Understanding Addiction

I just listened to the first 15 minutes of a lecture by Robert Sapolsky, a renowned biologist and Stanford professor. Sapolsky begins with an incisive lesson on why humans rely on categories. Categories, he says, make it easier to think about complex phenomena. And human social behaviour is nothing if not complex. My friend Tom insisted that this online lecture series was worth viewing, and he’s right. I plan to view the rest. But first, this post.

Take something a little simpler than human behaviour. If a colour falls between orange and yellow, you’ll have a harder time thinking about that colour and remembering it than if it’s either orange or yellow. Yet light frequencies fall along a continuum without boundaries. In other words, we actually invent colour boundaries, and different cultures see colour differently. It’s easier to remember a shape if you can call it a circle or a square than if it doesn’t fit any geometrical category. If the shape is squarish with rounded corners, or blob-like, you’ll have a harder time thinking about it, remembering it, and using it in a conceptual task. (Sapolsky demonstrates these examples on the white board.)

So, okay, categories are tools for simplifying perception and thought. But there are several down sides to categorical thinking. Sapolsky mentions a few, but here’s the one that inspired this post. Remember when 65 was the cut-off between a pass and a fail? (That was the cut point when I was an undergrad.) So you’ve spent much of the week partying, getting high, etc, and here comes the exam, and you cram for it that morning, give it your best shot, and wait anxiously for the result. A week later the prof hands out the exams, or you look up your grade on the bulletin board, and the thing you care about more than anything else is whether you got at least a 65. If you got a 64, you’re shit out of luck. If you got a 66, you’re sailing.

Now how much difference is there, really, between a 64 and a 66? How much information does that distinction actually give you, about your performance, your dedication, your intelligence, or your use of free time?

This isn’t the first time I’ve conceptualized addiction (intensity, duration, riskiness, etc) as a continuum — a continuum that does not lend itself at all to two categories, disease vs. health. Other addiction thinkers, researchers, treatment providers, etc, have also remarked that addiction is a spectrum, a dimension, a set of gradations at best — nothing like an all-or-nothing category. Yet the disease label cannot help but classify addiction as a category. You either have tuberculosis, or diabetes, or cancer, or you don’t. Never mind that, when it comes to addiction, the category label itself can do more harm than good. As soon as you classify addiction as a disease, you draw a line. (There is some discussion of this issue in the commentaries on an article of mine.)

Indeed, the disease labelling trend in the US and elsewhere makes it stupidly easy to put addiction in a wastebasket category. You’ve either got it or you don’t. And if you’ve got it, then free choice, self-control, empowerment, and so many other features of human thought and emotion are neatly defined. Easier to think about, right?

Sapolsky makes other cool points about how categorical thinking obscures real complexity. For example, falling into the same category doesn’t necessarily mean that two things are similar. As we know, two people, both categorized as having the disease of addiction, can be as different as giraffes and field mice (just two animals that came to mind).

Many of my readers will probably agree that categorical thinking, this mental-labour-saving device, misses so much — so much of the real complexity of addiction — that it can’t help but muddy the waters.

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This is remarkable: four hours after posting today’s post, I found an email in my inbox that contained nothing more than this link. If this man can face his addiction and challenge it, without submitting to the disease categorization, then…that’s all there is to say. The post is electrifying, extremely well written, and deeply moving. I’m honoured that my work figures in his thinking.

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.

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

Picasso –self-portrait across the lifespan

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

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

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

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

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

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

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

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

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.

…by Jenny Valentish…

Not everyone enjoys the label ‘sober’. I personally don’t call myself an ‘alcoholic’ or ‘identify as an addict’. I’m also far too English to use a dramatic phrase such as ‘in recovery’.

In my book, Woman of Substances: A Journey Into Addiction and Treatment, I don’t call myself ‘sober’ either, partly because the term reminds me of ‘sombre’, ‘sob,’ and ‘so boring’, but also because, since stopping drinking eight years ago, I’ve taken drugs. I ate a hash cookie at a dinner party; a psychedelic in the spirit of self-exploration; and then there’s been silly, teenage stuff for the ridiculousness of it – a whiff of amyl nitrite in the red light district of Paris, a balloon of nitrous while watching Twin Peaks. This freedom was a decision I made after two years of total abstinence, and it’s about joyous bursts, rather than the grinding self-medication of yesteryear.

Personally, having that pressure-relief valve feels safer to me. Telling myself ‘you can if you want’ doesn’t provoke the imp in my brain into leaping for the chandeliers because, as we all know, being given permission to do something immediately takes away the appeal. By contrast, telling myself I’m abstinent for life might result in an almighty blowout one day as the pressure builds. No system is infallible.

There will be people reading this with anger burning in their heart. To someone who is truly sober, my generous ‘you can if you want’ policy borders on betrayal. I know how that feels. I remember when a couple who had quit drinking told me that they’d each had a beer at a wedding, and reported with pleasure that they didn’t enjoy the beer and now they knew they didn’t need to wonder about it again. I felt an inexplicable fury. For me, alcohol was an absolute no-go zone; never worth risking. So that was the root of my rage: they’d made a decision that had worked out just fine for them, but it threatened my new blueprint for life.

Whatever your personal policy, drug and alcohol treatment shouldn’t be one-size-fits-all – and it isn’t, if you spend a little time investigating the options.

While some people classify as hardcore poly-drug users, most people have a leaning towards one type, such as sedatives, or stimulants. As a pertinent example, I’ve interviewed Marc Lewis, and he told me, ‘I don’t imagine I could continue moderate use of opiates, but a drink is okay for me because it’s not my drug of choice.’

Bill Wilson, the co-founder of Alcoholics Anonymous, quit drinking in the thirties but experimented with LSD with Aldous Huxley in the 1950s. He even hoped LSD could prove to be beneficial to those in recovery. These days, debates rage on recovery forums as to whether opioid replacement therapy is okay for NA members, or whether a ‘marijuana maintenance plan’ is acceptable when attending AA. In fact it might make sense to go to an outpatient drug and alcohol service and collaborate on a plan that includes, say, moderate pot use in the service of quitting methamphetamine (this option is already available in the UK and Australia).

Geoff Corbett is a senior clinician who works with young adults in Brisbane, Australia. He tells me this:

There are always going to be outliers that AA and NA can put on a pedestal, but there will be another thousand people that AA and NA won’t work for, which is why we [in Australia] provide options. If we work from our harm-minimization framework, abstinence can be at one end and safer use can be at the other end. The client chooses options in between. It requires good assessment and really good treatment planning to look at achievable goals and put some parameters into place. We keep in mind that a person’s life is in flux and we can move the goalposts any time we want.

Australian dry-community website Hello Sunday Morning also has a flexible approach to tackling alcohol use. Founder Chris Raine has this to say:

Nowhere do we dictate what a person has to do to be a part of Hello Sunday Morning. Our wording – ‘reassessing your relationship with alcohol’ – turns it into a subjective experience. Even government campaigns in Australia are starting to use that kind of wording, and that’s a good cultural shift. It’s not about ‘Are you an alcoholic? Are you addicted or not?’ It’s about ‘What relationship with alcohol would you like?’ It could be none; it could be some.

Certainly for some people, abstinence is the only safe option – and they know that. There’s a spectrum of severity, and I can’t compare my former levels of dependence to, say, those of the brother of a friend who died after continuing drinking post-liver transplant, or those of my mate who winds up in a hospital or psych ward every time she drinks.

The most important thing is to accept that mistakes, lapses, relapses, busts, lessons, errant evenings, experimental breaks – whatever you want to call them – are statistically likely, no matter what route you choose. That means maintaining vigilance for old behaviors creeping back in, whether it’s six months, five years, or twenty years after you’ve curtailed your habits. Vigilance, purposefulness, meaningfulness, curiosity, goals and altruism – they’re your new stash. Keep them close.

For more about Woman of Substances, go to the Amazon page or the author’s website.