Understanding Addiction

Hello people! It feels good to be back in touch with you….as though you are my long-lost family. I have posted some comments, haphazardly, in response to recent comments of yours. For anyone still waiting for a reply from me, I’m sorry. I’ll be home in three more days and I will catch up soon. Or if I miss you and you want to hear from me, just nudge me with a note from the “contact” page.

This trip has been amazing: stressful, tiring, but also satisfying. I’ve stopped in a lot of cities, done a lot of interviews, a few readings, a few talks, written a couple of pieces while waiting at airports, and schmoozed with a lot of people, both media types and scientist types – addiction scientists – and even a few ex- or wish-they-were-ex- addicts. They are – we are – everywhere.

For example, last night, after I finished talking to an audience of about 200 people (scientists/practitioners and “normal” people), one young woman comes up to me while I’m packing up my laptop, and says unsurprising things, like “…really interesting talk. I do research on rats…self-administration of nicotine…test for increased activity in cholinergic neurons…etc, etc.” After a short pause, she continues, “I have a problem, too. I guess you’d call it an addiction,” and she looks down shyly. Then she looks up and our eyes lock and I recognize her as someone just like me, a much younger female version, but there she is, divulging her struggles to a stranger. Struggles with an eating disorder, a self-destructive compulsion, and I notice how thin her hand is after it’s just shaken mine. I look at her more closely and see her anxiety, all wrapped up in her skinny body, I notice the openness in her face, and I instantly like her: she’s got the courage and dedication to fight addiction and study it at the same time. I admire her, feel for her, and hope that she will win in the end.

Last night’s talk was the climax of my trip. It was held in the main auditorium of the main psychiatric institute in Toronto, called CAMH, Centre for Addiction and Mental Health. I always thought that was a weird name, as if they’re dispensing addiction and/or mental health – take your choice. Anyway, the posters advertised Marc Lewis, no title, with my face next to a big picture of the book, and in huge letters: Memoirs of an Addicted Brain. Three TV cameras were being set up when I entered the auditorium. I was pretty nervous. But once I started speaking, and once I started to focus in on the faces of the audience members – interested, intelligent, and engaged, with friendly expressions, no hint of the suspicion or judgement I’d half-expected – once I got going, I lost my nervousness and the words started to flow.

When I was done people clapped and clapped, and I felt like a star. But even at that proud moment I was very much aware, as I had been all day, that I was standing in the building where I’d done my research, my rat research, for my Bachelor’s (undergrad) thesis, some 34 years ago. And this was the place where I first got serious about stealing drugs.

The halls and the stairwells still looked familiar, and when my host pulled out his master key, on the way back from the auditorium, I vividly recalled the days when I’d had my own master key…and used it to go from office to office, lab to lab, late at night, after I’d finished with my rats…looking for drugs. And finding them! Or else grabbing a prescription pad off someone’s desk, ready for a little art work, imitating doctors’ classic messy handwriting, working in those Latin symbols, so I could bounce into a pharmacy later that night, coughing as convincingly as possible, and find my way to a bottle of Hycodan or Tussionex.

So I was a little nervous all day yesterday, not only about doing my biggest public lecture of the tour, not only about doing it on TV (yikes!), but about being recognized or found out somehow. I kept imagining that some old researcher would come walking down the hall toward me and his eyebrows would suddenly shoot up in surprise, then drop down in an angry scowl. So you’re the one! You’re the guy who stole all the morphine. You’re the reason the supply kept dwindling through the winter of 1978. Caught you!

Actually, the morphine came from the basement of the Psychology building, a few blocks away. But I’d scoop out a gram or two (we’re talking pure morphine sulfate, powder, in a couple of jars the size of peanut butter jars) and bring it with me to the CAMH building (then called the Clarke Institute). And I’d take a little break, somewhere around rat #15, when things were getting really boring – except for the wave of excitement building in my stomach – and I’d take my precious powder, mix it with water in a small plastic vial, shake it, strain it, load it into a syringe, and shoot it into my arm in a tiny locked room, with only the rats to judge me.

I did this for almost a year. And of course I always wondered when I’d get caught. When would someone notice something, either here or in the Psych building? When would someone blow the whistle on this addict disguised as a psychology student?

I finally did get busted, about a year later, but not here in this building. I had left, intact, with degree in hand, and the shit didn’t hit the fan until graduate school in another city, when I began to steal from doctors’ offices, not from the cupboards of an underground lab. So only a few people around here could ever have known about the other me, the real me.

Tonight in my talk, I was both the person I was then and the person I am now, a weird hybrid – drug addict and neuroscientist – standing up at the podium, talking about how my book might be able to help people get a better handle on addiction. You take the uncompromising cookie-cutter of neural findings and sprinkle liberally with the complexities of real life, everyday life, captured in a memoir. Then you can get to addiction from both angles at the same time and you can make a little more sense of it than either perspective on its own. I talked about addiction as a developmental process, a self-perpetuating preference turned compulsion, a creeping, encroaching synaptic network overtaking the orbitofrontal cortex and striatum, crowding out other synapses that represented other goals (like friendship, success at school, or even just pizza and beer). I showed a picture of ivy proliferating from a few tendrils to a bushy mass.

And I talked about you! I talked about my blog, and all the people I’ve met through it. I talked about the guts it takes to fight something as insidious as addiction. I talked about ego fatigue and I tried to paint a picture of how hard we work, we addicts, to outsmart our impulses. Just try holding your arm straight out to the side, I told them. No problem…..for the first five minutes. But try it for an hour. Try it hour after hour, day after day. I sang your praises, dear readers. I cheered for you. I told them: contrary to popular belief, rather than being lazy, or weak, or self-indulgent, addicts work way harder than most people. Because they are determined to say NO to an overwhelming compulsion or desire, to overcome ego fatigue, to outsmart their cravings by changing something fundamental about how they view themselves, how they attend to the world, how they talk to themselves. They are the bravest people I know.

I told them how much I have learned from the people who write into my blog: about addiction, about recovery, and about the far reaches of imagination, courage, and determination – the strategies and eventual victories we achieve through hard work – so that we can feel decent, normal, better than normal, proud of ourselves…the way I felt tonight.

Thank you for that.

Tomorrow, for my last publicity event in Toronto, I’m giving a talk at a Harm Reduction group. I don’t know that much about harm reduction as a philosophy or practice. I do know that I like the idea that there are many and varied paths to recovery, or maintenance, or whatever you want to call a relatively harm-free solution to addiction. I also recently found out that the Harm Reduction folks don’t even like the word addict. I think I get their point. The tension here seems to resolve to the ongoing debate, both in science and in clinical practice, about whether addiction is a disease or a choice. Here’s what I think.

It’s a false dichotomy. Addiction is not a disease like cancer or diabetes. No way. It’s hard to get rid of, which makes it like a disease, but that’s really just an analogy. The resemblance stops there.You can’t catch it. It’s not communicable. And you can’t cure it according to some specific formula. This idea is very much at odds with the pronouncements of the American Society of Addiction Medicine, the high church of addiction, as it were.  So is addiction a choice, is it just bad behaviour, is it the result of a genetic predisposition to self-indulgence or a low tolerance to psychological pain? All of these other definitions fall short as well. Addiction has an incredibly powerful, self-propelling momentum that takes it beyond the realm of “normal” choice or “normal” bad behaviour. If addiction is neither a choice nor a disease, then the choice vs. disease dichotomy is useless. It creates havoc and argument, it’s confusing, and it takes our minds off the more important issue. Such as: What is addiction really?

The disease camp assumes that the brain is important for understanding addiction. Addiction, they claim, is a brain disease. But the choice people paint themselves into the opposite corner. They claim that the brain is not important for understanding addiction. Rather we need to understand how difficult circumstances — trauma, rejection, economic hardship, and so on — affect substance-taking behaviour. What’s that got to do with the brain?

It’s got everything to do with it! Choices are not some magical puff of our spirit selves. Choices come from the brain. And the choice to take drugs, or booze, or cigarettes, again and again, comes from a brain that has been altered by a series of similar choices in the past. It just takes a moment of reflection to realize that choices are rarely “free”. And while philosophers debate the very existence of free will, we can be much more practical about it. Choices involve an exchange between the part of your brain that wants something (the ventral striatum and related areas) and the part of your brain that thinks about consequences and directs behaviour accordingly (dorsal and lateral regions of the prefrontal cortex). That exchange takes place in the synapses (connections) that join these regions. And those connections are altered by so many aspects of experience: hardship, success, self-image, trauma, and very clearly by the spiralling of wanting and relief that results from substance-taking itself. No two people have the same brain to work with, but there are features of addicts’ brains that neuroscientists can describe in detail: high levels of dopamine continue to strengthen the feelings of craving that spring from the striatum, while the satisfaction of those pernicious goals continue to reinforce the circuits that give substances their meaning and value. And the regions responsible for self-control are themselves weakened by excessive demands for impulse control. So their connections to the regions of craving shrivel because they’ve lost their potency.

Understanding the brain is essential for making sense of the kinds of choices that addicts repeatedly make. But that doesn’t make addiction a brain disease. It makes it an aspect of the biology of being a sensitive human being in an often difficult world.

One problem with my last post was the implication that shaming and soothing both come from outside, from other people. IFS (and some other therapeutic approaches) take a very different stance. It’s what’s inside that counts.

The comments on last week’s post were great, and I’m sorry I haven’t had a chance to reply yet. But obviously people in the addiction community are very familiar with how shame exacerbates addiction. I ended the post with the (also familiar) observation that connections with caring others is the sure-fire antidote to shame. Yet this is so often a losing battle, because addicts increasingly isolate themselves.

So what happens when we focus on our insides, under the skin, not on the reactions of those around us?

First let’s think about where shame actually comes from. We imagine that it’s other people who cause us to feel shame, through their deprecating remarks, anger, accusations, and so forth. But other people aren’t required. Our own internal critic actually induces shame with little or no validation needed. IFS calls this critic a manager — a part whose job it is to anticipate others’ reactions and try to avert worst-case scenarios. But notice: anticipation is a mental state, not a social exchange. It’s really just a belief we carry around with us.

Second, in addiction, this internal critic grows increasingly hostile and shaming…the longer we continue using. And why shouldn’t it? Shaming children is a powerful (if often flawed) means for getting them to shape up. So try it! Except that now…nobody’s listening…

I spent years researching the emotional lives of young children, and one experiment stands out most in my memory. My grad student Carla and I set up scenarios where 3-5-year old kids would accidentally pull off the arms of a toy doll  — one she’d already prepped with an exacto knife. Then Carla would say “Oh no!” and “Oh my!” (at timed intervals) while gazing at the child’s face. The poor kid would then look away, hide his or her head, and often protest: It’s not my fault! An internal shame-inducing “program” was now at full throttle.

(Just so you know, psychologists aren’t all sadists. Carla took a lot of time to reassure the children by showing how the dolls were pre-cut and then playing with them, soothing and comforting if needed. )

Carla didn’t cause the shame. She helped trigger it. But it was the child’s  spring-loaded shame-inducing circuit that did the rest. And that network stays with us for life, simply adding to its bank of of contemptible deeds along the way.

Cece Sykes is an IFS therapist and Senior Trainer with the Internal Family Systems Institute, who has made it her mission to refine IFS ideas and techniques to help people with addictions. I’ve been lucky enough to engage her as a consultant for my psychotherapy practice. Cece points out that, especially in addiction (but also in abuse survivors), all that shame travels to exactly the wrong (inner) location. As you know from my previous posts, IFS relies on the idea of parts. And the druggie part (what IFS calls the Firefighter — and Cece sometimes calls the Distractor) is much too strong and too smart to listen to this shaming inner critic. I know exactly how to feel better, it says. I don’t have to listen to you. I’ve done this countless times before. See ya.

Defiance feels a lot better than denigration.

So you call your dealer and get some stuff. But what happens to all the shame flowing from the enraged and frustrated critic? It goes to the child part of us, the part that is already overcome by self-doubt, helplessness, despair, and yes, shame — the part that fuels the need to get high in the first place! Cece calls this “a reservoir” that keeps filling up. With shame. Because, as we can see from Carla’s experiment, children (including our inner child) are exquisitely vulnerable even to a hint of blame or accusation. So when that inner critic is lambasting us, we continue to crumble inside. And getting high is by far the most obvious solution.

As noted last week, the addict’s shame is so wounding because of lost connections with caring, loving others. So what’s left? How can we be soothed? IFS is all about establishing and reinforcing connections within us. The theory points to a calm, empathic centre in each of us. The part that’s not a part. They call it Self with a capital S. To me, that centre feels like a warm glow of self-forgiveness or self-compassion or just I’m-ok-ness, though of course words don’t do it justice.

When the inner child is writhing with shame, this self-forgiveness can connect with it, regardless of who’s out there in the world. You can say to that fragile part, I get how ground-up you feel, how long it’s been going on. I care about you. And I can keep you company, so you don’t have to be so alone. I know it sounds almost trite. Oh, that’s self-compassion…we know about that. No, it’s not that simple. This is the act of connecting with a part that has been expelled — innumerable times — because that’s what shame does. A part that’s desperate for compassion…or, at first, at least, a bit of company.

As the child’s shame is soothed and softened, the urge to use or drink may soften as well. But that’s not the whole story. There’s still this druggie/drinker part, this Firefighter, in full regalia, ready for action, laughing at the critic. According to Cece, that firefighter can also be helped by the part that’s not a part. It can be talked to — hey there! — but not by The Critic. Rather, it needs to hear from the Self, which can say: I’ve got your back. I’m not the familiar part that’s always screaming at you, that critic. I’m going to help take care of things. You don’t have to do all this drastic stuff yourself. And just between us, you do leave quite a mess.

When the firefighter actually gets a sense of that kind, friendly and competent person — who You are, despite the crazy gyrations of your parts — it gets to relax a bit, breathe a bit, and slow down. (We don’t have to get smashed every night!) It might also try other outlets. It may welcome the chance to be independent, even sassy, without making such an enormous mess.

The point is, now there are connections, internal relationships, a kind of sharing. When before there were only separated, isolated voices and needs, each with its own quirky strategy. From this place, anything’s possible.

Here’s some more “filler” while I prepare my next post. But I hope it’s worth the read. The Fix, which seems to be the most popular addiction/recovery magazine out there, published a Q&A interview about my book – how I wrote it, what I was trying to say, and how it changed my life. Walter Armstrong, the deputy editor at The Fix, asked some really good questions, and I hope I gave him some really good answers.

Walter seemed like a good guy: patient, tuned in, and empathic. Maybe those goes with the job. I had the strongest temptation to ask him whether he himself had been there and back. But I held my tongue on that one.

Walter clearly liked the book. Here are some of his very generous words:

Lewis’ twin expertise as a longtime addict and a brain scientist enabled him to produce a memoir mapping, in remarkably lucid and vivid detail, entirely new ground. Weaving together his objective accounts of drugs’ effects on the brain with descriptions of his mind’s subjective experience, he brings to light how the very shape of intoxication on one substance or another mirrors the shape of the specific chemical reactions taking place inside your skull.

These pioneering observations fit effortlessly into the overall narrative, which is as over-the-top suspenseful as David Carr’s classic The Night of the Gun.

And here’s the link to the interview. Take a look, and while you’re at it check out some of the other features of this unusual publication. There’s some rough stuff on these pages. Heavy-duty addicts bearing their souls, and blazing arguments about the pro’s and con’s of this and that treatment approach. Lots to learn and quite a few surprises.

My next real post is…..almost ready.

It ain't me, babe. Is it?

I have to figure out this blogging thing. About 2 weeks ago I was invited to host a blog on the Psychology Today website. So I set up a sort of parallel blog there, with most of the same posts. I’ve been making them a bit shorter and punchier for PT, and I’ve been providing more detail, including neuro detail, for my home blog (this one).

But I’m slightly mixed up on where to go from here. Should I retain two blogs? My PT blog gets up to 500 visits per day. It’s PT, after all. This one gets anywhere from 10 to 50 most days. And why bother with two, after all? Especially if they cover more or less the same content? But I like having my OWN blog/site, and all those flashing ads on the PT site annoy me. I have old-fashioned eyeballs.

Maybe the thing to do is to get more flowy — more personal, more newsy — and move away from essay-like postings. So says Isabel, my wife, who did a very successful blog during our last couple of years in Toronto. I like blog writing. It’s great to knock off a piece of…something…in an hour or so, rather than spend six months on a scientific paper that very few people will ever read. But the flow of my life is pretty calm at the moment, and I’m not going to try to interest people in what I’m having for lunch or my thoughts while stuck in traffic.

People who read this blog are, I think, I hope, either those with present addictions, past addictions, or people interested in the science and/or treatment of addiction. So what’s to flow about…that might be of interest to you? My addiction is mostly past, not present, though I have struggled with it in recent times. A “memoir” article in Toronto Life (November 2011  issue) recounts my difficulty getting off oxycodone last spring, after a stint of severe sciatica and recovery from spinal surgery. And I sometimes drink more than I should. So, yeah, I’m not completely in the clear. As far as I know, no addict ever is. But I’m in good shape these days.

I recently found a blog by someone who is currently — like this month! — getting off alcohol. She’s on week 2 or 3 of recovery by now, and I really admire her blow-by-blow description of what it’s like to quit: how it feels, the voices in her head, the spikes of craving, and the relief at moving on. That’s one kind of flow that can be of real interest to people in the addiction world. But my struggles just aren’t that dramatic these days.

And then there’s all this late-breaking news on the science, psychology, and politics of addiction. A special issue of Nature Reviews Neuroscience was recently dedicated to addiction. And the Addiction Newsfeed from Science Daily pulls all kinds of interesting stuff from just about everywhere — Click on Home and scroll down to see it. I can be more current and more, I guess, opinionated if I follow this stuff more closely. Maybe I’ll try that for a while.

I’m just thinking out loud at the moment. But I’d love to hear your thoughts as well.