Understanding Addiction

I just got a piece published in Newsweek! This makes me happy, to be sure. But if you see the paper version, the headline they picked does NOT appeal to me:  “My Kool Acid Test”. Hmmm….not my choice, but I couldn’t talk them out of it. Oh well, it’s Newsweek, and I’m a shameless publicity hound these days…

Here’s the link to the online edition. Below I’m going to paste in the UNABRIDGED text. Although I was after a story-line that focuses on the sixties, I think the “then and now” aspect is really interesting. And though they cut this part for the publication, check out the contrast between Ecstasy, today’s favourite party drug, and LSD, our drug of choice 40 years ago.

I’m a neuroscientist, I try and understand how the brain works, but I take a special interest in how it doesn’t work when people take drugs. That interest arose from memories of my own troubled youth: I used to be one of those people. For most of my late teens and twenties I ingested every drug I could find, and I became seriously addicted to hard drugs for part of that time. Now I try to make sense of those years, by exploring how different drugs modify brain function and how those modifications can become so terribly attractive. The drugs we find appealing reveal much about who we are; yet their effects remain mysterious, almost unknowable, until we look at the brain and its own intrinsic chemistry.

My drug-taking adventures began in the late sixties – when the world seemed wide open, waiting to reveal its wonders. I had just arrived in Berkeley, California, and my newfound friends and I were spellbound by the mind-expanding potential of LSD. But the world has changed since then, and the drugs we take today, including SSRIs and ecstasy, send our brains in a very different direction, toward comfort rather than freedom. The irony is that both these pathways begin with one very special molecule: a neurotransmitter called serotonin.

LSD (lysergic acid diethylamide) goes to work in the brain by blocking serotonin receptors, the gateways that allow serotonin into our neurons. As a result, serotonin molecules flowing from our brain stem have nowhere to go and nothing to do. Serotonin’s job is to reduce the firing rate of neurons that get too excited because of the volume or intensity of incoming information. That’s how it calms synaptic traffic, modulates extremes, regulates and supervises the brain. Serotonin filters out unwanted noise, and normal brains rely on that. So, by blocking serotonin, LSD allows information to flow through the brain unchecked. It opens up the floodgates – what Huxley called the “Doors of Perception” – and that’s just what it felt like the first time I took it.

My first acid trip was both wonderful and terrifying. I was in a friend’s apartment, among a rag-tag assortment of hippie types, and I swallowed a little purple pill during a prolonged Monopoly game. About 45 minutes later, the room started to disintegrate. I had to stop playing; I could no longer read the numbers on the dice. The dice, the plaster walls, the chattering voices, the facial hair of my compatriots – each perceptual gestalt broke apart into its constituent details, moving, changing, swirling, arranging themselves into patterns of geometric beauty or turgid ugliness. My senses and thoughts were out of control, and the world rushed in relentlessly.

LSD was invented by Albert Hofmann in the 30s, but its psychedelic properties were not apparent until he tried it on himself, in 1943, and thought he was going mad. For a couple of decades, psychiatric researchers tried  to treat disorders ranging from schizophrenia to alcoholism with LSD. The CIA and US military got into the act in the 50s and 60s, with the hope of manipulating potential informers or instilling mass confusion in enemy troops. But the effects of LSD remained elusive and unpredictable. It was deemed more trouble than it was worth in government circles, but it found its true calling as the emblem of a generation intent on change. For my friends and I, LSD was revered as a key that could unlock human perception and redefine human potential. So I took acid at least once a week and watched the grain of the sidewalk separate into rainbow fragments, gazed at the canopy of a redwood forest devolving into geometric scribbles, or tossed in the surf of my own cognition as it swelled in profundity. I wanted to open up my senses, strip off my mental armor, and let reality enter. And I didn’t give up for several years, until acid finally became routine, and I got drawn toward darker adventures with addictive drugs, heroin among them.

Still, for those few years from 1968 to 1972 , acid seemed the leading edge of a culture bent on charting new territory. “The times they are a changin’” chanted Dylan, and the world seemed rich with  possibilities. As far as my friends and I were concerned, LSD, mescaline, and psilocybin – all compounds that torpedoed serotonin – made that world accessible. Move over, serotonin. Safety is out. Infinity is in. So we popped our pills and wandered the frontiers of inner space. At least until the drug wore off and our serotonin molecules flowed huffily back into place.

In the last ten years, serotonin has again been the target of a culture-wide chemical invasion, but the new drugs shift human experience in the opposite direction. SSRIs (selective serotonin reuptake inhibitors) — like paroxetine (Paxil) and fluoxetine (Prozac) — are used to treat depression, anxiety, PTSD, OCD, and undefined feelings of ickiness. Instead of getting rid of serotonin, these drugs block the reabsorption process, so that serotonin keeps piling up in the synapses. The result: an extra-thick blanket of serotonin that filters out the intrusions of anguish and anxiety, making our inner worlds secure. Instead of turning on, tuning in, and dropping out, they help us turn off, tune out, and drop in – into a solipsistic safety zone, protected from too much reality.

Unlike the psychiatric researchers of the 50s and 60s, today’s psychopharmacologists are pleased with their progress. Every year or two, new and perhaps improved SSRIs are dumped into the waiting hands of millions of needy patients. (By 2007, antidepressants were the most pescribed drugs in the U.S., according to the Center for Disease Control.) But what do these new molecules tell us about our culture, about how we perceive our world? Apparently, now is not a time of exuberant exploration, but a time to hunker down and play it safe. The world seems too upsetting to wander in search of new adventures, too dangerous to explore beyond our own front porch. Instead of letting the world in, with all its uncertainties, we try to keep it out. And a barricade of serotonin makes that possible.

Even the recreational drugs of today’s youth point the weather vane of serotonin toward comfort rather than freedom. Ecstasy (MDMA) increases serotonin in the synapses, like a hyped-up antidepressant, making the world feel cozy. And while it’s true that most people don’t take serotonergic drugs, either from their doctor or their dealer, it’s no accident that those who do are resonating to a cultural theme much different from the optimistic vision of the sixties: Life is dangerous, protect yourself, or at least make yourself comfortable.

The drugs we take, the drugs we create, offer an idealized antidote to the cravings of our times. LSD was born from our craving for freedom. SSRIs reflect our need for security. Molecular makeovers never quite get us there, but they can show us where we are and where we’ve been.

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for addicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

The judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

……………………………………

I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

Any individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.

Self-destructive thoughts and feelings grow from ripples to tidal waves in people who develop addictions. But how does self-directed aggression become entrenched in our inner worlds, and how can it be dislodged?

Everyone who’s ever been addicted to anything is bound to know two feelings — craving and self-hatred. These feeling states essentially define addiction. They’re coordinates on the map. We more or less understand craving, biologically as well as psychologically. I’ve written about it and so have others. But we don’t understand its infamous partner in crime. How do people come to hate themselves? And why might this feeling be central to addiction?

Self-hate isn’t exclusive to addicts. Almost anyone you talk to about their inner world will admit to a hostile self-critic who blames them, sometimes savagely, for whatever they did that was wrong or stupid. Self-directed aggression spans many cultures. The tradition of seppuku (suicide motivated by shame or guilt) grew up in the warrior classes of ancient Japan. The Catholic Church spread the idea of original sin (leading to repentance) wherever colonialism took hold. Self-nastiness seems to have quite a hold on human civilization. But how does it seed itself in young minds? How does it grow?

Kids everywhere are notorious for one overarching concern: “I’m gonna get in trouble!” You hear it on the way home from school, when someone’s buddy suggests cutting through the construction site. Or when your friend starts opening drawers in your parents’ bedroom. Or when you lock the dog in the bathroom. There’s only one reason not to try and have some illicit fun. That if you do, and you’re caught, someone is going to get mad at you, which probably means you’re going to get punished.

Getting in trouble turns the world from bright to grey. It replaces ease and freedom with a sense of doom. So…when your friend or your little sister gets you in trouble, you get pissed off at them. Now look what you did! If that happens repeatedly, you start to avoid them, mistrust them, and dislike them. With friends like that, who needs enemies?

But around the age of four, little kids make several potent discoveries. They begin to understand that other people are defined not only by their behaviours but by the thoughts, feelings and intentions that generate those behaviours. They realize that other people have private and unique minds, and this discovery is called Theory of Mind. Shortly after that, kids begin to appreciate that they themselves have minds, and that their thoughts, feelings and intentions cause their own behaviours. They start to see “myself” as a human category, comparable to other selves.

This universal advance in cognitive development makes the social world a complex place and joins it irrevocably to the internal world. If you’re the kind of person who’s impulsive or defiant, I’d better stay away from you, so I won’t get in trouble. But if I’m that kind of person…then what? I can’t reject myself…or can I?

That’s the crux of it. We start judging and classifying others by age five or six. We start taking needed precautions so they won’t get us in trouble. And we start judging and classifying ourselves around the same age. But we can’t avoid being ourselves, being with ourselves, and we can’t avoid the feelings of desire and defiance that well up in our own minds. So…just as we reject others for being the kinds of people they are, we begin to criticize and reject ourselves for being the kinds of people we are. We can’t delete our inner states — states such as craving — but we sure don’t like it when they get us in trouble.

There are many ways adults get in trouble — saying the wrong thing, at the wrong time, in the wrong tone, looking too long or not long enough at the wrong person. But there is no more surefire way to get in trouble than to take powerful drugs (including alcohol) against the wishes of those around us. Other people reject us when we do these things. Yet somehow some of us continue to do them. And we quickly learn that these behaviours are generated by the very mental states — craving, anxiety, defiance — that define us.

We silently yell, Stop it! Don’t go there! I hate you for doing this to me! I hate you for getting me in trouble! The only glitch is that the person we hate happens to be ourselves. (And in case you didn’t see it coming, these are among the “parts” that IFS tries to identify and soothe.)

Most everyone is self-critical, to a degree. But addicts raise this human pastime to some kind of art. In all my interactions with addicted clients, in my reflections on my own years of addiction, I find no more lethal volley of self-abuse than the tuned self-denigration addicts level at themselves the morning after. I did it again. I hate myself. And there’s nothing more likely to trigger renewed craving than the sense of assholeness left simmering for the rest of the day.

So how do we overcome this dark spiral? For healers and humanists of many stripes, self-compassion is what’s needed. Self-compassion breaks through self-hatred, saying “I get what it’s like for you. You’re not so bad!” But self-compassion can feel foreign, and people often need help discovering it. It’s no coincidence that self-compassion is the main message behind many forms of psychotherapy, including ACT, EFT, IFS, and mindfulness-based approaches. Once you get the hang of it, self-compassion starts to extend itself, and that’s a lovely thing. Maybe that’s the reason former addicts often end up in better shape than those who’ve never strayed.

Following that invitation to meet with the Dalai Lama, I’ve been looking more into Buddhism and studies that link it with neuroscience – and with addiction. In one recent article, I learned that mindfulness/meditation (let’s call it MM) changes the brain in one important way. From the treatment community, we also know that MM helps people recover from addiction. Research has been sparse so far, but there are good results with respect to smoking. So my question is this: if we know that MM changes the brain in such and such a way, and if we know that it helps reduce addiction, will we come to understand what neural processes are at the core of addiction?

An important brain region has been identified in many labs in the last few years. It’s called the Default Mode Network. This area (which includes the posterior cingulate and medial PFC) “lights up” when we are daydreaming, self-reflecting, imagining our selves in past or future situations, or imagining interactions with other people. In other words, the default mode is where we go when we are going with the flow and thinking in an undirected way about ourselves. Most interesting is that the default mode network turns off when we become focused on a task. When we have to do something novel or challenging, we leave the default mode and enter a focused mode, supported by very different brain regions, including the dACC – a region I’ve discussed as critical for self-control.

This particular article shows that MM changes activity in the Default Mode Network – a finding supported by other studies. The more you meditate or practice mindfulness, the more likely you are to activate the “focused” brain regions and turn off the default mode, especially when you’re required to pay attention. This article also claims that the reason MM helps people recover from addiction is because addicted individuals have too much activation of the default mode network. In other words, the images, cues, plans, ideas, associations, etc, that come to your mind when you’re addicted are more like daydreaming than focusing. You are using a brain region that DOES NOT solve problems but maintains a habitual sense of who you are.

I found just two articles that show that addicts have more activation in the Default Mode Network than other people – not a huge number of studies so far, but still… One of these showed that the default mode network is highly activated in heroin addicts, and this activation does not go down when they’ve had a dose of methadone. So whether you’re high or not, this is home base.

I’ve usually considered addiction as being too focused. After all, craving – the main ingredient of addiction – means having one goal and only one goal consistently at the centre of your attention. But it’s also true that there’s something very unfocused about addiction. Your thoughts are following such familiar ruts, without conscious guidance, and your sense of yourself is habitual rather than flexible. Oh wouldn’t it be nice if…..here I go again…not too surprising….well I don’t have to quit this week….could wait till things get less stressful, etc, etc. So maybe that unfocused state is where the addictive plan starts to form. Look at this snatch from John’s Guest Memoir:

Resting after the first set [of exercises]; I do something I should not do: I trace with my finger along a raised vein on the back of my forearm, slowly, gently, slightly, thinly smiling — the blood’s rushing to my head already anyway — tap on that one good spot a couple times, and now here comes the idea. Ohhhh… and oh fuck that reminds me of the dream I had last night.

That pretty much typifies the default mode…not paying attention, letting your thoughts go, which includes letting them go to places where they really should not go.

So, if addictive behaviour arises from a brain network that supports habitual, undirected thoughts, and if MM helps bring focus and clarity to one’s thinking, by deactivating that network, then it wouldn’t be surprising that MM is an important tool for recovery. And this kind of research, which is starting to grow exponentially, teaches us critical lessons about how treatment can tackle addiction – right in the middle of our brains.

On January 28 I started a series of posts reviewing promising psychotherapeutic approaches to addiction. I managed to cover a few, though with stops and starts — mostly due to Covid hassles and anxieties. So today I’m continuing the series with a post on Internal Family Systems (IFS). I wanted to understand it better before trying to explain it, and I think I finally do.

For years my online therapy with people in addiction has relied on my early training in psychodynamic therapy, dobs of mindfulness-meditation, what I’ve picked up from emotion-focused psychotherapy, ACT, Gestalt and other gems, plus my own personal experience of addiction. Add to that 30 years studying developmental psychology with a focus on emotion regulation, and what I’ve learned about the brain processes that underlie addiction and drug use. All of this came together in my own hybrid style of therapy. And it usually helped. Yet there were people I couldn’t help at all. There were brick walls and false leads and levels of trauma, chaos and heartbreak that left me gaping, and left my clients no further ahead. I knew I needed more training.

Internal Family Systems has been around since the 80s, and more and more people are becoming aware of it. It’s not easy, primarily because its premises go against the grain of mainstream psychology. Instead of trying to fuse the parts of the person into one coherent whole, IFS allows the parts to remain parts, it sort of honours them, so that you can get to know them, listen to them, understand them, and eventually take care of them. With respect to addiction, you never hear “you must stop.”

What are these parts? Maybe you’ve thought of them as voices, or selves, or subpersonalities — it doesn’t matter. They appear as habitual perceptions or expectations with distinct emotional loadings (e.g., anxiety, anger, longing) — and they can be intrusive in the background or they can seem to take over.

In working with addiction, the parts are not hard to find. Addicts often identify at least two. One is the “addict self” who just wants to get high (or to binge or have sex). That part is powerful, it overtakes the system, it has no regard for tomorrow, and it’s very difficult to resist. In AA, it’s said to be doing push-ups in the parking lot. In psychology jargon, it’s called compulsion. NIDA calls it a diseased brain. But I don’t find any of these concepts at all helpful. From a neuroscience perspective, I can point to the part of the brain that “does” compulsion — the dorsolateral striatum — but all that’s really doing is putting a habit into play. And as we know, addictive urges are all about habit. So what happens if we consider this to be a part of a person that is young, energetic, one-track minded, and determined to overcome negative emotion in the only way it knows how? When you think about it that way, it’s hard to negate it or to hate it.

The other part addicts often identify is the voice that gives you royal shit for doing it, thinking about it, planning it, having done it (drinking, drugs, gambling, whatever) last night or every night for the last week or the last month. We often call this the internal critic, and its specialty is self-blame and self-contempt. So what happens if we see this part as a younger version of ourselves, who learned to be our caretaker or disciplinarian? You better be good! Don’t you dare goof up again! You’re going to be in real trouble if you do that!! Once we see this part as trying to help keep us out of trouble, it’s hard to feel alienated from it or even victimized by it. Instead, IFS asks us to open a dialogue with this part. For example: You come out whenever I’m likely to do something “bad” (like call my dealer), don’t you — I guess that’s been a full-time job lately. But then you get so upset with me that I get seriously depressed, and then I just want to get high all the more. Let’s try reducing the pressure a bit.

And there lies the problem for most addicts. (I use that word for convenience, as you know.) The critical voice and the “let’s get high” voice activate and augment each other. Endlessly. In IFS, both these parts are called “protectors” because their job is to take care of you. Neither one is evil. They just have radically different styles. The critical voice or “manager” thinks only of the future. The “getting high” distractor voice thinks only of the present. These two parts branched off and solidified, earlier in development, because you needed them. Or so it seemed. How many times a day do you suppose the average 6-year-old thinks about NOT getting in trouble? How many times did you do bad shit anyway? The trouble now is that those two parts are so busy trying to shut each other down that you can’t get anywhere. Neither part will stop doing what it’s doing. It all seems so hopeless.

IFS recognizes a third class of parts called “exiles”. These are (usually) the really young parts that have experienced trauma or abuse of one kind or another. They are terrified. They’ve been hurt or shamed beyond their capacity to heal. We normally can’t or don’t want to re-experience that hurt, so we keep it buried. Hence the term “exile” (what psychoanalysts call the unconscious). But we don’t bury all of that pain…the hurt rises up inside us when we feel desperate, alone, misunderstood, or threatened. Addiction itself can trigger these feelings! And that’s exactly when the distractor — the “I need to get high” voice — gets activated. I can take care of this awful feeling, it says. Right now! Which of course triggers the manager part: Don’t you dare! You promised. Then the savage back-and-forth between these parts pushes the exiles further down, hides them even more, and douses them with more shame and fear…in case there wasn’t enough already.

Having practiced IFS as a therapist now for several months, I am sold on its efficiency and its power. (I’ve even begun as a client, myself, with an IFS therapist. What better way to learn the ropes…not to mention some timely self-improvement.) My clients “get it” almost at once. I don’t have to sell them on the rather esoteric imagery and jargon. They just take a look inside and say, Um yeah, that’s pretty much what’s happening. And then they start to change.

This is just a bare-bones intro. Let me end by saying that the goal of IFS is to let your Self (they spell it with a capital S) start to take care of your parts — appreciate them, comfort them, ask them to turn down the volume, to step back a bit. And reassure them that you — the present whole you, the Self, the calm centre that you may find in meditation — are going to take care of things, and take care of them — so they can begin to relax.

It’s pretty remarkable to feel that start to happen. You don’t feel so desperate. And all those layers of hopelessness begin to lighten and float away.