July 2011 Archives

Blowing Up A Myth

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Understanding the true nature of addiction.

Addiction has been poorly understood for a long time, and recently the problem has become worse with the popularization of the notion that addiction is a "brain disease."

Supporters of this fallacy point to the fact that pleasure centers of the brain "light up" when people use certain drugs. They conclude this must be important to understanding addiction.

It isn't. Everyone who takes certain drugs will have his or her brain activated ("lit up") in the same way. The puzzle of addiction is not which section of the brain is stimulated, but why some people who take alcohol and other drugs feel compelled to use them repeatedly, while others do not. Alas, no imaging technology can explain this central mystery.

That something else is going on in addiction becomes self-evident when we examine the facts. For one thing, not all addictive behaviors involve drugs. It is well-known that people with addictions can shift their behavior back and forth from drug use to non-drug compulsive activities such as shopping, gambling, even cleaning house. Such astonishing variety clearly cannot be attributed to narcotic effect or a "brain disease."

For another, even where physical addiction is present, there are no simple rules. After the Vietnam War, thousands of soldiers who had become physically dependent on heroin stopped using it once they returned home, despite the famously "addictive" nature of this drug. Once they weren't subject to the stress of war, over 90 percent of these veterans readily gave up using -- a result that cannot be explained on a neurobiological basis.

Indeed, a more modern understanding of addiction reveals an interesting fact -- most addicts feel better not when they use the drug, but when they decide to use the drug. That means there is an emotional and psychological element at play here. In fact, the critical moment of decision to perform an addictive act can occur hours or even days before the act itself. It is the emotional content of this moment that is key to understanding addiction from the inside out, and what is important in that moment is a need to remedy a sense of helplessness as I've described in a number of academic papers and my book, The Heart of Addiction (HarperCollins, 2002).

We live in a time of neurobiological reductionism in which we are repeatedly told that the mind can be reduced to the brain. Yet this will never be true. Just as chemicals that make up living things are not alive themselves, cells that make up the brain have none of the psychology that make us human. Our emotional lives come into existence only when billions of cells work together, and what they produce can not be predicted by looking at a single cell and extrapolating. As Nobel laureate Philip Anderson pointed out in a seminal paper on complex systems, "Psychology is not applied biology, nor is biology applied chemistry." Those who study brain biochemistry are doing useful work in understanding biologically-based major mental illness such as schizophrenia . But they make a mistake when they believe they are discovering something about the vast area of conflicts and emotional issues that make up the lives of the rest of us.

If we could take a more accurate image of addiction in the brain, it would encompass much of the history and many of the events that make us who we are. The intolerable helplessness that drives addiction is different for each person, but this much is known -- it is far more personal and complex than a bright spot on a screen. Until we invent a machine that can read our souls, a compassionate understanding of ourselves and talk therapy remain the most effective tools we have.
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Breaking Addiction

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Let's face it; addiction treatment has not been very successful. But there is a clear reason for this: we haven't understood how it works. Once you do understand it, though, there are some critical steps you can take to break it. In my new book, Breaking Addiction: A 7-Step Handbook for Ending Any Addiction (HarperCollins, 2011), I describe those steps.

As previous readers of this blog know, true addiction (versus simple physical dependence) is neither more nor less than an emotional solution to manage feelings of intolerable helplessness. When people feel utterly trapped they have to do something, and if they feel they can't act directly to get out of the trap then they have to do something else. The "something else" is a substitute action or displacement. It is this displaced action that we call an addiction.

For example, Ron was sitting at his desk at 1 o'clock in the afternoon when a pile of new work was dumped on his desk. He already felt overwhelmed with all he had to do, and he'd promised his children that he'd come home and help them build a fort that evening. On top of that, he'd told his wife that tonight, for a change, he would come home early. He was trapped.

But Ron suffered with alcoholism, so at that moment when he felt helpless in the face of the work that was piled high on his desk, he decided that, by God, he was going to have a drink when he got out of work. Significantly, as soon as he made this decision he felt less pressured. He could and would do something that he knew would make him feel better. He had reversed his helplessness. And his solution, drinking, was driven by the furious intensity that anyone feels when utterly trapped. However, his decision to drink was not a direct response to the actual work problem. He didn't go to complain to his boss, or determine that he would do a less thorough job with his new tasks. His drinking (or even just his decision to drink) was a substitute activity driven by all the intensity of a person trapped in a cave-in. We have a name for such intensely driven substitute actions: "addictions."

Once you understand this is how addictions work, then there are steps you can take to combat the process. First, notice that the beginning of Ron's path toward drinking was hours before he actually drank, when he first thought about having a drink. I call this the "key moment" in addiction, and it is crucial to be able to identify it. Sometimes doing this is pretty easy, as in Ron's case. But the key moment can be harder to spot, because of your own defenses. For example, in another case in the book I describe a woman who became confused just when she felt most overwhelmed. This made it impossible for her to recognize when she felt anxious and despondent, just the moments that always led to her addictive behavior. Recognizing your defensive style is another of the steps in my book.

But what can you do when the addictive urge is upon you? The basic idea is fairly simple and I describe it in the book in Step 6, "Short-term Strategies for Dealing with Addiction." If addictions are just displaced actions -- substitutes for doing something to directly deal with the trap -- then it is only necessary to undo this substitution and take a more direct action. For instance, a woman with food addiction regularly went home and binged on junk food when she felt left out and unimportant, such as often happened to her in social settings. After she learned how her addiction worked, she was able to manage the next meeting of her pottery group very differently. She didn't have to do anything extraordinary; she just spoke up a bit about her concerns as a new member of the group, and when she got home she didn't need to eat. She had learned what made her addiction go and addressed it directly.

Another woman (whom I have described previously) felt she had to comply with her husband's demands to create a dinner for many guests on short notice. Usually, she meekly accepted these demands, and then took her Percodans. But when she was able to come up with a more direct solution ("I know I should have just told him to make his own damn dinner, but at least I figured out another way out"), and ordered take-out Chinese food, her addictive urge vanished! There was no magic here. She had just taken a more direct action to deal with her helplessness trap, so she didn't need her addictive act.

Sometimes, though, finding the more direct action is more complicated, such as when there is no clear action that will solve the problem. In the book I describe a man whose urge to use heroin became nearly overwhelming when he realized that his girlfriend was going to break up with him. Here, there was no clear direct action he could take to reverse the helplessness he felt. He needed to think about his helplessness trap in a different way: from the standpoint of what this loss meant to him, rather than just the loss of his girlfriend. I describe how to go about refocusing on your feelings, rather than only the external reality, in Chapter 6.

Step 7 in Breaking Addiction describes long-term strategies. These involve not just knowing how to identify the key moment on the path to addiction and how to manage the urges when they occur, but how to anticipate when they will occur and thereby avoid even having to reach the stage of intense feelings. When you have reached that point, the addiction is broken.

There has been a great deal of pessimism about breaking addiction. But we are embarking on a new era in understanding and treating this very common problem. There is now very good reason for hope.
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