Understanding Addiction

Hi all. This is ridiculous. I’ve been back from South America for a month and have not yet returned to blogging. I haven’t even responded to many of the comments and sweet sentiments following the last post. Though I have skimmed through most of the dialogue and debate — with interest.

I have so much to share with you, but it will still have to wait a bit longer.

Having two publishers (one American, one Canadian) means having two editors. They each have very different specialties, and I have to edit the whole manuscript twice, once for each of them. This has been a burden, but also a blessing. They are both really good!! And the book will be that much better due to their excellent skills. That is, if I ever finish the edits and get a final manuscript into them in time for the publication date.

I’ve also received amazing help with some chapters from Matt Robert, a frequent visitor to this blog, and his partner, Cathy. Matt is a SMART facilitator and he knows the addiction field inside-out. Their help has been particularly useful for thinking about the historical context of the addiction field, current debate on many issues, and the implications of my framework for recovery.

Some day soon, it will all be done.

To provide a little content before I publish this, I’m inserting several (slightly revised) paragraphs from the second last chapter — the wrap-up chapter. Here’s a cool way to think about desire, which is, after all, the most prominent word in the title.

Why desire?

The potency of desire — which we can call an emotion or a motivational state — deserves a lot of respect, as does the neural terrain bequeathed to it by evolution. Focus on your mental state when taking a bite of pasta (or anything else). Notice where your attention is directed while you are eating. While the food is approaching your mouth, en route from your plate, at least some of your attention is likely to be focused on the food. For now, attention is linked with the goal of getting the food where it’s going. And you are feeling desire, at least at some level. Desire and attention converge into one beam. But as soon as the food is in your mouth, your attention goes elsewhere: back to the conversation or to the book you’re reading or the show you’re watching. The amount of attention you pay to the taste of that mouthful is a drop in the bucket compared to the amount you paid to getting it there.

So, perhaps sadly, maybe ironically, pleasure is a small part of the common experience of eating, even when you’re eating something delicious. Desire and expectancy make up most of the experience: the approach is by far the main act. But this disproportionate relationship makes perfect sense. The evolutionary requirement to focus on pleasure is almost nil. Once the food is in your mouth, it’s a done deal. But if you weren’t deeply engaged, focused, attentive, and determined to achieve the food-in-mouth goal, your survivability would be a poor bet.

This is of course the same with all other highly motivating goals. Like, for example, getting drugs, booze, cigarettes, money, or sex. I get into the brain mechanics a bit in the book, but the gist is this: the brain regions devoted to desire occupy far more volume and are far more complex than the roughly cubic centimeter responsible for pleasure.

The biology of desire not only helps us understand addiction; it helps us understand why addiction is not a disease. Why it is, rather, an unfortunate outcome of a normal neural mechanism that evolved because it was useful.

I hope that was a tasty tidbit, and I promise more soon!

Here’s most of an email I recently received:

 
> Subject: why does the addiction resurface when we least expect?
> Marc,
>
> I really enjoyed your memoir. In so many ways I feel I can relate….
>
> So… Here’s my question…
>
> Why, after being sober for 7-months, did my craving for alcohol become
> that much more intense? Gave up alcohol in August 2013… Started
> drinking again in February 2014… It’s like….. thought I was on my
> way toward a happy peaceful sober life, and then, BAM! Drinking more
> and in ways that I see are perhaps more self-destructive?
>
>
> What’s up with me?

Here’s most of my reply:

Hi  _____, Thanks for your note. I find it thought provoking, and really very moving, partly because I had similar experiences when I was taking drugs. Also, your note goaded me into writing this long-overdue post.

This is what happened to me: In 1979 or so, after several years of struggling to abstain and remain abstinent, I finally quit “successfully” for a few months, and then BAM! — I fell back in. Just as you describe. I had quit taking any and all opiates in late December, at the same time as extricating myself from an extremely painful marriage — many strings, much guilt — and making binding promises to myself. Now I was living in my own apartment, I’d given up trying to influence my wife’s state of mind, I was getting good grades in my first year (of graduate psychology), and I was thoroughly delighted to be “unhooked” physically and, so it seemed, psychologically.

Then I went to a party at someone’s home in April, about four months later. I went to the bathroom to pee, and while standing in front of the sink I impulsively opened the medicine chest. And there, staring me in the face, was a large-size bottle of Tussionex — about 1/4 used up, so…. ideal for taking a few sizable gulps without anyone being the wiser. (Tussionex is a cough medicine whose main ingredient is hydrocodone.) Soon after that night, I began using again regularly, and breaking into medical offices again regularly. I guess I was so upset with myself for ending my fast that…well you know how that one goes. Then, one night, three months after that, I climbed out of the basement window of an enormous medical centre, my pockets stuffed with drugs and needles, and walked directly into the waiting arms of several officers of the law. Ironically, I was working as a psychology intern at the time. In other words, I was supposed to be one of the healthy ones. Six weeks later I was given a suspended sentence. But far worse than that, I was kicked out of graduate school, essentially black-listed from all psych departments in Canada, at least for a few years, and I ended up washing windows and house painting to make ends meet.

So what goes on when we are sailing, in the clear for months, and then BAM! — we suddenly find ourselves in the throes of our addiction, as bad or worse than ever?

I figure the two most important brain changes that go with addiction are (1) the rewiring of the striatum, from ventral (nucleus accumbens) to dorsal striatum, and (2) the rewiring of prefrontal areas responsible for self-control, decision making, and so forth. The striatal change takes drug-seeking from an impulse to a compulsion, so that the behaviours we engage in to get/take substances or engage in other addictive acts become at least partly automatic. This is an example of classical (Pavlovian, i.e., stimulus-response, i.e., S-R) conditioning. Stimulus now leads directly to response. The prefrontal change blunts our capacity to think flexibly and switch goals as needed, so that addictive goal-seeking is no longer harnessed by cognitive control.

If those two brain changes are central to addiction, then ongoing brain changes in both systems — essentially in the opposite direction — are probably central to recovery. We recover some cognitive control, and those prefrontal networks become more efficient once more, but slowly, and mostly because we work on it like hell. We practice cognitive control daily, and thereby awaken the synapses that got too sleepy. In fact, a study I recently reviewed on my blog shows that we grow extra synapses in cognitive control areas after several months of abstinence. These function like a suit of armour that protects us from addictive impulses….until the automatic S-R response finally weakens.

But here’s the problem: On any given occasion, the cognitive control network is slower to power up than the impulsive/compulsive network, and this is especially true while the cognitive control network is still being “tuned up” (so to speak) during the recovery phase. So the synapses in the striatum and its close neighbour, the amygdala, get activated extremely rapidly by drug cues — even during recovery — compared to the prefrontal control networks. Approximately one-fifth to half a second faster (my speculation based on EEG findings). So these “control” networks (which Kahneman refers to as System 2) are not only intrinscally slower to begin with, they’re even slower (and more deliberate) than usual because they’ve gotten rusty with disuse.

So when I opened that medicine chest, my slow deliberative control mechanisms did not have a chance to act BEFORE the rapid, automatic, Pavlovian-style response took effect — as soon as I saw that bottle. Stimulus = Tussionex. Response = Grab and drink. Reflective self-control doesn’t even power up until half a second after the sight of the bottle. And that’s another important point:  action tendencies break off and have a life of their own. My whole brain was already set into a response mode (triggered by the stimulus) that was extremely hard to interrupt once it got started. All those striatal synapses were already singing in choral unison: “fuck it”, “just do it”, “I have to get this inside me”, “do it now before anyone (including myself) can stop me”. Those synapses were still functioning as a coherent, efficient network — the net result of all those yeas of addiction.

I don’t know if this explanation works for you. You mention increased craving. But that could be a sort of byproduct. I’d say that many people slip because they’ve let down their guard, they’ve stopped concentrating very hard on beating back those action tendencies (and maybe even imagined they could experiment a bit) — simply because they’ve been sober long enough to believe they’re out of danger — at a time when they actually need extra effort while cognitive control networks are just beginning to blossom again. They figure they’re safe. They open up medicine chests on a whim, or sip a glass of bubbly at an office party. And, as you say, BAM! Down you go again. And this ride really is more self-destructive than the last, because you are terribly angry at yourself for letting it happen. What an ideal time for a self-destructive feast!

Here’s a brief Q&A hosted by a website called 52 Insights. It’s quite a spiffy site, with interesting authors and speakers presenting their views on popular culture, science, politics, and so forth. My piece is about my personal history, my book, habit versus willpower, and a bit about the War on Drugs.

Here’s a longer Q&A, done as a podcast, conducted and beautifully annotated by Barry Daniel for The Middle Way Society. This is a fascinating group in the UK that takes the Buddhist concept of “the middle way” and translates it into philosophical and practical ideas for thinking about and living in our own paradoxical era. My interview is, not surprisingly, entitled Why Addiction is Not a Disease.

The founder (I think) of the Middle Way Society, Robert Ellis, reviewed my book in an essay offering several unique insights into the role of the brain in overcoming addiction. This is where philosophy, neuroscience and addiction studies come together. Ellis says many nice things about my book, but he challenges my claim that addicts lose touch with some of the most critical functions of the left frontal cortex. Namely, the capacity to see one’s life as a linear progression, a trajectory or narrative, extending from past to present to future. I think that addicts have to rekindle that capacity before they can move themselves toward a future they choose for themselves. Ellis says I pay too much homage to the left hemisphere, and it’s really the right hemisphere that goes dim when people lose themselves to addiction.

What do you think? (See my reply for what I think.) The two hemispheres of the brain are responsible for fundamentally different human capacities. Which side of the brain needs to do push-ups to help us acquire the strength to overcome addiction?

My blogging days may be winding down. But if they do, as they do, I want to put more energy into methods for helping beat addiction than ideas for explaining it. It’s critical to understand addiction in depth, and I still believe that linking neuroscience with lived experience provides a potent frame of reference. But lately I’ve been moving on, thinking almost exclusively about treatment. Is there a connection from brain parts to mind parts to effective methods for helping people? Let’s see.

I started this blog with an emphasis on addiction neuroscience. I can sum up most of that brain stuff in a few simple conclusions, but I’m going to add some points of clarification:

-even though brains change with addiction, addiction is not a brain disease, as often claimed. The brain changes with any and all learning, and the more emotional and repetitive the learning events, the greater and more enduring the resulting brain changes.

-habits are inscribed in synaptic networks (networks of connections among neurons). Those networks become the hardware for processing new information: “What fires together wires together.” Thus, novelty gets sidelined by habitual patterns of thought, feeling, and behaviour. That’s the case with love, politics, religion, and yes, addiction.

-the “narrowing” of synaptic networks is mirrored by a narrowing of the social world. Friends, family, finances, legal circumstances all become more limited, more “narrow,” for the person who finds fewer neural avenues for pursuing rewards. You’ve heard that life imitates art? It’s also the case that social change imitates brain change. (See my review article here.)

-the “narrowing” metaphor suggests that the connections between different brain parts become more entrenched, less open to change. But that doesn’t mean that diverse neural regions become fused in some way. The brain retains its functional components (e.g., frontal regions underlying conscious attention versus limbic structures in charge of automatic behaviour) and those components are designed to compete.

So now what? With all we know about the science and psychology of addiction, how do we put it all together? How do we help?

The neuropsychology of addiction is important! It exposes us to many critical concepts, like the biological embedding of habit formation. Yet we don’t generally treat addiction, either in ourselves or others, by altering the brain. At least not directly. We don’t perform lobotomies or lobectomies, nor is it common to use deep-brain stimulation or transcranial magnetic stimulation to help people recover. No, when it’s time to turn from thinking to helping, we turn to talk, often in the form of psychotherapy.

Talk is social behaviour. So the goal is to free up addicted people by expanding their social world, especially the social world they carry around in their minds — the way they talk to themselves, the way they interpret messages from others. At that point the neuropsychology of addiction takes a back seat, as an aid to our clinical intuitions and our capacity to listen. Once again, lived experience, both that of the client and of the therapist, becomes the needed partner for our scientific theories.

Now if both the brain and the social world “shrink” in tandem, then we should be able to “grow” the brain (the realm of synaptic possibilities) by “growing” social-psychological flexibility. How can this be achieved?

(There is one method of acting on the brain directly, bypassing all that messy talk stuff. We can give the addicted person drugs that directly affect their neurophysiology and/or how they think and feel. Antidepressants and antianxiety drugs to target underlying mood states, methadone or naltrexone to nudge drug-soaked synapses out of their ruts. But in my view, psychotherapy — if it works — goes deeper, induces changes that last longer, and provides a sense of well-being that no drug can mimic.)

I find Internal Family Systems (IFS) therapy to be the most effective form of talk therapy available. You’ve heard me rave about it over the last few posts. I’ll end today by pointing out that IFS brings to the table a fundamental experience that most addicts find exhaustingly familiar. For them (and of course I include myself) the internal social world, the voices in our heads, are most conspicuous because they are at war with each other. The internal critic tells you that your wishes and goals are reprehensible. But the childish wishes don’t go away. In fact, they get stronger, fueled by defiance against the internal critic and desperation to meet needs that are hunted down and locked away.

By recognizing this internal duality, this multiplicity of conflicting part-selves, IFS brings empathy and clinical intuition to bear on what neuroscientists already know but never think about. Brains are composed of components that are designed (by evolution) to compete with each other. Frontal inhibition (lateral prefrontal cortex) versus learned habits (striatum), future oriented action tendencies (dorsal cortical circuits) versus preoccupation with threats (ventral cortex and amygdala). These tendencies are supposed to compete. That’s what gives humans their incredible capacity for choice and intelligent action.

How did we psychologists forget that when going about devising treatment strategies?

So, here’s the breath of fresh air provided by IFS. Conventional methods of treating addiction involve training people to “just say No.” That doesn’t work. Mounds of disappointing outcome stats make that clear. Why doesn’t it work? Because it ignores the lived experience of people in addiction and it ignores the way brains actually work. In contrast, IFS trains people to listen to the voices or “parts” that occupy their minds and accept them, welcome them, soothe them, without trying to shut them down. In that sense, it respects the idea that the mind — as well as the brain — is multiple, and it is composed of competing functions.

But that’s enough for today. In my next post I want to be very explicit about the IFS alternative to “Just say No.”

I’ve written about the benefits of stretching your sense of yourself outward, freeing it from the repetitive, stagnant “now” of addiction, extending it all the way from a distant but familiar past to a wished-for future. But how can we turn this abstract idea into an exercise, a therapeutic method, for recovery, for whatever you want to call the next stage?

I’ve been thinking vaguely about a workshop I’m to give in Australia this July. So I ask myself: what on earth do I have to offer front-line workers in addiction? What can I suggest that’s concrete enough to help real people struggling with addiction in the here and now? Well an idea finally came to me while I was meditating this morning. I do sometimes get good ideas while meditating. I’m no expert meditator by the way, and I know you’re not really supposed to be thinking things through. But sometimes new perspectives just appear, and I value them.

So here it is:

What if, either alone, maybe in a guided meditation context, or maybe in psychotherapy with an expert, what if the cravings, the fondness, the attraction of getting high kind of slid down a slide of time, from the present to the past. After all, those cravings don’t really belong in the present tense, that’s not their home. They come from long ago. From the dark oppressive helplessness that followed something awful, some period of abuse or chaos. They come from a depression that started when you were a teen. Well, didn’t they? I know mine did. And they show up in the present, in the now, in the “should I or not?” of today, as stubborn visitors. They continue to visit you in the present. Like unwelcome guests, they don’t leave when it’s time for them to go, even though they’re taking up half the house.

So imagine the whole continuum of your life as though it were a slide or a slope. Let those desires slide backward in time, and follow them, observe them, see where they land in the past, see where they really belong, like an observer on an archeological expedition. When I try that exercise, I get a rush of self-compassion and self-understanding, and, as a bonus, present-tense cravings pack their belongings and clear out.

It’s like an overcast sky when the clouds start to part and little bits of sun filter through. And then you realize there’s a whole blue sky waiting on the other side of the clouds.*

Then continue the metaphor: imagine the slope of your life continuing upward, rising, unfurling, as it opens into the future. That future really is different from the past — and the present. This is not an abstraction. It’s a completely different place, a place you’ve never been to, but a place that sends tendrils of possibility, rays of hope, back to you, now, in the present, where you’re sitting wondering about and yearning toward freedom and change.

Maybe a better image is that of a cone…maybe an ice-cream cone. After all, there’s only so much mileage you get from a shoe horn. Maybe picture an ice-cream cone and let all the slush gravitate to the bottom, which invariably starts to leak. So the goo leaks out the soggy bottom, and what’s left on top is…I don’t know, the good stuff, the untasted flavours? The chocolate sprinkles?

Maybe a snow-cone?

I can’t quite find the right image. Any ideas would be appreciated. It would be nice to develop this metaphor so that I could actually talk about it, elaborate it, teach it. Here’s another image that might work better, because you can see the “bad stuff” emitting downward and out the bottom while the “good stuff,” the possible future, radiates from the mouth of the cone.

Try it and see what you think. For me, this is unfinished business, a rough draft. But I’m sure there’s a palpable feeling to letting the present-tense sludge slide back into the past, where it really belongs, and then…then, I don’t know, the sky’s the limit.

*I got this metaphor from “Andy,” the guide for the Headspace meditation app. I think Headspace is fabulous. Try it!