Understanding Addiction

At the heart of the discussion about addiction and recovery lies a trilogy of questions: whether abstinence is necessary or even helpful, what “harm reduction” offers in its place, and what is the best way to deal with cravings. These questions are intertwined. In fact they merge into a single issue. Today I want to approach this issue from the perspective of part-selves, and look more closely at harm versus care.

You probably know the parts better than you think. My addict self comes out of nowhere and roars into life. She’s incredibly determined, so I end up giving in before I even know it. Twelve-steppers say she’s doing push-ups in the parking lot. That part seems so evidently not-self, and yet it obviously is a part of the self. Or: I give myself such shit the morning after. You’re just a fucking loser, addict, drunk. You don’t deserve sympathy. You don’t even deserve to be alive! Again, that voice comes at us, so it feels like not-self, yet it obviously is a part of the self as well. Who else could it be?

Those are “parts” we recognize most easily. But according to IFS, Internal Family Systems therapy, there can be many more parts to us. I wanted to be at an IFS workshop this week. I’d paid the fee, bought my ticket to Bristol, reserved an Airbnb, cleared my calendar. And then the coronavirus came along and dashed my plans, as it has obliterated plans, wishes, normalcy, for so many of us. So I won’t write about IFS today. I don’t understand it well enough yet. But I already practice a kind of psychotherapy that recognizes “parts” — so I feel an intuitive connection with this approach, and my reading on IFS continues to flesh it out. More on IFS later.

For now, here’s my take on the parts:

Clearly craving is the single biggest challenge to people who want to overcome their addiction. The recommended methods to deal with cravings are (1) urge surfing — watching the craving come, peak, and then dissipate, while maintaining a mindful objectivity, and (2) developing new thought patterns, usually with the help of others, that result in abstinence until the cravings subside over time (or, less optimally, “white-knuckling” until you can start to relax). If these work for you (or your friend, family member, client) then that’s just great. And sometimes, when the consequences of substance use are dire and immediate, abstinence may be the only sensible choice.

But abstinence has a huge drawback. It’s incredibly difficult! It can feel like turning your back on your best friend, on love and comfort, forever! It can feel like kissing goodbye to the one thing in your life you could control — changing how you feel. It can leave you staring into an existential void, facing an abyss of emptiness and meaninglessness. So, abstinence very often leads to “relapse.” We know this story well, and it provides a (false) rationale for defining addiction as a chronic disease.

Abstinence erects a steel fence around the part of us that wants and feels it needs to get high (or get full, in eating disorders). But what if we were to take that part and, instead of turning our back on it, telling it “No, never again!” what if we were to embrace that part, listen to it, and comfort it. What if, instead of banishing the needy part, we were to get to know it, maybe even get to love it, so that it doesn’t have to feel so walled off, shunned and hated.

The logic is simple: as long as we wall off this part of us, it not only continues to exist, it gets more desperate and determined. Now it has to weaponize and force its way through. In psychodynamic parlance, the more you suppress a powerful urge, the stronger (or more devious) it becomes.

So, instead of banishing that part, in IFS and other psychodynamically-oriented approaches (including ACT and my own cobbled-together approach), the idea is to listen to the craving and connect with it. Can there be value in this?

It’s such an outlandish idea in many people’s minds, that I’m not at all sure this approach gets tested very often. (Research on IFS is still in its early stages.) But I’ve seen it work with some of my clients. And obviously I’m still developing the relevant skills.

Little kids crave what they can’t have, and the cookie jar doesn’t lose its appeal by being placed out of reach. So we give the little kid something else to eat, maybe a piece of fruit or cheese (think methadone). And/or we create a bridge to the treasured outcome. We say, you can certainly have a cookie, in fact two cookies, when it’s dessert time. That’s after dinner, at 6:30. Do you think you can wait that long? Let me help you. Let’s get busy doing something else.

Connecting with cravings doesn’t mean you have to be stupid about it, run out of your apartment and score as much coke as you can snort. In fact, being smart about cravings is one way to hold and soothe the part-self that feels so needy.

But the benefit of accepting and embracing the needy part isn’t just scaffolding it and keeping it from tearing the house down. Its greatest benefit is the feeling of integration you foster in yourself. The craving part is young and wild, defiant, and very much alone. But it’s a part of you! Finding out where it comes from — in your growing up years, in your efforts to control troubling emotions, in your battles against depression and anxiety — allows it to relax and connect with the rest of you. This opens the door to self-acceptance and self-love, which often seem so elusive in addiction.

And when the need is no longer desperate and isolated, that’s when you can manage to count your drinks, call a friend, watch a movie instead, shift from whiskey to wine (my target these days — I’m down to one scotch and a glass of wine most nights) …and taper, gradually — develop a schedule of controlled use or stop entirely. Once you feel less fragmented, once the warring factions have laid down their arms, you might find that place much more accessible, and it’s a lot less likely to give way when life throws its next curve-ball…or its next virus.

To me, this is harm reduction. Specifically, a psychological approach to harm reduction that makes sense and feels right.

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In response to my last post, some of you expressed interest in mindfulness/meditation as a means for overcoming addiction. Today I want to relate the calm centre of IFS with the calm place we find in meditation. They are similar in some ways and very different in others.

There will be more posts on mindfulness, and I promised to visit “Mindfulness-based Relapse Prevention”, a fusion of mindfulness with CBT expressly developed for addiction. But today’s post will be about my personal experiences and thoughts.

Last night I sent the finally-fully-edited draft of my first novel to my agent. I’ve been working on this manuscript for roughly four years, so you can imagine, today I feel this sort of yawning emptiness. Like, now what am I supposed to do? The day seems to lack structure and meaning. I have moments of delicious relief, but at other times I feel confused and lost.

So I did my morning meditation (nothing heroic — just 12 minutes with the Sam Harris Awakening app) and it happened to be an episode focused on emotions. True to Buddhist tradition, Sam H urged us to let emotions come…and go. Anger, anxiety, whatever it is, let yourself feel it, don’t fight it, don’t hold onto it, just recognize it as colouring the field of consciousness. And that’s all, he reminds us. You don’t have to do anything, because consciousness is its own goal. Just be there and be aware.

I figure this is the centrepiece of (Vipassana?) mindfulness meditation. Good stuff, to be sure. Especially when craving is a real problem. Recognizing that craving is simply a feeling, without a particular requirement or needed resolution, can be most beneficial.

But nowadays when I meditate I often go into IFS land. (See my last eight posts if you’re not familiar with IFS, or go online). It’s different. The emotions I felt this morning, while meditating, were mostly a mix of anxiety and resentment, tinged with a wish to rebel or even get high. So…what the fuck’s that about? Simple, according to mindfulness meditation: let the feelings be there without being carried away. Simply let yourself be aware of them. What does IFS say?

In IFS, as I’ve tried to explain, there’s a place they call Self (with a capital-S) which is different from the “parts”. It is a place of being centred, calm, patient, compassionate, accepting, noticing, even welcoming whatever comes. As you can imagine, whatever comes usually involves the “parts” that have needs, concerns, and fears. Now this central place of calm acceptance seems very similar to the calm place you get to in meditation. But here’s the difference. You don’t just sit there in the centre of it, you meet and greet, as it were, the parts that need something. You connect with them, welcome them, follow them to their origins…you can sit with them, and you can soothe them. One form of soothing is to invite the parts to come and be with You (captital Y?) in the present, away from the bleak place where they remain fixated. A mysterious and perhaps mystical process that can work wonders.

So today I went and followed the dissatisfied angry part to get to know it better.

I had an experience of sexual assault in my teenage years. I have never disclosed this publicly, but after listening to Tim Ferriss (a very popular podcaster) disclose his history of sexual abuse, I thought, what am I trying to hide? Many of us who’ve been addicted have experienced something similar. In fact the link between trauma and addiction is well known. I want to understand this link in my own life. To look the other way is unhelpful — both personally and as part of a community.

I’ll leave it at that, without details, for now. The aftermath is what preoccupies me.

My first year in Berkeley, California. It’s 1968-69. The sun is shining, exotic flowers and trees line the streets, the hippie types (including me, sort of) wear their colourful clothes with playful exuberance. There were smiles on many faces. Fascinating men, beautiful women. We felt like we were ushering in a new age of humanity, a real cultural revolution.

But I was lost. I wandered the streets feeling empty and unreal. I didn’t know what to do with myself. Depression crashed down on me every evening I was alone — that is, without my roommate or my part-time girlfriend, Susan. I had a very hard time being with family members, because I felt there was something deeply wrong with me, beneath contempt. I resented the walls of politeness that seemed to shut me out of their lives. I lived in a pool of shame that was almost impossible to sense clearly because it was so constant. I have no doubt that my traumatic experience created or refined this part of me — broken, shamed, empty.

But there was one way to feel better, to feel…vital. Drugs. You can bet there were a lot of drugs available in Berkeley in those days. And they worked. From cannabis I went to psychedelics, acid two or three times a week, riding my motorcycle through thickets of hallucinations, and then from psychedelics to heroin, and then on to pharmaceuticals and crime. Check out my first book on addiction — Memoirs of an Addicted Brain — for the gory details. Two parts of me: one sinking into this sickening, passive emptiness, this incoherent shame, the other energized to find new and more powerful drugs and drug-tinged adventures, to fill up that empty space with magical potency. And through drug use, defy everyone who’d tried to tell me how to behave.

The wounded part never went away. Nor did the defiant part. That’s a fundamental insight of IFS: the parts can evolve, but they don’t disappear. As for the wounded part, its sense of being lost and helpless still hobbles me with a certain anxiety, vulnerability, and hesitation — but not nearly as much as it did. And I have other strong, brave parts with impressive energy. Often they lead — sometimes brilliantly. Now, when my meditation leads me to my wounded parts, I greet that 17-year old kid and let him know that it’s not his fault, that I accept him completely — him and his 12-year spree of crime and self-abuse — and that I love him. I let him know that he doesn’t have to live in that crazy, tilted world anymore. And that’s all he needs, that acceptance and care. It heals him.

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I should mention that Ferriss also interviews Richard Schwartz, the founder of IFS in a recent episode. This is a cool podcast: Schwartz explains IFS succinctly, compares it to aspects of psychedelic (MDMA) psychotherapy (fascinating!), and then does a live IFS session with Ferriss as the client.

Hi all. I’ve taken a little break from blogging. The final send-off of my book manuscript gave me a chance to catch up with email, reading, and some other writing projects. I even sneaked in a novel. It’s called The Humans, by Matt Haig. I picked it up at an airport bookstore on my way to Budapest, where I gave a talk at the International Conference on Behavioral Addictions. Beautiful city, great conference, and a really engaging novel: it’s about an alien who comes to earth on a mission to kill a math professor whose discovery threatens the entire universe. Humans might now acquire the technological capabilities to wreak havoc on a cosmic scale. But against his better judgement, he actually learns to like us, and before long he wants to be one of us. Sweet, funny, and often wise.

Anyway, I’ve thought about where I want to go next in blogging. I want to move on. Through this blog and my writing, I’ve arrived at a place in my own understanding of addiction which I think covers the basics, so to speak: the neural, psychological, and experiential elements that converge in addiction. I’ve shared all this with you: the neuropsychological basis of craving, the cycle of seeking and losing that accelerates learning, the narrowing window of desire and attention and its biological foundation in the dopamine system, the critical importance of self-narrative, of connecting desire with a self-defined future rather than remaining stuck in the present. And all the rest of it.

This leaves me with the sense of having built a good solid foundation for a model that makes addiction comprehensible without shovelling it into a pat category — like disease, or choice for that matter — and filing it away for the experts to dissect.

But there’s a lot farther to go. I want to build more floors onto this model. I want to make it as big, comprehensive, articulate, balanced, and realistic as possible, using the tools I know: psychology, neuroscience, others’ experience, and my own self-honesty.

I think the next level has to do with the way we talk to ourselves — the running dialogue or monologue through which we organize our thoughts and orchestrate our feelings. The hells and heavens we create for ourselves in imagination and reality. We all know that drugs and other addictive substances and acts can have tremendous appeal, or they can feel like relentless attackers. We sometimes pursue them even while we revile them, and sometimes we shun them even when they call to us in their sweetest voices. Our ruminations, our internal rebellions against real and imagined authorities, our construction of plans, limits, goals, and rules all have a great deal to do with whether, when, and how we pursue these angel-demon entities. Whether we remain addicted or break free.

I think these psychological processes are critically important for understanding addiction in a more detailed, more intimate, and more realistic way. And I think we can access them, bring them into the daylight of examination, and work with them — in ourselves, our loved ones, or our clients — in order to gain mastery over addiction.

So that’s where I want to go and I want to bring you with me. We learn a lot from each other. We’ve graduated from Kindergarten; now let’s move on.

…by Lynn K. Thorsen…

Out of the blue I found this poem in my inbox this morning. I contacted the author, Lynn, and she gave me permission to publish it here. You will see why I had to share it with you.

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Top Ten

(Reasons I Addicted Myself to Heroin)

Because when I was nine and we moved away and my grandmother died,

I thought I killed her because I didn’t write often enough.

Because having to move every three years and say Goodbye to everyone,

even my dog, was so unbearable

That I pretended that anyone I said goodbye to didn’t actually exist.

Because when my parents sent me away when I was Thirteen and just starting

to develop breasts,

I thought they sent me away because I was just starting to develop breasts.

Because when they sent me away I had to pretend

That they had never existed so I wouldn’t miss them.

Because my mattress couldn’t fly out of the

Window and fly me away.

Because when I found out I was pregnant at seventeen

And thought I was in someone else’s play,

I wasn’t.

Because I lost track of who I was and who I wanted to be.

Because I didn’t care about myself, or care for myself.

Because the pain I carried cut me off from

Everything, even my own childhood.

Because Penny said, “It takes away the pain.”

And it did.

…by Colin Brewer…

Greetings from London and thanks, everybody, for what are — amazingly for this field — almost entirely positive comments on the ‘language’ analogy that I first suggested in 1989 and that my co-author Emmanuel Streel and I have been writing about since 2003. (Emmanuel is a neuropsychologist but also a psychopharmacologist.) Since Marc has honoured me with an invitation to do a guest column, here it is, partially in response to comments following the previous post.

First, my removal from the medical register had absolutely nothing to do with rapid opiate detox under anaesthesia. From about 1995 to 2001, we detoxed over 700 people with this technique without any significant problems. It wasn’t even discussed at my hearing. I qualified in 1963 and when I saw my first heroin detox two years later, it was routine to use generous sedation if severe distress tempted patients to withdraw from treatment rather than from heroin. If patients can withdraw — slowly or quickly — without much medication, that’s fine by me, but if they can’t (and there are many in that category) I think it is the traditional duty of doctors to make unpleasant procedures as comfortable as possible. Does anyone — apart from the extreme ‘no pain, no gain’ fundamentalists — seriously disagree with that? Consequently, for patients who wanted to try or resume abstinence, we offered a wide range of withdrawal techniques, from slow tapers, through 4-5 day withdrawal with mainly oral sedation to 24hr techniques under oral and/or intramuscular sedation to i/v sedation and full General Anaesthesia. (Historical note: at one point, I was threatened with a lawsuit by the Spanish-Israeli CITA group who claimed I had infringed their ‘patented’ GA detox technique. Apart from the fact that the use of particular drugs (as opposed to the details of their manufacture) can’t be patented in Europe, I had described and published the technique, in an admittedly obscure journal, several years before they first used it.)

Because addiction treatment provided by the National Health Service (NHS) was so lousy in the 1980s and 90s (for example, the addiction establishment were very anti-methadone maintenance from 1980-1999), there were long waiting lists for in-patient withdrawal, and when they were eventually admitted, completion rates in one of our flagship centres were barely 25%, of whom nearly half had relapsed four weeks later. We therefore found ourselves treating many people who would not normally have considered — or been able to afford — private treatment, and quite a few more prosperous patients whose insurance had refused to continue paying or who had simply impoverished themselves through repeated self-funded treatment. For this large group, we devised a home detox programme that involved training the family to act as carers. As with all our detoxes, after completion and naltrexone (NTX) induction, we very strongly encouraged patients to take family-supervised oral naltrexone for at least six months and, after 1997, to have a NTX implant, to increase the chances that they would get through the crucial and often difficult first couple of months, when relapse rates are highest. We did around 2000 home detoxes before one family fatally misunderstood the instructions. Naturally, I feel bad about that but I don’t feel bad about trying to devise affordable treatment. I think that case made the difference between a reprimand and being removed from the register, but many addiction clinicians and academics in Britain (and several abroad who gave evidence for me) will tell you that the establishment were out to get me and were looking for excuses.

Marc asked me if I’d ever written anything about the hearings. I haven’t, and these are my first published comments, but the two most bizarre features were (1) some three weeks spent by the panel trying, unsuccessfully, to prove that a case not written by one of our counsellors, whose handwriting was similar to mine, had actually been written by me, even though one of his notes read: ‘Must discuss this with CB’! and (2) a serious — as in six-fold — miscalculation by two of our leading academics of the methadone equivalent of another opiate.

If Marc thinks I look a bit weird in some of the online images, that’s probably because they were taken when I was trying to force my way through a rat-pack of paparazzi after the final hearing. Fortunately, the clinic I set up continues and is still doing most of the things that we had been doing up to the hearings. Some of those — e.g. using slow-release morphine for people who don’t get on well with methadone or buprenorphine — are now pretty normal, at least outside the USA. The clinic is also expanding its patient groups to include the growing problem — though it’s still small by US standards — of prescription opiate abuse and the management of ‘therapeutic addiction’ to opiates in pain problems. I only have an advisory role these days but we hope to extend what Emmanuel and I suggested should be called ‘Antagonist-Assisted Abstinence’ (AAA – geddit?) to benzodiazepines. Using s/c or slow i/v flumazenil infusions, it’s quite easy to take people off fistfuls of diazepam and other benzodiazepines in five days with very little discomfort, and a flumazenil implant is being developed in Australia.

The clinic still does plenty of maintenance treatment, and I was told recently that the new emphasis on ‘recovery’ (read: we don’t like indefinite methadone maintenance) means that, as in the 1980s, increasing numbers of well-functioning methadone-maintenance patients — many with good jobs that they don’t want to jeopardise by having to take weeks or months off for withdrawal — are being put on forced reductions. I never claimed to be perfect (as we say in the trade, ‘if you haven’t made any mistakes. you’re not seeing enough patients’) but I don’t think that anything I did caused remotely as much misery and disaster to opiate addicts as the policies encouraged by the addiction establishment in the face of mounting evidence for the value of methadone-maintenance treatment.

Finally, I wrote a paper a few years ago suggesting that harm reduction in family planning (avoiding unwanted pregnancies) could teach some useful lessons to conventional harm reduction (avoiding unwanted addictions), in that it uses a variety of techniques and tries to fit the treatment to the particular needs of the patient, rather than the prevailing ‘one size fits all, take it or leave it’ approach of so many clinics and — even worse — rehabs. I’ll provide references to this and other papers on request.