Understanding Addiction

Now that the shock of it has passed, I’m left with a fog of sadness and anxiety, a sense of things being wrong in the world — more wrong than usual. Everyone loved Robin Williams. He gave so much of himself in his films and on-stage that we felt we knew him intimately. He was easy to connect with. He became part of our personal worlds.

A few people have asked me what I think happened. Was his addiction to alcohol the problem, was it the inadequacy of his AA and other treatment choices, was it the shame he still carried during his dry periods, or his yearning to go back to booze and coke?

I think these are the wrong places to look for an explanation. In a somewhat bizarre interview with Decca Aitkenhead at The Guardian, published four years ago, Robin shifted the flow of dialogue directly to his personal problems.

After 20 years of abstinence, Robin started drinking again while shooting a film in Alaska in 2003. Here’s what he said about that moment in his life, quoted from the Guardian article:

“I was in a small town where it’s not the edge of the world, but you can see it from there, and then I thought: drinking. I just thought, hey, maybe drinking will help. Because I felt alone and afraid. It was that thing of working so much, and going fuck, maybe that will help. And it was the worst thing in the world.”

So why did he start drinking again?

[From the same article:] Some have suggested it was Reeve’s death that turned him back to drink. “No,” he says quietly, “it’s more selfish than that. It’s just literally being afraid. And you think, oh, this will ease the fear. And it doesn’t.” What was he afraid of? “Everything. It’s just a general all-round arggghhh. It’s fearfulness and anxiety.”

He continued drinking for about three years, then stopped. A residential rehab seemed to have helped, and he attended AA meetings about once a week since then.

He did not go back to drinking after that, as far as I know. But he must have been unable to deal with the anxiety that drove him to drink in the first place.

Those of us who’ve been through addiction know all about that fearfulness, that anxiety, that arggghhh. And the depression that is closely linked with it, and that reportedly engulfed Robin Williams in the last month of his life. Of those I’ve talked with, most have seen it up close, a jungle beast staring them eye to eye. I still feel it often. But I don’t use anymore, chiefly because that just makes things worse. Then the fear becomes concrete: this is what’s going to get me.

Otherwise, it’s just anxiety.

Just?!

We live in a dangerous world. The love and protection we got as children (whether we were smothered in it or had more occasional helpings) is gone. We realize that was a childhood gift. The world is a dangerous place. Everything is uncertain. We cannot control the threats of loneliness, loss of loved ones, the onset of disease or disability, the vice-like grip of sadness, and eventually old age (if you’re lucky) and death. We cannot even control our desperate deeds aimed at self-protection, harbingers of shame and self-loathing. At least not always.

We live in a time dominated by an existential view of reality. Few of us feel buoyed up by religion or hope of a pleasant afterlife. And yet we’re not very good at being here now. It’s not something we’re taught, and it doesn’t come naturally.

I think the fear, anxiety, the depression, the arggghh that became unbearable to Robin Williams is something we also know well. His death disturbs us so much, not only because we will miss him, not only because we feel for him, but because it reminds us of the brutality of that incessant uncertainty, that desolate isolation, which can turn into terror.

Of course we hear about the casualties. Philip Seymour Hoffman, and now Robin Williams. Yet most of us endure. We’ve learned something that Robin may have been too busy to learn. How to love ourselves a little. How to accept helplessness and keep going. How to absorb some degree of warmth and wonder from the universe, the same universe that refuses to grant us safety or permanence. Maybe battling our addictions has made us stronger, more open, more accepting.

I’m sorry that wasn’t true for you, Robin.

I was overjoyed to see that Salon.com published a large excerpt from the first chapter of my book. (The headline may still be on the front page!) Until I saw the title: Addiction is Not a Disease. Good so far… Then: How AA and 12-step programs erect barriers while attempting to relieve suffering. Not so good.

They got the phrasing directly out of the excerpt (i.e., the book), so I can’t fault them on that. But now I understand the double-edged buzz/sting of being taken out of context. Nice to be taken… Thanks, guys! But does it have to be out of context?

There’s been enough AA bashing in the last…I have no idea how many years….to just give it a rest. Anyone knowledgeable about the addiction field knows that their success rates are far from stellar: estimated at 5-10% by Lance Dodes (an articulate critic) and other sources. Take a closer look and you’ll see that the way they estimate success is rather stringent, as it depends on total abstinence, and many of us believe that AA/12-step groups do not serve a cross-section of addicts. They serve those who are in the worst trouble. And they’re free. And they’re a support group, not a treatment organization. Etc. Etc.

It’s true that there’s been a sort of merger between 12-step programs and the disease model, mostly manifested in institutional settings such as residential rehabs. This has been going on for decades, due mostly to the influence of mainstream medicine and the coercive power of the court system. It’s exemplified by the doctrine that addicts had better follow the 12 steps in order to fight off their disease — or else. Of course I oppose this view. But it’s not the heart of AA/12-step philosophy as I understand it. Rather, it’s an unfortunate branch in the evolution of a rehab industry that often feeds off the worst of both worlds.

If you want to get an even-handed picture of the pros and cons, truths, myths, and lies about AA/12-step, I suggest you go to Anne Fletcher’s recent article: Setting the AA Record Straight.

I wanted to set my own record straight. Salon.com has a huge circulation. I respect a lot of their coverage, and I’m always up for healthy debate.

But, as my readers know, my book is about reframing addiction as a learning process, countering the dominant view of addiction as a disease, showing why this reframing is scientifically valid, showing why it makes sense in the lives of those affected, and suggesting implications for new perspectives in the science and treatment of addiction.

It’s not about AA.

This guest post is by Peter Sheath, another good friend, who, like Matt, I’ve only met in the flesh for a few hours. Peter knows a great deal about addiction and rehab. Here’s what he’s got to say about power and powerlessness…

I have been student of addiction for many years. Much of it involving the personal and, sometimes, painful elements of self-experimentation. I’ve talked to thousands of people and I’ve experienced the privilege, honour and genuine unfettered pride that comes when a person decides to trust me and invites me to share some of their journey. There is something very special that inhabits almost everyone I have come across who struggles with addiction. I see it in their art, I feel it in their performance. Read anything by Hemingway, The Old Man and the Sea in particular, or watch a Tennessee Williams play. Watch Philip Seymour Hoffman as he steals the show. Working with addicts, when you are really with them, is much the same. It’s almost as if they have a magnifying glass attached to them that blows up every little human characteristic to an almost unbearable level of magnitude. Beyond all the ego, bravado, and defiance are, almost always, frightened children. Who have lost their way and come to rely on the predictability of substances. Until they’re ready to move on.

To try to work with these people I firmly believe that I have a professional responsibility to work with myself. I need to be able to see beyond the narcissism of self and meet them exactly where they’re at without wanting to control them. In a line from a song, Willie Mason says, “It’s a hard hand to hold that’s looking for control.” That reinforces the idea that, if I do not have the presence to meet someone and accept them as they are, I shouldn’t bother meeting them in the first place. I have found, through bitter experience, that if I’m not with them it becomes my space that I’m working in. A space often populated by my dark side: a space I need to control.

Unfortunately many of the people working in treatment do not see any need for self-reflection and continued self-development. They have come to believe that they simply don’t have time. I’ve travelled all across the UK, delivering training, coaching and consultation, and it’s the same everywhere. Blame, intimidation, threats and arrogance become the tools of rehab, the vehicles of control. It’s just easier that way.

During a training session I was delivering a couple of weeks ago, one of the delegates said that the training was great but how was she supposed to do it when she had 70 people on her caseload? She was genuinely upset and was expressing her sense of being overwhelmed by the situation. I invited her to just take a step back, consider the situation as an observer, and try to see the 70 people as 70 individual opportunities for change. I said that each of those 70 people had the propensity to take responsibility for their own lives, begin to address the risks they were currently involved with, make some decisions and commit to actions to help with their wellbeing. Not rocket science, but it really did help her to see the situation differently, and  to realise that, by approaching her work in a different way, by handing over responsibility, she may have a lot less to carry on her own shoulders.

Unfortunately, and here’s the rub: when we have absorbed the ideology that addiction is a disease and we need to sort it out or cure it, we are unknowingly removing from the person the very thing that is going to get them well. By assuming the “expert” status we are telling people that they are sick and, as such, unable to take responsibility for their recovery. Walk into any treatment centre anywhere and suddenly you become completely incapable. You can’t even fill in a form yourself and you certainly have no capacity or competence to manage your medication. Even if you begin to take responsibility by getting honest and telling the workers you have used again, they will need to take a confirmatory drug test to prove it! “You will need to undergo an assessment, looking at everything that’s wrong with you…” Using a form filled out by a worker, because you can’t do it yourself. The process is repeated by any further “expert” you may need to see. Any initiative on your part will be viewed the same way: as an obstruction. If you don’t want a script or you want to go straight to detox, you will be met with, “you’re not ready for that yet”, or the classic, “people die doing it that way.”

In fairness, it is beginning to change, but I believe that change needs to begin with the workforce. It needs to begin with an admission that we’ve got it wrong. Then recovery can become a team process that includes the person doing the recovering.

Please note that we have a new Guest Memoir. Click the link above and check it out. Send in one of your own. These are potent, personal, and searingly honest portraits of the struggles and triumphs of addiction.

…by Bill Abbott, M.D….

Bill has been a long-standing member of this blog community and he has contributed his leadership and knowledge to the SMART Recovery movement. Thanks, Bill, for taking the time to share your thoughts here.

……….

I’ve recently completed two books. The first is Marc Lewis’s recent one and it is a winner. In this book Marc describes a “model” to explain addiction that is counter to the prevailing “disease model” and he does so in a very credible and lucid way that is based on neuroscience integrated with personal experiences of people he interviewed. A very effective approach indeed.

The second book, republished recently, is entitled Love and Addiction by Stanton Peele, which was first published in 1975 – 40 years ago. In this book (and other books of about the same vintage, such as Diseasing of America) Peele described the problem of addiction in very similar ways – obviously without the neuroscience available today — and showed the similarities between addiction and some forms of love, as Marc does also.

This has left me both frustrated and somewhat sad – that is, so much was clear forty years ago and yet we seem to have learned so little, and I can only come to conclude the following:

1. The current way we approach the problem of addiction in the United States is abysmal; it isn’t working because it is wrong.
2. We have failed to learn from our mistakes.
3. Much of what we really need to know to understand addiction has been known for a long time, but we haven’t paid attention.
4. We know enough about the problem to effectively deal with it.
5. And finally, the disease model is not only wrong; it is harmful.

Marc suggests that the disease model is harmful to a certain extent, but my purpose here is to expand on that idea. I feel justified perhaps because I am a medical doctor — and in long term recovery from alcohol misuse.

As a disclaimer, what I describe pertains to the United States, where I live… but probably to some extent to other western countries as well.

The harm stems from two sources:

The first is a practical issue. If addiction is a disease, doctors will be expected to “treat” it. That may not be too bad in theory, but unfortunately the medical profession (in the United States at least) is ill-prepared by virtue of knowledge, training, and — most problematic — insufficient time.

What about psychiatrists, you say? They are doctors. This is true (although many seem to forget clinical medicine)… but because they are doctors they treat patients by managing their patient’s diseases by prescribing medication, hoping for cure.

The underscored words lead to the second and greater problem with the brain disease model; and that is that it shifts the focus away from people with a problem to an outside entity, thereby mitigating personal responsibility. This position in essence means looking for an outside solution for an inside problem…that only an inside solution can help.

Let me expand on that a little.

Marc brings up two very important concepts in his book: what he calls “now appeal” (officially delay discounting) and ego fatigue or depletion (the depletion of cognitive resources for applying self-control). A related idea is the concept of locus of control.

This concept has been around for a number of years and has been described a number of ways. In general terms what it refers to is whether an individual believes in or relies on self-management or tends to look to outside resources for problem solving. This is not a fixed or constant trait but rather a tendency that varies with the problems and stresses people face. It often tends to be more on the external side in those encountering hard times – not uncommon in the addicted person. Some incorrectly call it low self-esteem.

So if addiction is a formerly useful coping strategy, now gone amiss, then one needs to look for other coping strategies that work better and be motivated to put them to use. And these work better if they are self-empowered. They don’t work if you rely on someone or something else. They just can’t.

The neuroscience points to the same conclusion; it is the “desire” that Marc is talking about that makes recovery work.

What is needed is a shift toward an internal locus of control. Something which the disease model tends to undermine because it fosters dependence on another power.

Surely you can and ought to seek help, advice, support, or what have you, if that can help. But ultimately you have to do it—for yourself

This is why the disease model is so insidious and counterproductive to successful recovery in many people. Although your doctor will encourage your participation, basically he is telling you what to do. This is prescription — be it medication or behavior. “You must stop drinking or you will die,“ my doctor said to me. I went home and poured a drink to think about that.

The evidence supporting the self-management approach is all over the place.

Consider so-called natural or spontaneous recovery — statistics show that as many as 80% of those who meet criteria for substance use disorder in the DSM-5 recover with no intervention or support whatsoever.

This is the epitome of self-management and empowerment.

For those who do need some help, self-management can be learned or better relearned in any number of ways… but I am skeptical that it will ever be learned in a doctor’s office, where you wait next to people with medical illnesses like hypertension and hemorrhoids.

A disease like cancer needs the doctor to manage it; addiction does not.

What those of us who solved the problem of addiction share is self-empowerment and then learning the skills to manage life’s many stresses in a different and ultimately less destructive manner.

The whole disease model concept is based on some really bad science and that in itself is harmful. But the fallout is potentially more damaging.

I only hope people start paying attention, because the problem is getting worse and we gotta do better. The people who suffer deserve that much, and if we help them to see what they can do for themselves, they may in fact do it — and feel good about the fact that they did.