Understanding Addiction

I’ve been warming up to a post or two on the power of the internal dialogue. But first, as a lead-up, here’s a little patch of last night, a mundane yet eventful exchange with my son. Strangely, it made me think about quitting drugs. So I wrote this down before I went to bed.

Isabel was gone as of this morning, off to California for the week, and I had my twin 12-year old boys to put to bed. They were tired but not exhausted. They could still think, and reason, and certainly argue (the last cognitive function to blink out for any self-respecting preteen). But more than any of that, they could feel.

As often happens when Isabel goes away, they each wanted to sleep in our bed, with me, to cuddle, or just to feel the close company of a parent who loves you completely. This has become our routine when one parent is travelling. I’d likely read for an hour or two while one boy slept beside me.

But a problem presented itself: how were we to decide whose turn it was? Who got the first night?

They each had arguments. Ruben claimed that Julian always got the first night, and if that wasn’t the case, and Ruben had had the first night last time, then Julian would probably have had the last night. Which would mean that it was Ruben’s turn after all. But naturally Julian didn’t agree. He suggested they do a Rock, Paper Scissors. What could be fairer than utter randomness? But that wasn’t okay with Ruben. Ruben said — and he might be right — that Julian wins way more than half the time. The tears were already rising to his eyes and about to spill over. Julian could see that. Julian remained calm. It didn’t seem as critical to Julian, yet there was no reason for him to surrender his right to engage, because…why should he?

So I got Ruben into our room, his voice already huffy with emotion, with need, with the vertiginous sheering of his self-esteem. Soon he was under the covers, even though no ruling had been announced, surrounded by his seal, his other seal, and his alpaca (who’s attained the status of a sacred object). Julian was in his bed, wide awake, waiting for the next move. His demands weren’t spent, just in pause mode. Julian could still win this one, and Ruben would be reduced to soggy rubble.

So I said to Julian: Maybe, just this once, without judging or recording or calculating your advantage, maybe just tonight you could let Ruben have the first night.

Why? he asked.

Simply because…because he really needs it. And you can do this. You have the strength for it. I can see it in your eyes.

But what do I get out of it? he replied, with typical 12-year old logic.

What you get out of it is just the feeling of being good, being the strong one.

I let him think about it and went back to soothe Ruben, who was still at the high-water mark. Then I went back to Julian and I asked him: Well, what’s your decision? Can you let it go…just for tonight?

In a calm voice he said, Okay.

That’s all. He gave it up. I told him I was proud of him, because he’d risen to the occasion. And a minute later I asked him how he felt. And in the calmest imaginable voice he said, I feel good.

That’s when I recognized the moment of reckoning we often face when we quit drugs. When we let it go, when we say, I don’t need to get high tonight. What we get out of the deal is no calculable advantage, no currency exchange, but simply the feeling of being strong and good and right.

How precious that feeling is! I could see it in Julian’s eyes. He was no longer seeking. He’d let the need go because he could. And his reward was this unity, this glow of self-satisfaction, so different from the moment-to-moment, hour-to-hour strategizing that usually occupies his 12-year-old mind. His reward was a sense of peace, of both letting go and remaining stationary, solid, proud that he could do it, and relieved that the cost wasn’t as great as he’d imagined.

That eye in the hurricane, that moment of grace, is the place we find ourselves in when we say, No, not tonight, I don’t need it. And then…an almost shocking sense of calm, strength, accomplishment, at the core of our being. We didn’t know it would be there until we relented, until we let the desire spin off into space and didn’t pursue it. That’s when we found ourselves to be whole, and there’s no better feeling than that.

I think Julian’s final retort was: “Why should I? Why should I give up something I don’t have to give up?”

I could see that all his sparkling 12-year old intelligence was bound up in that question. And all I could say was: “Because you can, and you know you can.”

(He also got a free back rub out of the deal.)

The expression on his face when I left the room was a soft glow of serenity.

Hi again. I know I haven’t been posting much lately, but it’s time to get back on that horse. One thing I did in the interim was write a chapter for a volume on addiction. Which led to a strange conundrum…and some soul searching.

But before getting to that, I’ll tell you what inspired me to keep blogging for now. First, I opened Google Analytics and found that I’m still getting 200 hits per day…even after weeks with no new posts. People remain interested in our alternative and progressive approach to addiction. Wonderful! Second: I met Sandy P at my father’s memorial in California last week. And she told me she not only still exists but she follows my blog. Amazing. Sandy was my brother’s girlfriend, and Abbie, her next-door neighbour, was mine, when we were in our late teens. (When I was first getting into drugs, Abbie was my salvation. Until I took off for Asia: no Abbie, lots of drugs.) Thanks, Sandy, for a sweet hit of nostalgia.

Now about that chapter. I’ve had papers rejected by publications lots of times. It’s part of the rat race of being an academic, a researcher, submitting your best work to journals, waiting for the letter from the editor, finally getting that heart-stopping email and reading it and Oh Shit! They’re rejecting it?! Without even a “revise and resubmit!” Damn ignorant asshole editors. Too good for your shitty journal anyway… Then the anger and disappointment start to evaporate and you start thinking about what journal to send it to next. That’s the life of an academic. And that’s one reason I was glad to be done with it, and why, about eight months ago, I swore to myself I was done with academic writing.

But I caved. A colleague in Toronto, an addiction doctor, urged me to write a chapter for a book for addiction doctors, to spell out my learning model of addiction, and how it reconceptualizes the data on brain change in addiction, for the benefit of…well, addiction doctors. Because, even though they’re doctors, they don’t necessarily buy the disease model of addiction. At least they don’t necessarily buy all of it, or maybe they’re uncomfortable with it, or maybe, just maybe, the field is changing. (This particular doctor specializes in ACT for his patients.)

So I wrote the chapter. Took pieces from other work, revised them, wrote some new stuff, trying to make it accessible for all those doctors out there, because they don’t really understand human development very well and they sure don’t understand psychology very well. So, why not give them the benefit of my stratospheric perspective. (LOL) I spent a couple of weeks working pretty hard, sent it in, and soon heard back from the editor. Thank you for submitting your chapter for publication in “A prescriber’s guide to methadone and buprenorphine for opioid use disorder…” Which is when I said to myself, those ignorant editors! They got the wrong book. Or the wrong title. Or something. I can’t write a chapter that urges ditching the medical model for a damn prescriber’s guide!

As mentioned, I’ve had my work rejected by numerous publications. But this was the first time I rejected the publication. Even after I’d done all the work. Even when they said Yes, we want it! I wrote back and said, I’m sorry but I can’t contribute a chapter to a prescriber’s guide, or to anything called a prescriber’s guide. Because if the whole point of the book is to get a better handle on prescribing methadone and buprenorphine, then GO AHEAD AND CALL IT A DISEASE! Why not?

My colleague hadn’t told me that this “book for addiction doctors” would be entitled a prescriber’s guide to anything. Maybe he didn’t know. He emailed me after I withdrew my submission and said: Addiction doctors prescribe opioid substitutes to 95% of their opioid-addicted patients. Like: duh…didn’t I know that? Yes, I knew that, more or less. And I knew that opioid addicts are often in desperate need of opioid substitution therapy (OST). It helps them get off the street and sometimes stay off, it relieves the overwhelming anxiety of withdrawal, and it saves lives. As Maia Szalavitz often reports, it’s the only evidence-based treatment that saves lives. And of course that’s because heroin, especially when it’s laced with or replaced by fentanyl or its analogues, can be deadly.

So why would I avoid being featured in such a book? Maybe I should have just swallowed my whatever and revised the chapter. All those words distinguishing physiological dependency from addiction (which I maintain is a psychological process)…they would have to go. And so would that pep talk about listening to the person, not the diagnosis, and using your counselling skills, your human skills, to reach beyond just prescribing. I’d have to shelve all that. I fully advocate the use of methadone and Suboxone. I agree with other progressive addiction specialists (e.g., Mark Willenbring) that they should be easily available wherever they’re needed, free of cost, free of line-ups, free of stigma. But I’ve got nothing to contribute to that argument. Right?

Can we social-development-oriented “addiction specialists” refute the disease model and still advocate OST?

I told myself I’m trying go avoid an awkward irony: that there’s maybe one good reason to call addiction a disease. In the US and Canada it’s the only way to get addicts their medicine, their heroin substitutes. I’ve thought about this lots. But I remain concerned and confused. Maybe “medicalization” is the best we can do for people who are in a real jam, on the street or close to it, hunting for heroin day by day. Yet it maintains, in fact it strengthens, the premise that these people are sick, and it sidelines all the familial, social, economic, and cultural forces that pushed them into that lifestyle in the first place.

Somehow these two perspectives on opioid addiction have got to come together. At least in the present social climate. But I’m at a loss as to how to help that happen.

Or maybe it’s simple. Maybe we just need one or two catchphrases to merge these two approaches: phrases like “harm reduction,” or maybe “working with the individual where they’re at.” In my next post, I’ll tell you about a treatment program in New York City where that kind of conceptualization governs everything they do. I gave a talk there two weeks ago, met some fabulous people, and learned how the field is changing. Stay tuned.

Hello my lovelys! I’ve been thinking of you. Actually I thought of you mostly last night, New Year’s Eve, when my own addictive tendencies and my self-concept as someone who can drink alcohol safely (and socially) growled at each other for a little while.

I feel grateful that I’m no longer at the cliff edge that once defined my existence. We’re all at various distances from that scary place, some on the brink, caught by sudden vertigo when we look over the edge, others living on the flatlands, far from the escarpments that were so familiar. But we recognize each other as members of the same tribe, connected through experiences that others view as ugly, perverse, or mythical.

I feel particular empathy for those who are torn by temptation and confusion at a time when everyone around you seems to be having a good time. If there’s anything I can say to all my readers, some kind of ad-hoc post-modern blessing that would make sense to all of you no matter where you’re at, it’s this:

Accept and forgive yourself for wherever you are. You got to where you are through a sequence of events and experiences that no one else has encountered. Wherever you are and whatever you’re doing, enjoy, be safe, and see who you are now as a natural product of where you’ve been, en route to where you’re going. If sadness and loneliness are part of the picture today or tonight, take them in stride, with some humour and some optimism. If you’re with others, take stock of that magic — it doesn’t all have to come from you. This is probably not the last day of your life, but it’s an important day — the bridge between where you’ve been and where you’re going. Give yourself a warm hug whether or not you’ve got others to second the motion.

Happy New Year to all of you!

Whenever I take a couple of weeks between postings I start to feel home-sick for my blog. I miss you guys. I miss having something to say to you — something that’s at least a bit thought-provoking and interesting — and I miss your comments. Whether lengthy and rich with content or brief musings, reactions on the fly, your comments engage me, teach me something, or remind me of things I’ve thought about, insufficiently, or simply touch me with some shared emotion, maybe a recognition of past or present feelings and struggles of my own. And of course, after all this time, I’m getting to know many of you, becoming familiar with your personal style of questioning or arguing, extending or contextualizing, trying on ideas, accepting, rejecting, fitting, refitting – one way or another joining me in a deep exploration of addiction and trying to understand its massive reverberations in our lives.

But I’ve started teaching this term, and the last two weeks have been something of a blizzard: reading, preparing slides, lecturing to 200-plus undergraduates at a time, and then coming home to my own kids, still only six but starting to ask big questions. From a teaming mass of unnervingly young, stylishly dressed, device-laden, Dutch-speaking, half-interested (on average) post-teens to my own little haven of unnervingly witty six-year-olds with ever-changing constellations of teeth (new and old).

But now here’s a free couple of hours, and I’m ready to serve the first course of something I’ve been cooking up for awhile.

In my recent posts I outlined four stages leading from unguided daydreaming to the ironclad compulsion to get or do the thing you’re addicted to. Here are the steps in summary:

Note that the brain column is pretty skeletal. Most (but not all) of these brain bits have been fleshed out in earlier posts and/or the book. Also note that I’ve skipped any step labeled “cognitive control attempts” — because I think these evolve in stages as the addictive urge evolves, with or without success.

So here’s the question: what is the time scale? How fast do we move through these steps, from the first fluttering of addictive images, interrupting our innocent fantasies, to a lurching momentum — gotta have it, gotta do it?

And the answer is: there is more than one scale. I count at least three different time scales for moving through steps 1 to 4.

A lot of natural phenomena have a property called self-similarity. That means that the same pattern gets repeated at different scales — whether in time or in space. Examples include the geometrical motif in the fronds of a fern, the curvature of beaches within bays within inlets that give shape to a shoreline, and the clustering of nests within communities within societies. Those natural forms show similar patterns at different scales — in space — from small to large. But we see the same kind of thing in time: for example, the back-and-forth cycles of advance-retreat in a conversation or argument can also be seen in the large-scale progression of a relationship: when one or both partners oscillate between confidence and surrender over weeks or months. And ocean waves break in dramatic clusters, leaving periods of relative calm, while the small wavelets within them follow the same rhythmic pattern of interspersed bunches. Maybe you’ve heard of fractals — patterns within patterns within patterns: where you see the same geometrical images at very different scales, all expressions of some common theme, some common structural principle.

Well this is all a bit dense, isn’t it? And what does it have to do with addiction…and the brain…and the way our lives unfold over time?

It’s going to take another post or two to flesh this out, but here’s where I’m going with it.

In addiction, we see this pattern: attraction leading to craving, leading to pursuit, leading to…a brief period of pleasure or relief, followed by more attraction and craving. In other words, wanting leading to getting, leading finally to loss or emptiness, which leads once more to wanting. For example: craving booze, drugs, or food, leading to binging, leading to saturation or tolerance, and then loss or maybe even withdrawal symptoms, then running out of the substance or the money to get it, leading to more emptiness, more craving. And this kind of cycling is fairly well recognized in the addiction field. A prominent review of addiction neuroscience has this to say:

Three major components of the addiction cycle have been identified — binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation (craving) — and incorporate the constructs of impulsivity and compulsivity…

But the first amazing thing is that this pattern, this cycle, can be seen at different time scales.

The slow scale tracks our hero as he or she develops a fondness for some substance or activity, leading to repeated experimentation, leading to a period of more intense experimentation, greater amounts, more potent concoctions (beer to vodka?  painkillers to heroin?) as the fondness turns into strong desire turns into addiction. Self-control is easy to come by in the first month or two; but a couple of years later, once you’ve gone all the way, self-control is a plastic bag you’re chasing in strong wind.

The fast scale tracks our hero as he or she wakes up one Saturday morning, lies in bed daydreaming, suddenly gets hit with vivid images of doing it, tries to chase them away, fails, starts to crave, starts to plan, lifts up the phone and starts dialing…so that by early afternoon he or she is pacing frantically, waiting for Mr. Dealer to pick up the phone.

It’s the same sequence! The same sequence of psychological states, and — here’s the second amazing thing — the same sequence of brain stages. With one difference. The slow scale traces the development of addiction, the development of that unholy love affair, and the gradual brain changes that support it. The fast scale traces (the microdevelopment of) an addictive episode, or, we could say, the activation of the addiction on one particular Saturday morning.

And what about the brain changes? At the fast scale, the wiring pattern of your brain isn’t changing; that’s already set. Rather, the wired-up brain regions become activated — in roughly the same order they got wired up — and that happens fast! Because you are the proud owner of a set of biological connections, giving rise to a familiar cascade of feelings and actions, that took years to develop. At the slow scale, what fired together time and time again ended up wiring together. Remember Hebb’s Law? And now, what got wired together over months and years quickly starts to fire together — over seconds and minutes. Enjoy the ride: that downhill cascade that takes just an hour or two, and that’s self-similar to the developmental cascade that took years to complete.

As for a third scale, stay tuned.

My next post, coming much quicker than this one, I hope, will flesh all this out in detail. I think I finally get it, and I’m serving it up all month.

This post links to a recent podcast, where I join Dick Schwartz, the founder of Internal Family Systems (IFS), and Gabor Maté, a well-known commentator on addiction and its impact on marginalized communities. As I’ve blogged about lately, I rely on IFS as a ground-breaking therapeutic tool in my psychology practice. Here in this podcast, the three of us put our heads together to examine how parts psychology and self-compassion can ease the anguish of addiction and related difficulties.

The Weekend University disseminates progressive, evidence-based ideas and opinions about the workings of the human mind and the possibility of relieving suffering, worldwide, through sharing this knowledge in our work and our lives. This post is hosted by Niall McKeever, the founder and curator of the Weekend University podcast series. The series regularly features lectures in psychology, cognitive science, neuroscience, evolutionary studies, and mindfulness approaches, as well as new ways to conceptualize pernicious social and geopolitical issues through the lens of these disciplines.

I was delighted when Niall invited me to share the mic (and camera) with Maté and Schwartz a few weeks ago. In a previous podcast in this series, I described how IFS enriches the reservoir of therapeutic techniques available for working with people in addiction. But this episode was a special treat for me. I’ve known Gabor Maté for some time, I often recommend his Hungry Ghosts book, and we spent a few hours walking around Vancouver and chatting years ago. But I’d never met Dick Schwartz. I’ve listened to scads of talks and interviews with him, taken online courses with him, I’ve truly immersed myself in his psychotherapeutic brainchild, but I’ve not had the pleasure to connect with him directly. Until this podcast.

So without further ado, here’s the episode: Rethinking Addiction.

I hope you’ll give it a listen. And before, during, or after that, take a look at the following point-form summary and relevant links posted on the podcast website: