Understanding Addiction

If you’re a regular on this blog, you probably know that Peter Sheath and Matt Robert have enough knowledge, compassion, and common sense about addiction and recovery to lead us to a far far better world. I’ve grabbed these gems from their comments to a recent post. If you’ve already read them in context, well read them again. If not, now’s your chance.

Peter Sheath:

I feel like there is an amazing amount of synchronicity going down, especially between you [Marc], Matt and li’l ol’ me. I can almost guarantee that I will have had my interests stimulated by a client, book, lecture or simply talking to someone and, a few days later it will be there in your blog and Matt will have made one of his beautifully eloquent comments on it. This may not sound so apparent at first but please bear with me.

Over the past couple of years I’ve been doing a lot of thinking, talking and research around this whole co-occurring conditions/dual diagnoses thing. I think we, organisationally, have got astonishingly good at not dealing with it. We love to have these imaginary silos that we place people into, develop manuals and protocols to either keep them there or embargo them from going there. We’ve even developed competency/accountability frameworks, skill-sets and governance systems that ensure that, supposedly, the right person is working with the right person, at the right time, in the right place.

The trouble is that it mainly creates confusion, uncertainty, apartheid and exclusivity. Only the other day I received a phone call from a friend who is managing a substance misuse team for people with complex needs. He had been asked to develop a “criteria” for the people his team would be working with. I said that I’m very sorry but I really do not believe in having criteria for people we do or don’t work with and everybody who comes to substance misuse services for help will have complex needs. Turns out that he is of exactly the same mind but has to do it because that’s what he’s been instructed to do.

Doing things in this way means that we often screen more people out than we do in and I have real difficulties understanding why we continue to do it. Jordan Peterson’s 12 rules for life, motivational interviewing, open dialogue, ACT, CBT, person-centred counselling, narrative exposure, etc. are all transdiagnostic and probably work best under the collective umbrella of the therapeutic relationship.

I’m currently working with a paying client who has had a lifetime of psychiatric diagnoses and various dependencies. He came to me because he had approached his local alcohol service looking for a community alcohol detox. The detox would need to fit around his work, because he works for himself and is the only employee. He was drinking at least a 750-ml bottle of vodka every day and was getting increasingly desperate and depressed. The service said that, because of his underlying mental health problems, levels of alcohol use and not being able to take time off work they couldn’t help him! I know it beggars belief, doesn’t it? I negotiated a course of Librium with his GP, involved his mother and his local pharmacist in the plan (open dialogue), then did some motivational interviewing type interventions to boost his confidence and ensure that getting sober was the right thing to do. We arranged a daily telephone check-in and weekly face to face, with myself, and I taught his mum and him how to do blood pressure monitoring. He agreed to call in to the pharmacy if his BP raised or reduced by 10.

Got a phone call last night to say that his detox had finished a week ago and he is now 21 days sober. He has struggled a bit because the weather over here has been lovely and he has an association with sunny days and sitting outside the pub drinking beer. He has used some psychotropic meds sparingly, because he does get worried about his anxiety levels, panic attacks and past psychoses. I’ve also been teaching him mindfulness-based meditations, relapse prevention and managing his mental health. We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope. We’ve also focused on very small steps, although he is always wanting to make massive leaps. Fingers crossed.

Matt Robert:

Hey Peter!! It keeps coming back to this, doesn’t it? It takes a village…but a coordinated one that meets the needs of the individual as well as the tribe. Your sentence captures it all:

“We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope.”

There has to be autonomy, agency… individuals need to feel in control or we don’t feel safe. I have to trust my fellow participants, the method, the goal, because I’m not going to stick with a process of arduous change if I don’t believe in it. And none of it is gonna work if I don’t feel like I’m in a sharing, connected, reciprocal relationship with the humans who are helping me. Something all effective recovery traditions have in common. All human endeavor, for that matter.

The thing about open dialogue that is so simple and compelling is that it is the same model humans have used to cooperate, help each other, and progress throughout history. It’s getting all the stakeholders, the people who care, in the same room, on the same page. It’s putting the puzzle that’s fallen apart back together.

We all know how to do this because it is a human thing, not an “addiction” thing. Addiction is a proxy for meaningful relationship.

I see a lot of comments rolling in on my recent post. That really makes my day. Or night, in this case: it’s currently just after 4 AM. Can’t sleep.

I had an amazing two days in England just now, visiting people who work in one way or another with addiction. My first evening there, spent in Oxford, was with two Australian philosophers who’ve received a large grant to study the identity issues of addicts. Lovely people, but I did not learn much from them. In all fairness, they have just begun to analyze the first wave of data in a multi-year study. Still, I recall JLK’s contention that a high level of abstraction sometimes seems to miss the boat when it comes to addiction.

So let’s get down and dirty.

The following evening I met Peter, who has recently posted comments on this blog. I won’t tell his story – it’s his to tell – but after a three-hour train ride to the north of England, I’m received by a large, smiling man, who lives in a small house that seems to be tilting on its foundations, together with a very large dog and a quiet friendly woman, his partner.

But we didn’t go to his home first. On the long drive through rush-hour traffic I told Peter I’d never been to a 12-step meeting. Hint hint. Would you like to got to one tonight, he asked? Indeed I would. He said we’d be a few minutes late but it didn’t matter. We were on our way to a meeting of one of about 30 NA (Narcotics Anonymous) groups in the region.

We walked in the door of a modern, nondescript building, and approached a group of about 30 or 40 people sitting in chairs in a large ragged circle. Many looked up at Peter as we approached, nodding or smiling. He seemed the granddaddy of the group. He’d been clean and sober for over ten years, a state many of the others could barely imagine. I felt their love and their respect for him. And they looked over at me, some with flickering smiles: who is this diminutive, academic looking fellow, never before seen in these parts? What’s his story? I heard them thinking.

So we sat down at the outskirts of the group and just listened. Through very strong accents from the north of England, their stories found their way into my brain and my heart. These people, mostly men, looked like they’d been through the ringer. Their faces were hard, their endurance carved in the creases around their eyes and the grim holding pattern of mouth and jaw. But there was a softness here too. They listened to each other’s miseries with real caring, with a kind of empathy that doesn’t run out, because if there’d been any limit to it, it would have run out ages ago. Later, I asked Peter what was the approximate range of clean time for the people there that night. He said: mostly under a year or so, some a few months, some a few weeks, some just a few days. I could recognize the last group from their constant sniffling and jerky movements. Everyone there was a heroin addict.

With all my negative presentiments about the 12-step program, I found myself shifting like a boat with no keel. There was something intrinsically good here. And I knew what it was: that old thing variously called friendship, warmth, brotherhood, support, caring. These people cared for each other, and given the degree of their helplessness, what better treatment could you want? That’s why they kept coming back. Their stories were sad, of course they were, full of bitter irony and gut-wrenching failure, self-rebuke, hopelessness tinged with a bit of hope. But there was always a smile there too. Maybe not until the last sentence, at which point the person might look up, his face finally relaxing into a crooked grin, as if to say, I know you know that I probably won’t make it, at least not for good, at least not this time, but you know, I might…

On the way back to Peter’s crooked house, I asked him how many of the people sitting there tonight would stay clean…for a good long time, maybe barring the occasional relapse. He thought for a moment and then said: maybe 30%.

He also explained what some people mean by being a “true addict” – a phrase we’ve recently argued about on this blog. From the perspective of NA or AA, being a true addict means that you could not, simply could not, after trying everything under the sun and the moon, time after time, year after year, could not stop. So these groups were really the only thing left. And sometimes they worked. But even if they didn’t, they probably made life bearable. Peter felt that the “true addict” polemic did more harm than good, magnifying differences rather than commonalities. But at least now I knew what it meant. And I was damn glad I didn’t fit that bill.

I asked Peter a lot of questions that night, and I’ll just mention one more. I asked: why the dogma? Why do some 12-steppers insist that this is the only way…when we all know it’s not the only way? He thought about that one for a while. Then he said something like this: When you’ve been trying that long and failing that long and then, finally, something works, you don’t look around and compute the statistics. You tell everyone who will listen: This is what works. This is the only thing that works. The unspoken part remains “for me.”

…by Matt Robert…

Consider what you believe about the causes of addiction. Now consider what you think about the importance of anonymity in recovery communities. Is there a relationship?

  Yes, at least historically. In the very early days of AA, most people viewed addiction as a moral failing or a character defect. There was no disease model to ground the argument that addiction should be treated. In the 1930s, anonymity was a saving grace in the design of AA. People could enter recovery in the company of others who understood their experience. Progress could be made without the shame of exposure to the society at large.

Currently, it’s useful to make a distinction between two kinds of anonymity: personal anonymity and public anonymity. Personal anonymity is a right that any person has to choose when, how, and whether to reveal their personal circumstances to others. In my view, as long as there is addiction, some will choose to remain personally anonymous in their recovery efforts, and this right must always be respected. Public anonymity is something else. It refers to the requirement, put in place in the early days of AA, that a member can never “go public” with their membership in AA, or talk about the enterprise in a public way.

Recently, a number of strong voices have come out arguing that public anonymity has outlived its usefulness in the recovery community. This does not mean that meetings would be televised, or that rosters of membership would be published, or that individuals would have to reveal themselves in any way. Rather, it means that when some individuals choose to go public they should not be censured or ostracized by the recovery community, particularly the 12-Step community. The film The Anonymous People makes this issue vivid and compelling.

The film draws a link between public anonymity and beliefs about the causes of addiction. When the disease model became more prevalent and well-accepted, personal anonymity was still useful for most people as they entered treatment. But as the comparison between alcoholism and diabetes, or heart disease, became more commonplace, it became possible for some people to imagine a world of recovery that allowed personal anonymity but did not require public anonymity. If it’s a disease, just go into treatment. And furthermore, let’s publicly advocate for more treatment funding!

Even though the policy of public anonymity in AA is motivated by the goal of subordinating personal aims to larger principles—no monomaniacal “leaders” needed, thanks—some feel that it is now getting in the way of the recovery community’s need to advocate for more treatment and less shame. And that brings us to the latest views on the causes of addiction.

Many of us are now contemplating the views of Stanton Peele, Gabor Mate, Maia Szalavitz, Marc, and others, in which addiction is not a disease but a phenomenon of deep (and pernicious) learning triggered by personal suffering. What—if anything—does this view imply about anonymity of either kind, personal or public? When addiction is conceptualized as learning rather than disease, maybe we should go back to feeling ashamed—ashamed that we were dumb enough, miserable enough, or indulgent enough to allow ourselves to learn to be addicted. Or maybe we were just unlucky enough to be born into a situation where addiction was the best option out of a limited set of coping mechanisms. But still, that’s not quite as innocent as contracting an illness, which could happen if you were in the wrong place when someone sneezed (or because you just happened to get the wrong copy of some dopamine receptor allele).

Or perhaps the learning model of addiction will allow us now, even more clearly than before, to see addictions as something to be accepted and addressed in the open, where we can come to grips with the developmental and environmental variables that make people vulnerable. This post is a call for us to begin to consider the complex issue of anonymity from the new vantage point of addiction as learning.

Actually quite a few words. At times I seem to be in the throes of some seriously run-on sentences. I was a tad nervous. George seems like a really nice guy. Somehow he finds a way to connect with his guests and ask questions that are both challenging and friendly. That friendliness — what seemed like authentic warmth — made me feel less like a dork than I might have. I’ve always found it damn disconcerting to talk about the nasty things I did, on the air, especially on TV, where there’s really nowhere to hide. And there were a lot of cameras and lights, and real live people in the audience. So yeah, I was kind of nervous, especially at first.

For my readers outside of Canada, the Strombo show is our version of The Tonight Show…laid back chatty interviews with a very charismatic host, on national TV. When we taped this segment, way back in October, I was in awe of him. I guess I still am.

Here’s the interview, as posted on YouTube. Thanks to Sharon, a reader — no, not that Sharon! — who either posted it our found it there.

I’ve generally felt critical of the “disease” label for addiction. But having read your many comments and looked up some recent literature, I can now give it its due. In my last post, I argued that models and metaphors are not intrinsically different. A metaphor is a kind of model. And I commented that the different metaphors/models of addiction work differently for different people. So the way a model functions should be a criterion for its acceptance.

But what about the “disease” model? Psychiatrists – because they are doctors – rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem fits a label, a medical label, from borderline personality disorder to autism to depression to addiction. These conditions are described as tightly as possible, and listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases) for anyone to read.

The idea that addiction is a type of disease or disorder has a lot of support. I won’t try to summarize all the terms and concepts used to define it, but Steven Hyman does a good job (thanks to Elizabeth for the link). His argument, which reflects the view of the medical community (e.g., NIMH, NIDA, the American Medical Association), is that addiction is a brain disease. (Also see this piece in the Huffington Post.) Addiction is viewed a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Specifically, the dopamine system is altered so that only the substance of choice is capable of triggering dopamine release to the nucleus accumbens (ventral striatum), while other potential rewards do so less and less. The nucleus accumbens (NAC) is responsible for goal-directed behaviour and for the motivation to pursue goals, as I’ve described in detail in my book.

Different theories propose different variants. For some, dopamine means pleasure. If only drugs or alcohol can give you pleasure, then of course you will continue to take them. For others, dopamine means attraction. Berridge’s theory (which is the one I follow) shows that cues related to the object of addiction become “sensitized,” so they greatly increase dopamine and therefore attraction…which turns to craving when the goal is not immediately available. But pretty much all the major theories agree that dopamine metabolism is seriously altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all.

What’s wrong with this definition? Not much. It’s pretty accurate. It accounts for the neurobiology of addiction much better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It explains the incredible persistence of addiction, its proneness to relapse, and it explains why “choice” is not the answer (or even the question). That’s because choice is governed by motivation, which is governed by dopamine, and your dopamine system is “diseased.”

So, do I buy it? Not really. I do think it’s often very helpful. It truly does help alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and if I follow my own words, then a good metaphor and a good model aren’t much different. Their value depends on their usableness.

Then why don’t I buy it? Mainly because every experience that has some emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get when you’re on your way to visit Paris, or your favourite aunt, a disease. Each rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s true of Paris, Aunt Mary, and heroin. In fact, during and after each of those experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, sex, music…they don’t turn you on that much; but coke sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.

So how well does the disease model fit the phenomenon of addiction? How do we know which urges, attractions, and desires are to be labeled “disease”, and which are to be considered aspects of normal brain functioning? There would have to be a line in the sand somewhere. Not just the amount of dopamine released, not just the degree of specificity in what you find rewarding: these are continuous dimensions. They don’t lend themselves to two (qualitatively) different states: disease and non-disease.

Thus, addiction doesn’t fit a specific physiological category. But what about the functionality, the useability, of the disease model? That’s disputable. It works well for some, not at all for others. And I think that’s because addiction is an extreme form of normality, if I can say such a thing. The function of modelling addiction as a disease is limited because “disease” and “normality” are overlapping, not mutually exclusive, when it comes to the mind and the brain. Yet we sure recognize addiction as distinct from “normal” in our everyday lives. That’s the problem.

My solution will come several posts from now. Meanwhile, I hope readers will comment on other aspects of the disease model that fit, or that don’t fit, the phenomenon of addiction.