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"Stuck" Treatment for Addiction

We've been stuck for a long time.
Published on February 24, 2013 

Recently, someone told me he thought that when people relapsed to their addiction after many years, it was a different phenomenon from people who relapse quickly. He had decided that different factors might be at work when it comes to relapsing after long-term sobriety – perhaps some social reason, or inability to stand success, or forgetting the consequences of returning to addictive behavior. He felt the need to come up with these hypotheses because he had found an inexplicable problem: The folks who relapsed after a long time had been successfully abstinent through their involvement in 12-step programs. That they should relapse after so much time seemed strange to him; it did not square with his understanding of addiction. Therefore he reasoned that, since these people had truly “gotten” the 12-step method, he would need to think of a new explanation for their relapses. His idea reminded me of a basic fact in science.

Whenever we humans don’t know the cause or nature of a phenomenon, we instinctually generate many possibilities to explain it. Multiple hypotheses are themselves a good and healthy thing, of course: More ideas mean more things that we can test against experience or experiment. The downside to the many-hypotheses state of knowledge, though, is that before answers are actually understood, people often become attached to their views, whether they are correct or not. For thousands of years, many fervently believed that the earth was the center of the universe. That was a reasonable hypothesis if one didn’t understand the motion of the celestial bodies. But even when presented with overwhelming evidence to the contrary, the people of the 17th century clung to their outdated beliefs. Galileo was imprisoned in his house for the rest of his life for daring to dispute that ancient earth-centric idea. Today many millions of people are still waging already settled debates about issues like evolution.

Hostility to new ideas arises in addiction as well. Treatments for addiction that have arisen from old ideas have become especially “stuck” because of the investment by those who have benefitted from them. When a person is helped, it is understandable that he or she will feel their own experience “proves” the rightness of the approach. New ideas are especially hard for the therapists and counselors who provide treatment according to an old model. If all they know is that old formula, they may well fight to the (professional) death to defend it, since their jobs and professional identities are at stake.

This is what has happened with much of the addiction treatment industry today. Despite the now enormous body of evidence that 12-step programs are effective for only a very small minority of those who attend them, its defenders are commonly unswayed. This “stuck” system is cemented in place by the large financial interests of 12-step based addiction rehabilitation centers, who need to have people believe that their programs are sound in order to justify their often enormous expense.

One of the common byproducts of clinging to an outdated idea is the need to invent ever more elaborate “work-arounds” to account for new information and contradictory evidence. The model grows more and more complex, and the arguments more byzantine, as adherents struggle to incorporate the total tonnage of countermanding evidence. This man's ideas about relapse to addiction are a good example.

If one understands the psychological nature of addiction, there is no need to hypothesize new and distinct factors depending on when the relapse occurs. It is characteristic of every psychological symptom that it may occur at any point in a person’s life. Symptoms don’t die off with age (though their form may change); their reappearance depends on whether the factors which produce them are present. A woman who is meek in every circumstance, and drinks to reverse the sense of utter helplessness this creates, may marry a man who treats her well despite her need to capitulate. Her symptom may disappear. But whether it is six months or six years later, if she finds herself back in that old helpless position, she will be at high risk of drinking again. The psychology behind addiction doesn’t change when the drinking stops.

The best treatment for her would be psychotherapy to help her understand the connection between her meekness and her drinking, to see the ways she has unconsciously recreated her helplessness in her life, and ultimately to work out the roots of her need to be submissive. With this work done, she would have the best chance to avoid relapses forever. 12 Step programs work for a small number of people for reasons that are more complex than they perhaps even know, but such programs are not designed to do any of this work.

Unfortunately, at the present moment, referring everyone with an addiction to 12-step treatments has become routine in our culture. If this is going to change, then both those who have benefitted from the 12-step approach and those who rely on it to treat people will have to let go of some of their old and cherished beliefs.

Posted on Monday, February 25, 2013 at 11:36AM by Registered CommenterLance Dodes, M.D. | Comments1 Comment | References29 References

Legalization of Marijuana Is Okay

Colorado and Washington will be fine
Published on December 3, 2012 by Lance Dodes, M.D. in The Heart of Addiction
Readers of this blog know that addiction is a psychological symptom, a compulsive behavior driven exactly like other compulsions, and readily understandable and treatable. This perspective can be helpful in thinking about the recent election, in which two states legalized the recreational use of marijuana.

Legalization of marijuana has been opposed for several reasons:

• It has been believed to be immoral to use drugs
• There are health and injury risks to individuals
and society (e.g. motor vehicle accidents) related to the use of marijuana
• Marijuana is believed to be a “gateway drug” that will lead to use of stronger drugs and higher levels of addiction.

Proponents of legalization point to reasons of their own:

• The failure of the “War on Drugs” to reduce drug use or the problems it causes
• The cost to society of fighting this “war” (estimated at a trillion dollars since the 1970’s)
• The increase in prison populations and cost of imprisoning so many people
• The enabling of violent criminal drug cartels whose income would be destroyed if their product were made legally available.
• It is nonsensical to criminalize marijuana when alcohol and nicotine are legal.

Understanding addiction as a psychological symptom allows us to do something that is rarely done in this discussion: separate the drug from its use, and its use from addiction.

Addiction is addiction no matter which substance or activity comprises its “narcotic” – alcohol, other drugs, shopping and eating can all act in the same functional way. This is the reason that so many addicts switch throughout their lives from one drug to another, or even from a drug to a non-drug addiction like gambling. It is nonsensical to speak of such people as being “dually addicted” or even being multiply addicted; the inner engine of addiction—its meaning—is consistent for each individual, namely an effort to relieve feelings of being trapped or helpless and to establish a sense of control. “I may not be able to tell off my boss,” is a common example, “But by God I’m going to have a drink or have a joint, and nobody is going to stop me.”

All compulsive or addictive behaviors are substitutions, or displacements, for a direct action that is felt in some sense to be impossible or forbidden. The particular form this substitute action takes can be almost anything. The “War on Drugs” is not just a misnomer; it reflects a real failure to understand that addiction lies in the individual psychology of each person – why he uses the drug – and not in the nature of any, or all, drugs. (Of course, one can develop physical dependency through the heavy use of certain drugs, but as I have described before, physical addiction has little to do with the problem of addiction. Likewise, the notion that drugs cause brain changes which produce addiction in humans has been amply disproved.)

Naturally, increasing the availability of any drug will increase its use and will increase the problems arising from that use, with or without addiction. If marijuana were more widely used, for instance, some people will drive while intoxicated on marijuana exactly as people do now with alcohol. From this standpoint it makes as much sense to criminalize alcohol as marijuana.

And yes, if more people have access to marijuana, then a portion of them will also use it addictively or compulsively, again like alcohol. But will this increase the total number of people with addictions? For that to happen there would have to be individuals who begin compulsively using marijuana but who have no prior addiction. While some people might shift to marijuana from other addictive focuses, there is little reason to think that people without any emotional need for addictive behavior would develop that need because of availability of marijuana.

Okay, but what about the “gateway” idea? This notion assumes that once people use marijuana they will seek a more potent drug. But recreational use of any drug, as with alcohol, does not create a need to move on to other drugs. There should be no surprise here; the psychological purpose of the addiction may be completely satisfied by marijuana. In fact, there is no reason to think that heroin would do a better job, and it could well do a worse job if people experience the drug effect as disempowering. (“I need to get some relief so I drink or smoke pot, but no way do I want to be a junkie”). Part of the confusion is that many people who use harder drugs started with marijuana, but this is simply the well-known “post hoc ergo propter hoc” fallacy: just because B follows A does not mean A caused B. Saying that earlier use of marijuana led to later use of heroin is like saying that since 90% of bankers had tricycles as a child, tricycles lead to banking. In fact, a recent study in the American Journal of Psychiatry following a group of young boys into adulthood found no basis for the idea that marijuana was a “gateway” to later drug use, fitting with what we would expect from a psychological perspective.

If marijuana ever became completely legal, then it is likely that more people would use it. It is also likely that some ill effects would occur from that use. There may be a few more people who use marijuana addictively, but it is unlikely to catalyze a major shift away from current addictive use of alcohol or other compulsive behaviors, and it is unlikely that the total number of people with addictions will rise significantly. There is also little reason to fear that it will lead to increased use of more potent drugs. Parents and teachers would need to counsel their children about marijuana use just as they now do about alcohol, but those kids will develop in more or less the same world we occupy today with alcohol.

And we could save some of the estimated 75 billion dollars we spend yearly on the War on Drugs and put that money into replacing a failed and outmoded drug treatment industry with a more sophisticated psychological approach.
Posted on Wednesday, December 12, 2012 at 11:52PM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References7 References

I Used To Be Addicted and Then I Quit. Am I Still an Addict?

The answer to a common question.

This question comes up fairly often. It is the kind of question that cannot be answered if you look only at the surface of addiction: at the behavior itself. But if you peek beneath the surface, the question and its answer becomes obvious.
As readers of this blog or either of my books knows, true addiction is neither more nor less than a psychological symptom, a compulsion like any other. Of course, there is such a thing as physical addiction due to creation of physical tolerance to certain drugs, but that has nothing inherently to do with true addiction. Many people have physical addictions yet can quit their behavior once they decide to do so (as did millions with physical addiction to nicotine). Conversely, many people with true addictions never have a physical addiction, such as binge drinkers, people who addictively use drugs like marijuana or LSD that are incapable of producing physical addiction, and all the people with non-drug addictions such as compulsive gamblers or compulsive eating. No, physical addiction is simply not a part of true addiction even if it is sometimes also present. And neither is the false “chronic brain disease” neuropsychological model as I’ve discussed extensively in previous posts.
Once it is clear that addiction is a psychological symptom, we can begin to see how the wording of the question itself makes it impossible to answer: whether people were or still are “addicts.” It is misleading and confusing that we label people “addicts” when they have the kind of compulsive symptom that we call “addiction.” After all, when the compulsion is different, say, compulsively cleaning the house, or shopping or eating, we don’t use their symptom to name them! We don’t call them “cleaners” or “shoppers” or “eaters,” as though their symptom defined something about their essence as human beings. Symptoms come and go, even addictive symptoms. So, the original question needs to be re-thought.
Let’s rephrase it: “If I ever have addictive symptoms and they go away, does that mean they will ever come back?” Obviously, this is a much easier question to answer: just like every other psychological symptom, they might not, but they could. And this raises the main practical question: how can I prevent this symptom from returning? Part of the answer to that one will involve tackling another question: What made the symptom go away to begin with?
What makes any symptom come and go? Symptoms are the mind’s way to solve emotional problems. So, they arise when the problem is at hand and disappear when it is not. Depressions, anxiety, compulsions, and so on rise and fall with the factors that cause them. Here is an example. Bill had always suffered with poor self-esteem. From an early age, and now deep inside, he believed he was less valuable and important than others. Since this was a lifelong feeling, he usually did have symptoms: low-grade depression and some anxiety in situations in which his self-imagewas going to be challenged. But sometimes things worked out great for him. He got a promotion, caught the eye of an attractive woman, won a game of tennis. At those moments he wasn’t depressed or anxious. And if Bill’s main symptom were an addiction, like gambling or drinking, his compulsion to do these activities would also fade in good times, only to return later. But things could go even better for him. After years of feeling like an outcast, he might find a wonderful woman to marry and his self-esteem would receive a long-lasting boost. He might go for years without the compulsion to drink or gamble, though he would have a permanent risk of returning to those symptoms. This is the sort of thing commonly observed with another symptom: depression in old age. When sources of self-esteem end (such as meaningful work or relationships with friends and relatives), depression, anxiety, addictive behavior, and other symptoms can return after a long absence.

Life changes are only half the story, though. Symptoms arise because of internal factors. What if Bill’s low self-esteem could be repaired? Then it wouldn’t matter so much whether the circumstances of his life – his job, his relationships – changed or not. Then he would have the best protection against the slings and arrows of life, and the best protection against return of his addiction. This is the job of psychotherapy. I have written extensively about psychotherapy of addictions in this blog and two books, so I will not repeat that here. But the main point for our original question is this: If you have ever had a true addiction, it is an excellent idea to find a good therapist to talk with in order to figure out what that symptom was treating. Mind you, you will want a therapist who can do this work, somebody trained and experienced in human psychology who will focus on the emotional factors that produce the compulsive need to drink, gamble or eat. Unfortunately, most addiction counselors have little training of this sort. If you find that the treatment you are receiving is focused on advice about avoiding stress or urging you to join a 12-step program then you are in the wrong place. If you are examining the emotional story of your life then stick with it and you can truly break your addiction.
Posted on Monday, September 3, 2012 at 08:14PM by Registered CommenterLance Dodes, M.D. | Comments7 Comments | References113 References

The Right and Wrong Way to Measure Progress with an Addiction

As usual, it’s more complicated than it appears

Everybody takes for granted that progress in addiction means abstaining from, or at least cutting down, addictive behavior. This is the standard of measurement for addiction treatment facilities and research outcome studies. But this is naive, since progress can be occurring before any change in behavior, and behavior can change without any real progress. Worse, using addictive behavior as the measurement of progress can make addiction more painful and harder to treat.

First some background. As readers of this blog know, addictive actions are the result of an emotional process – an attempted solution to feeling helplessly overwhelmed. Addictive behavior is therefore a symptom – a very destructive one, but a symptom nonetheless. In psychology and medicine we regularly treat symptoms, of course. But the primary focus of any treatment must be on root causes, when we know how to treat them. Before antibiotics were discovered, for example, treatment for tuberculosis consisted of exposure to fresh air and rest because this approach improved its symptoms. “Progress” in those days meant less coughing and fewer night sweats. But this symptomatic treatment did nothing to kill the bacteria that cause TB. The disease was very much alive inside, and frequently returned with a vengeance.

In addiction, we are still defining progress by symptom reduction even though we now have much better knowledge about its emotional cause and treatment. It’s no wonder that treatment programs that spend patients’ valuable time trying to motivate them to change their behavior fail so often. Like TB, the emotional nature and process of addiction remains alive no matter how encouraged, uplifted, and educated about addiction they are.

Besides failing to address the real causes of addiction, this symptomatic approach creates its own problems. When treatment programs (or individual treaters) measure their own success by the amount of addictive behavior of their patients they create a destructive feedback loop. In order to improve their “success” numbers they must push for behavioral change all the harder, whether or not their patients are learning about the kinds of overwhelming helplessness that precipitate their addictive urges. It is the same problem we hear about in the business world, when companies focus on reporting a profit every quarter rather than living with a temporary deficit because they are investing in improving their product. When the business fails, we often hear from executives about the pressure they felt to maintain the appearance of doing well.

A similar effect occurs in individuals. If you are in a good psychological therapy where you are looking closely at the immediate and deeper emotional precipitants of addictive behavior, both you and your therapist should understand that progress consists of doing this work. In the course of any psychotherapy symptoms disappear and return. Too often, people in treatment feel they are failing because their behavior has not turned off like closing a spigot. It is a tragedy when people drop out of good treatment because they measure progress on the basis of symptomatic behavior. Of course, good treatment never means ignoring addiction. Quite the contrary, as I’ve described many times in this blog and both my books, it is just those moments of feeling you have to get a drink, or eat, or gamble, that are the best opportunities to figure out the underlying emotional causes of the behavior and how addiction works in you. And, if addiction is ever unmanageable or too dangerous to be allowed to continue, hospitalization is appropriate until the situation stabilizes. But that is emergency care, and should not interfere with therapy that is making true progress.

The issue arises in spades with family members. If addictive behavior continues during a psychologically-knowledgeable therapy, family members often become suspicious that the treatment is not working. In the worst cases, they stop supporting the treatment. It helps if family members can learn about the psychological nature of addiction.

Finally, when researchers use addictive behavior to measure treatment effectiveness, they make it all the harder to allow for creative growth in the way the addiction treatment industry works. True, it’s tougher to measure internal emotional change. But anyone with psychological training knows that that’s where all meaningful progress is. Researchers need to look beyond behavior if the industry is to be convinced to adopt newer approaches to treatment.

If measuring progress by the amount or frequency of addictive behavior is misguided and hurtful, how then do you know if you are making progress? If you are dealing with an addiction yourself, or in therapy, when you are able to see the themes in your life that always precipitate addictive feelings and are working to find ways to manage or resolve these themes when they arise, you are getting better.
Posted on Friday, July 27, 2012 at 06:34PM by Registered CommenterLance Dodes, M.D. | Comments2 Comments | References17 References

Alcoholics are not powerless over alcohol

Alcoholism is not even about alcohol

The myth that people with alcoholism are powerless over alcohol is deeply misinformed, and just as dangerous. Addiction arises from inside of people – their drive to excessively drink, use other drugs, eat, gamble, and so on. To think that alcohol is the problem in alcoholism is to believe it has a magnetic power to enslave people. This is sheer nonsense. And when people think that their problem is a chemical in a bottle, they focus on trying to resist the chemical rather than doing what is truly useful: trying to understand their minds. 

Of course, if we are talking about physical dependence then the chemical is relevant, but as readers of this blog or either of my books (“The Heart of Addiction,” and “Breaking Addiction”) know, the real problem in addiction is not physical addiction, which can affect anybody and is readily treatable, but why some people compulsively repeat their addictive behaviors even when there is no physical dependence at all.
Addiction is all about seeking a remedy for overwhelming feelings of helplessness, and the exact form of an addiction, whether drinking or eating or watching online pornography, is no more than a focus for the addiction, not its cause. This is why people so often change the form of their addiction, moving from alcoholism to compulsive gambling tocompulsive shopping, and on and on. Wouldn’t it be strange if people really were powerless over the focus of their addiction? When a person switched from alcoholism to compulsive gambling we’d have to say he was now powerless over something new. As the focus shifted there could be no end to the things he was powerless over – his powerlessness could spread like wildfire! (“I used to be powerless over just alcohol, but now peanut butter has me in its grip.”)
The notion that people are powerless over the focus of their addiction is also terribly demoralizing. Addictions are neither more nor less than compulsions, psychological behaviors most people have to some degree. That fact has been a great relief to people with addictions who have been made to feel different and less than the rest of humanity. But if you buy the idea that you are powerless over the chemical in a bottle (or the peanut butter on the shelf or the offshore gambling website) then you are deprived of this honest relief. Instead, you must admit your worst fear: you are in fact different and certainly less capable than everyone around you who is able to drink with impunity.
“We admitted we were powerless over alcohol” is, of course, Step One of Alcoholics Anonymous. 12-step programs have been statistically shown to have a 5-10% success rate. Step One isn’t the only reason for this, but it is clearly a part of the problem.
Posted on Sunday, June 17, 2012 at 11:41PM by Registered CommenterLance Dodes, M.D. | Comments10 Comments | References252 References