint in one of them. Private therapy is always an option for those who can afford it. For everyone else, it mostly comes down to white knuckling it or AA. But in recent years 12-step programs have been attacked on many fronts, charged with being too religious, dogmatic, disempowering, cultish. Which is unfortunate because although 12-step is not the only way to get sober, it is one way, and it’s been effective for millions of people over the past 80 years.

I certainly had a lot of judgments when I first started going to AA, but in my state of utter ruin I was in no position to be picky. I dove in despite my aversion to all things Christian. The internal conflict I experienced as an atheist and a feminist being told to ‘turn my will and my life over to the care of God’ was agonizing. I thrashed against concepts like “powerlessness” and “character defects,” made grand pronouncements in meetings, and challenged my long-suffering sponsors. Over time, I made peace with the program and have been clean and sober since 1982. Though I haven’t been to meetings in some fifteen years, I will always sing their praises.

In recent years I’ve been studying neuroplasticity on an informal basis and applying its principles to my daily life, especially vis-à-vis my addictive propensities: Chocolate truffles! Mad Men! Facebook!

Not long ago, musing about how 12-step really works, I realized that one of the oft-repeated AA sayings was in fact a description of neuroplastic change: “We don’t think our way into a new way of acting, we act our way into a new way of thinking.” If you take action to foster your sobriety deliberately, repeatedly, and within a supportive community, change happens precisely because you are altering the very structure of your brain. And it happens, I argue, whether or not you believe in God.

This may come as a surprise to those who think that the program is all about ‘turning it over.’ Countless people do precisely that, but sobriety doesn’t happen in the absence of a tremendous amount of real-world footwork. And footwork, be it psychotherapy or working the steps, is what changes your brain and paves the way from addiction to freedom.

As with any new practice, consistent participation in 12-step programs gradually and methodically builds new neural networks. Every sober foray into a situation you used to get high for — first date, party, being alone and lonely — strengthens your capacity to do so again. Thanks to your malleable brain, the more you do something sober the easier it becomes. But you may need to muddle through a thousand situations sober before it comes as naturally as it did when you were drunk. It’s hard for most of us to stick to our resolve that many times. But with the support of others it is possible.

AA contends that because our willpower has “failed utterly” to get us sober, we have no recourse but God. Really? Well, what does every participant at every meeting find every time? What is the common denominator? Not God, but other people getting sober. We find community. The generous support of other human beings carries us when we cannot carry ourselves.

I was thrilled to discover, through Marc’s books and others, that my theory about how we get sober is corroborated by science. By integrating the research into my own experience, I have developed a pragmatic approach to recovering from addiction—an unauthorized 12-step workaround.

I want to share this approach with addicts who know they need help but are unwilling to explore the 12-step route. I wrote an essay in STIR Journal for them, their loved ones, and those who would help them, and Marc has generously invited me to share it here.

By unpacking the neural mechanisms through which we achieve behavioral change I give addicts who hate “the God thing” a different way to access the 12-steps—and recovery.

Read the full essay here.

Marc: Also see this article for a recent court case pitting the 12-step oligarchy against one person’s atheism.

Hi guys…I’ve missed you. I’ve missed putting up regular posts for the last couple of months and I’ve kept mostly out of the discussions and debates in the comment sections….but scanned them enough to see that you are still in top form. I encourage all readers to take a look at the comments on the last few posts. There are some really valuable views, arguments, and insights being posted.

Anyway, for now, I wanted to wish you all a good year and maybe touch on some current controversies that will affect us in the coming months.

What have I been up to? Mostly editing and proof-reading a couple of articles, updating a talk that I plan to give next Saturday in London on sex addiction, planning a new talk circuit, and zillions of little things that I can’t name or categorize or even remember half the time. Paying backlogged bills, replying to emails buried in my inbox, trying once more to learn Dutch, changing light-bulbs, driving or biking (with) my kids around to various lessons, shopping, etc., and doing a fair bit of psychotherapy. Remember I mentioned that I’m starting a Skype-based counselling/psychotherapy practice for people “in addiction”? Well, it’s happening. I have about six clients so far, and I really like it. Sometimes I feel like I’m good at it, and sometimes I even seem to be helping people, which of course feels great. And relaxing…a bit more than usual…especially over the holidays. That was gooooood.

So what are some topics that should be addressed in this year’s postings? Here are some thoughts:

The “opioid epidemic” in the US. This is obviously a big issue, it’s on the front page half the time. I even get asked by people why I haven’t contributed to the debate yet. Well partly because it’s so complicated, partly because I’m not sure I understand it, and partly because it makes me sad.  One avenue of debate involves prescription vs. street drugs. And that divides into two sub-themes, addiction and overdose.

First comes the evidence that most people who end up on heroin started off on prescription painkillers. What does this mean? Does it mean that getting opiates for pain is the cause of long-term addiction and all that goes with it? Not according to Johann Hari, as revisited in his recent op-ed piece. He reminds us (despite a spat of criticism) that by far the majority of people who take prescription meds for pain don’t get addicted. Carl Hart pounds out the same message. So is this just a rehash of the gateway drug idea — remember how they used to blame smoking weed for graduation to hard drugs? Most people ride bikes before they learn to drive cars. Does this mean that bike-riding is a dangerous precursor to auto deaths? Or is it smart for addicts to avoid heroin if they possibly can? How do we extricate the logic from the rhetoric here?

Obviously prescription opioids have to be handled with great care. Yet prescription opioids are often mixed with each other and/or with heroin, by people who want to get high, not pain-free. So how do we balance their risks against the needs of  the millions who really need these drugs for pain control?

Which brings us to the overdose epidemic. Which is obviously highly interwined with the above. Although overdose deaths are reported to result from the use of prescription drugs more than from heroin, these deaths have everything to do with mixing drugs, as I’ve reported elsewhere. And this issue has taken on deadly significance now that fentanyl has entered the scene. Stanton Peele has a few things to say about that. With fentanyl so widely available (it’s entirely synthetic, you know), and with doctors getting increasingly tight-fisted (partly due to pressures from regulating bodies), what choice will addicts have other than street drugs (or abstinence)? So is legalization the only other answer? With all the problems that entails? But even without fentanyl…why exactly do people take so much dope? What does it tell us when they’re mixing heroin and methadone? I’ve touched on that one as well.

So those are a few of the headline topics that we can deal with this year. And there are others. With Trump in the US, Duterte in the Phillipines, and Putin in between,  getting arrested for using drugs is starting to look more lethal than overdosing. What is going on in terms of the international pendulum swing between draconian repressive approaches and the ever-more-enlightened drug policies of countries (like the UK, Canada, and Australia) where people are stepping away from the “brain disease” model and the nasty habit of throwing addicts in jail? Cannabis will soon be legal throughout both Canada and the US!  And it seems they’re finally about to close Tent City — that horrible concentration camp for addicts in sunny Arizona — if they haven’t already. Are things getting better or worse?!

And there’s so much more to talk about. More acceptance of the validity of “controlled drinking,” as we heard about from James Morris a few posts ago. Ongoing turmoil but also some radical new perspectives regarding 12-step approaches and AA. See next post. And sure enough we keep learning more about the addicted brain. In a radio interview with KABC Los Angeles last week, I fell back into this interminable squabble between the brain disease model and my (alternative) no-it’s-not-a-disease-but-yes-it-still-involves-the-brain model of addiction, and all I really wanted to say, by the end of it, was: it’s time for a truce! We’re not listening to each other! Well maybe this year, on this blog, we can find a way to do that.

Please suggest other topics you’d like us to explore. That would be very welcome.

So Happy New Year, welcome back, and let’s hope it’s a good, better, maybe even best year for those of us who care so much about addicts and addiction.

An “attractor” is really just a description of how a system (e.g. a person, a person’s brain) behaves — how it looks from outside. Here, in the second half of the article (revised), I look at the underlying mechanisms that explain why addiction works as an attractor — why it behaves the way it does.

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Most obviously, addiction is characterized by a strong desire to pursue a substance or behaviour. The substance or activity temporarily relieves the desire, but a negative emotional state is left in its wake. Loss, disappointment and anxiety emerge as soon as the substance or activity is finished or no longer satisfies — e.g., once the drugs or booze are gone. And so desire builds once again. In this way, addiction perpetuates the need it was intended to satisfy. But it also perpetuates the behaviour: the addict learns to satisfy the recurring state of need by getting more, doing more, thus further consolidating the learning — and the neural patterns underlying it. What fires together wires together. The biology of learning locks in the habit, so choosing to stop is not a simple one-step decision. You have to choose to stop repeatedly and continuously until these neural patterns have a chance to reconfigure.

Brian taught in a community college in Cape Town, ran a successful business, and generally used his fine mind to good advantage. But the pileup of obligations and a mild attention-deficit problem saw him begin taking various stimulants to stay awake and clear-headed. Within two years, he was smoking crystal meth several times per day. Sleep became sporadic and unpredictable. He could no longer think in straight lines, and fantastical whims soon replaced his customary rationality. His business fell apart, he moved in with his dealer, and his precious relationship with his young daughter turned into a parody of parenting, with him sneaking out to the car every hour or two for another hit. Meth comes on strong and brings with it clarity, optimism and brilliant energy. But Brian’s sleep loss meant that the high was increasingly short-lived. With the first hints of loss, he would grab for his pipe, eager beyond reason for another launch.

Other (interconnected) feedback loops facilitate and consolidate addiction. They include social isolation, reinforced by the addiction, which leaves the addict with fewer opportunities to reconnect with people, or with healthier pleasures. They include the rationalizations that addicts know too well: if I’m such a bad person, or so misunderstood, then I might as well do it again. Brian was a self-reflective guy; he knew how much he had lost. His ongoing self-destruction seemed a punishment for what he perceived as his failure.

Addiction isn’t about rationality or choice; it’s not about character defects or bad parenting, even though childhood adversity is clearly a risk factor. Addiction is about habit formation, brought on through recurring, self-reinforcing feedback loops. And although choice is not obliterated by addiction, it is much harder to break deep habits than shallow ones.

With respect to mental health more generally, addiction can be seen as one member of a family of attractors. Depression, anxiety disorders, post-traumatic stress disorders and other stable conditions are highly resilient despite their unpleasantness. They are identifiable as attractor states — unattractive attractors we might call them — as readily as addiction.

According to classical learning theory, rewarded behaviours proliferate, while behaviours leading to adverse consequences are extinguished. Yet this clearly misses the point when it comes to the development of emotional problems. Rather, it sometimes seems that the most unpleasant conditions are the most likely to become entrenched. Mental and emotional states characterized by suffering appear in adolescent development with remarkable frequency, and they continue to dominate the personality for years if not for life. Why would such negative states become attractors, become concretized and stuck?

Perhaps emotional problems like depression and anxiety are diseases. These are indeed the conditions that psychiatry has labelled and pretended to understand — then remained impotent to prevent and treat. Even the medications prescribed for these ‘illnesses’ are notoriously ineffective. (Antidepressants simply do not work for most depressed people, except as placebos.) So it’s not surprising that addiction might also be viewed as a psychiatric illness — one that’s hard to treat and therefore “chronic.”

Deep psychological attractors such as addiction, depression and anxiety disorders stabilize for a reason — and it’s not because they make things easier. In general, they stabilize because the interactions that forge them involve strong emotions that call for cognitive compensations that end up making things worse. Depression, for example, involves a sense of loss and rejection that calls up ruminative thoughts whose very character tends to be self-deprecating. The more we examine ourselves, the more fault we see; and so rejection, sadness, and shame are amplified. Anxiety draws attention to threat. That is its evolutionary purpose. Thus anxiety disorders arise from a very simple, very pernicious feedback cycle. The more anxiety, the more attention to what could go wrong, to the dangers implicit in the environment. In turn, this thinking amplifies the feeling of anxiety. And so on.

Thankfully, most people pass through their depressions, conquer their fears, and come to terms with their traumas, through some combination of effort, circumstance, skill and luck. With respect to addiction, the news is generally good. With all substances, including heroin, methamphetamine and alcohol, most addicts recover. Depending on the researchers’ claims, methods and definitions, proportions vary roughly from 50 per cent to 90 per cent. The latency to quit or to achieve controlled use varies with the substance, the person and the culture. But experts increasingly agree that development itself drives recovery. While repetition leads to habit-formation, it also leads to boredom, frustration and despair, and these negative emotions impel us to keep on trying something we might have failed at before, as our skills and self-knowledge continue to mature.

Donna stopped taking opiates as soon as she began psychotherapy. She was lucky to find a therapist who not only understood her addiction but understood her, especially the childhood hurts that had sent her searching for chemically induced peace while rationalizing the triumph she’d achieved through deceiving others.

Johnny stopped drinking just before he killed himself. Our interviews took place when he was in his late 60s – an age he’d once seemed unlikely to reach. Johnny used AA, psychiatry, yoga, massage and just about every other trick in the book. His suffering was too great for him to stop trying.

Brian, meanwhile, not only gave up meth; he is now completing a PhD in addiction studies. He holds three international grants for applying addiction-treatment strategies to difficult populations, and he was invited to speak to the United Nations about new directions in drug-policy reform.

Not all addicts grow out of their addictions. Some remain enslaved for life, and some die. But the very stuckness of addiction, the redundancy and stupidity of chasing the same narrow goal each day, constitutes a worthy challenge for all that’s creative and optimistic in the human repertoire.