Understanding Addiction

…by Matt Robert…

Wouldn’t it be nice if we never had to think about our addiction ever again? I posted about 10 months ago on the benefits of mindfulness in recovery. One of the points was that mindfulness informs all cognitive-behavioral approaches: it’s important to pay attention to what you’re telling yourself, and that takes practice. Practice as in mindfulness practice. Mindfulness practice helps us recognize old thoughts, feelings, and habit patterns that can lead us down the road to relapse. It keeps us on track so that we can stop, redirect and avoid those patterns. To notice and arrest a state that many call “prelapse.”

Prelapse is that state where your addicted brain is trying to juke you like a sly basketball player, fool you with cognitive card tricks, and swindle you out of your sobriety. It’s where your mind will tell you skiing might be a healthy idea to distract and reward yourself, even though it’s at the resort where you always got high in the past. It tells you to take the old route home from work, where your favorite liquor store used to beckon your car into its parking lot. It gets you to tell yourself “Pot is okay. It never triggered me in the past. I’ll just have one hit.”

There are many mindfulness methods other than meditation, the one everybody associates with mindfulness. One of the things I like about SMART Recovery meetings is that people are encouraged to find what works for them, and that varies from person to person. SMART groups allow us to self-reflect on our situation and get creative with our recovery. We all have to find our own techniques.

For example, one group member used a mindfulness bell on his iPhone that would go off at random intervals. When it rang, it reminded him to look at what he was doing— and thinking. For instance, if his brain was in the default mode Marc has described, or was engaging in negative self-talk, he could catch himself, redirect his thoughts, pay attention to what he was doing, and change it. He could modify his thoughts and behavior right at that moment—the present moment— and thus better train his brain to respond differently. He could start to modify old habit patterns into new ones. This strategy embodies mindfulness without meditation.

An animated acronym worked for another member. When he noticed himself feeling triggered and wanting to use, he pictured an “escape pod” with the acronym POD painted on the side. The initials stand for Pause (when you feel yourself getting drawn in by a triggering emotion); Observe (what you’re feeling, what you are telling yourself), and Do something different (different from the habitual reaction, to start breaking the habit pattern). The “O” for “observe” launched a mindful state that came about in midstride, without having to sit still with eyes closed. The technique didn’t work right away, but eventually he got better at it and his slips diminished. In other words, he got good at being mindful when he needed to be.

From vague malaise to intense compulsion, you can’t change your behavior until you change your mind.  That’s why mindfulness practices are so important in recovery. Listening and sharing in meetings, noticing the bright colors of spring again, catching ourselves in negative self-talk, being reminded of relevant anecdotes or pithy slogans that have personal meaning. All these are mindfulness, not just sitting on a cushion chanting mantras.

There is a saying many psychologists dislike and recovery groups promote, “What’s the definition of insanity? Doing the same thing over and over and expecting different results.” It may not be an apt definition for insanity, but it certainly is for addiction. And if we don’t remain mindful, the opportunities around us can pass us by, and we’re more likely to end up stuck in the pitfalls we ignore. When I finally began to recover, I became more open to everything. I started to let go of the past and expectations, and came back to my real self. Practice helps me continue to avoid prelapse, and pay attention and notice change—particularly when it is headed in the wrong direction.

The paper I recently published in the New England Journal of Medicine (linked here, summary linked here) detailed my best arguments against the disease model of addiction. But it also explored new territory, and that’s the topic of today’s post.

I emphasized (as I have for years) that addiction is learned. It is not a pathology but a learned package of desires, actions and expectancies that keep leading back to the same reward. We call it a reward, but most of us who’ve been through it know that the experience itself gets less rewarding even as the desires and expectancies continue to strengthen. Is that pathological? No more than being in love with a hurtful partner, or praying to an unresponsive god, or being devoted to a sports team despite their string of losses. When the power of a reward arises from strong emotions and needs, the tendency to pursue it isn’t rational. When we seek and find that thing again and again, then, through learning, the synapses of our brain form into dense networks (pathways of connected neurons) that become very difficult to circumvent. Learning on overdrive, through repetitive need-satisfaction, is habit formation — addiction is a deep and insidious habit.

Well, you’ve heard me go on about this before, and my second addiction book, The Biology of Desire, makes the point pretty well. But my recent article came out in a journal read by more doctors than any other journal in the world. To convince that audience, I tried (with the help of Shaun Shelly, who co-wrote or edited much of it) to show that each of the brain changes highlighted by the disease model are not pathological. They’re the sorts of brain changes you’d expect when expectancies and emotions become attached to a specific goal, leading to behaviours that are partly automatic — and partly not. Habit formation results in automaticity,  sensitization to some rewards, and desensitization to others. The brain changes seen in addiction are just the biological underpinnings of this natural learning progression. And…they can continue to update; they’re not carved in stone.

The new territory I wanted to explore sits outside the brain, in the world, in the environment of the addict (I use that term without disdain or judgement, having been one myself). Our environment, especially our social environment, consists of the people we care about, many of whom care about us, and of opportunities for care, for sharing, for pleasure, for relief, for a sense of fulfillment. These opportunities require certain resources, such as social skills, knowledge, self-esteem (at least a little), financial stability, the capacity to understand others. Opportunities are bridges between our needs and their satisfaction. Resources are the capital we use to pursue them.

When people fall into addiction, their environments shrink around them. Good friends, stable romantic partners, available, loving family members, physical comforts such as a safe place to live, job opportunities, and all the rest of it, gradually become less available. The opportunities for getting them back also become less available. Our attention and motivation, riveted now to just one source of satisfaction, lose their connection with the other sources of satisfaction that “normal” people enjoy. I see this as a literal narrowing or shrinking of the environment. Because of what I’ve called “now appeal” — or simply habit strength or deeply learned habitual behaviour patterns — we focus only on what’s in front of us and forget how to go after other rewards. So other rewards fade in availability. They evaporate. They get lost.

When I was an addict, I lost close friends, I lost a woman I loved, I lost the opportunity to communicate honestly with my parents, I lost money, I lost a sense of social and physical safety, I got kicked out of school and lost that opportunity (for a while) and all the rest of it. This picture is typical, one way or another.

But what blows me away conceptually is how this narrowing of the available, reachable, usable social environment precisely parallels the narrowing going on in one’s brain. My synapses fell in line, in pathways and networks that had a single purpose, so to speak, rather than multiple pathways supporting multiple purposes. This “narrowing” in the brain corresponded with a shrinking or narrowing in my available environment. Neither is pathological. Both, especially both together, create a kind of prison.

Perhaps of interest to those into philosophy or psychology, this tendency has been studied as a universal feature of living organisms. The sensory and behavioural specialties of a species get synchronized with aspects of that species’ environment. Both change together. This can happen over evolutionary time. But it can also happen at the scale of human development, as I’m talking about here. The study of this process is called “embodied cognition.” Google it.

One more point made in the article that Shaun and I thought was crucially important: people who study addiction know that there are massive correlations between early adversity (e.g., neglect, abuse, poverty, racial segregation, parental depression, parental alcoholism — in childhood or adolescence) and the probability of becoming addicted later in life. When thinking about how the narrowing environment corresponds with the narrowing of brain function, we can see that the addict’s environment starts off narrow! Kids with happy, healthy social-emotional worlds, who have not experienced trauma, rarely become addicts.

It’s really so simple. The narrowing begins early, sometimes even before birth — look to the family of origin. (Gabor Maté has emphasized the impact of adversity in early childhood. Bruce Alexander targets sociocultural adversity.) This helps us understand how environments and brains influence each other all the way along. If your childhood is hampered by obstacles and dead-ends, whether emotional, social, financial, or some combination of these, the narrowing has already begun.

This video was sent to me by Shaun Shelly, a frequent contributor to this blog. It conveys how a well-practiced “mind set” can end up being so much more than a momentary wrong turn. It can be an inescapable ride on a vehicle that’s about to crash. And it can have a vast nonverbal dimension that is entirely  invisible. Like an iceberg, most of its mass is probably below the surface.

I’m talking about addiction, of course. We want to understand how we can shift from one “you” to the other “you.” That was the theme of my post a couple of weeks ago. But the craving self is so thoroughly sculpted in brain tissue, so overpowering in the moment, that it’s difficult if not impossible to just shift out of it. We want to turn it off like a buzzing light bulb, and we keep flicking the switch, and nothing happens. You can’t switch it off because it is a stable, learned pattern that arises in mind and brain whenever drugs or booze are present.

Okay, so watch the video, then we’ll talk. (The creator, whose name sounds like “Destin,” comes across pretty manic, but don’t let that stop you.)

https://www.youtube.com/watch?v=MFzDaBzBlL0&feature=share

Destin has learned a pattern of motor responses triggered by the sensory information that comes from getting on and riding a bike. As have most of us. The trouble is….it’s the wrong pattern for his particular bike. Every time he tries to ride, the sensory information (feel of the handle bars, changes in the visual field with motion, tilting of the bike with gravity) triggers his well-learned motor response pattern — without his say-so. Even his intense cognitive efforts can’t change it: “Knowledge is not understanding.”

But it’s the “wrong” pattern. So he continues to fall.

There are a few places we can go with this.

(We could consider his weird bike to be analogous to addiction…..In which case we’d say it took him a long time to  get addicted — and once he got it, he found it hard to unlearn. He finally manages it 6 minutes into the clip.)

But let’s keep it simple. Let’s imagine that the way he learned to ride a normal bike all those years is like learning an addictive mental habit. It became ingrained. When he wanted to shuck that habit, he couldn’t. It was too well learned.

For Destin and for addicts, the ingrained habit comes to life in a matter of moments. The cues for the bike rider are the sensory inputs I mentioned above. For the addict as well, sensory inputs can be hazardous. That’s why you don’t drive past the liquor store or chat on the phone with your former dope partner if you’re serious about staying abstinent. But addicts don’t need to experience that inflow of sensory information. All they have to do is bring the image to mind. Remember how great it felt, fondle that memory, taste it, and then the craving explodes to the surface.

We could consider how anxiety itself amplifies the cascade that leads to the fall for Destin — how the first glimmer of imbalance is enough to propel the motor movements that will rapidly defeat him. Not much different from addiction at all. To paraphrase Frank Herbert’s Dune, anxiety is the mind-killer.

What holds the pattern so firmly in place for the bike rider is the urgency of turning the handlebars to offset the first hint of imbalance. That urgency is the middleman that sends the messages to the muscles…turn the handlebars this way, which is sure to complete the disaster. For addicts, what holds the pattern in place is also urgency — but it’s entirely mental, not physical (except in the case of physical withdrawal symptoms). The addict doesn’t need physical uncertainty to propel the wrong moves, just emotional uncertainly, which accelerates to urgency, which rapidly calls up habitual responses: I want it, yes, I really do, just this one time, I deserve it, I’m going to do it, and it’ll be all right.

In addiction, the urgency, craving, desire, whatever you want to call it, is the psychological product of dopamine flooding particular synapses in the striatum. But I’ve told that story elsewhere. For now, what’s most important is that, once the habitual pattern arises on each occasion, two things happen:

1. We are lost, at least this time around, we’re going to fall — unless we’re really clever and we’ve already been practicing bail-out techniques.
2. The pattern, having overtaken our nervous system yet again, is reinforced in our synapses, and thus more likely to arise in the future.

There’s one more point that I hope you’ve noticed: Destin finally did learn to take control of his riding pattern, to rid himself of the habitual response set that led inevitably to a crash. But it took practice! Five minutes a day, for eight months! The moral is simple: well-learned brain algorithms need not be permanent. You can change them, especially if they’re not working for you. But it takes time and it takes practice.

Why the new book image on the homepage?

My book is going south. It just got published in Australia/New Zealand, and on March 6th it will be released in the US. The cover you see now is the US version. The Australian version, which features my addicted brain as a moth-infested lightbulb, can be seen on the “Buy” page. Who is that fellow, and what’s his problem?!

Interviews and reviews are gearing up again. I’m starting to get calls from reporters, columnists, reviewers, and producers for radio and TV shows, and I’m going on a US book tour in two weeks. All very exciting…and weird. I’ll keep you posted as to the reception.

Meanwhile, if you’ve got anything to say about the book (and it doesn’t have to all be positive), please consider writing a “customer review” for Amazon.com (not Amazon.ca). That will help spread the buzz southward.

Hi people. I wanted to write one last post before leaving for India. (tomorrow!!!) So here’s something that’s been on my mind a lot lately. We have discussed many ways of seeing addiction and recovery in terms of choice. We mostly agree that, if using or abstaining is a choice, it’s a very unusual kind of choice. It is often irrational, it changes over time, it becomes more pressing (or less pressing) as the moment of action approaches, it is highly dependent on biases and motivational undercurrents, etc, etc. If it’s a choice, it’s not the kind of choice you make when you decide what movie to watch or what you’re going to make for dinner.

Or is it?

Here are a couple of quotes from a paper about intentions, by a philosopher named Marc Slors (Philosophical Psychology, 2013).

[T]here is considerable evidence against the causal efficacy of proximal (short-term) conscious intentions… [my italics]

Libet, Haggard, and others…showed that simple conscious motor intentions occur only after the unconscious neural onset of actions.

Um, what?! Slors reviews studies (both behavioural and neural) that show that people’s actions are not determined by their preceding intentions. In other words, our actions happen without our intentions, or despite our intentions, or preceding our (imagined) intentions…all the time! Not only when we “impulsively” or “compulsively” reach for the bottle or the phone to get high. If you believe the results of this research (and I don’t see how you can avoid it), it makes your head spin. It blows a big hole in the idea of “free will.” And yet free will is a fundamental assumption we make all the time. To imagine that free will doesn’t exist is almost blasphemy. Yet it makes addiction a lot easier to understand…

A classic experiment demonstrating the irrelevance of “choice” or “intention” would be this. Subjects are asked to make a simple choice, with very little consequence for anything. For example, they might choose whether to press the button showing the red circle or else the one showing the green square. Once they’ve made the choice and seen the result, they are asked about it. Did you choose which button to press? When did you make the choice? Without fail, people report that they made the choice from a moment or two to several seconds before they pressed the button. But in fact, the likelihood of pressing one button or the other was strongly determined before that time. It was already predicted by cues (words, images) given to them (without their noticing) before they (think they) made the choice. For example, cues like the pairing of pleasant pictures with the colour green (or with squares) and unpleasant pictures with the colour red (or circles). Other studies have found that brain activation patterns strongly predict the choices people make, before they themselves have any conscious idea of what they are about to choose.

Here’s another quote from Slors:

In this experiment…thoughts are “inserted” into the heads of people just prior to their being coerced, unbeknownst to them, to perform an action that matches the thought. In such cases, people turn out…to think that their action was caused by their thought.

Well I find this stuff completely astounding. So, whether I make fish or chicken tonight will not depend on my thoughts just before “making the choice.” I’ll think it will, but it actually won’t. Rather, it will depend on unconscious processes already at work. These will probably include how I feel about the last few meals I’ve made, how I think my wife and kids will respond to soy sauce, etc. But I won’t be conscious of any of that. I’ll think I’m simply making a free choice.

So, immediate intentions (called “proximal intentions”) really don’t have much effect on our actions. But that’s not the end of the story. Long-term intentions (called “distal intentions”) do have an impact on our actions. A very strong impact. For example, I’ll be flying to India tomorrow. That action will have nothing to do with any choice I make between now and then. That action was determined by what I decided several months ago. I decided I wanted to go on this trip and I bought myself a ticket — which took an hour of fussing online. Get the point? Free will isn’t dead…but it works in a very particular way.

I’ve written various posts and comments about the fact that addicts have an especially hard time making good choices because the immediate goal (e.g., getting high) overtakes the whole motivational system (the striatum) and overwrites the value of long-term goals — like having a bank account and staying out of jail. But it turns out that this is just a more extreme version of a very general issue: immediate choices are illusory — they are already determined by the value you have attached to something. The fact that you just love cocaine, and you’ve devoted about a billion synapses to fondling it mentally, is going to determine whether you get high tonight — not the choice you make in the next two hours.

What I’m getting to is this. If we recognize that short-term, proximal choices are weak, meaningless or illusory — if we recognize that only long-term, distal choices actually determine our actions — then the only way to quit being an addict is to plan ahead. The only way to stop is in advance of the moment. This may not be big news to some of you. We already know (don’t we?) that you have to get rid of all the booze in the house if you want to make sure not to drink later on. And we know (don’t we?) the value of rules, like “I will never drive home on Yonge Street after work, because that would take me right by the liquor store.” Or telling your buddy, Joe, that the next time he calls you you’re going to call the police — because you have to make sure, in advance, that you will never speak to him again. Or joining a group. Or telling your doctor, look, Doc, I have a problem… Or maybe just emailing him or her. That would just take a moment. You could do it right now. That’s a version of “sneaking up on choice” (recent post), because you can do it without thinking about it intently (this time, anyway).

Rules and plans are not only important for choosing to quit. They are almost the only things that work. (Mindfulness is great too, surely, but then you also have to plan to meditate regularly.) Proximal intentions don’t matter. By the time you are getting close to the point of action, the dye is already cast. Setting up intentions in advance is called “self-programming” by Slors, and I think that’s a great name for it. You are indeed programming your own future, by changing contingencies, determining circumstances, setting up non-negotiable outcomes. You are programming your life, and your brain, and your environment,  your unconscious as well as your conscious mind, by intending and planning what’s going to happen.

Now that’s free will. Use it wisely!

P.S. I will be giving your regards to the Dalai Lama. Seriously. Enough of you have asked me to do that…I figure the feeling comes from all of us. After all, the dude must be pretty interested in addiction to have a five-day meeting on the subject.