Knowledge is better than ignorance.

Published on January 23, 2012

Recently, a man suffering with alcoholism told me how he approached his problem: when he had thoughts of drinking, he tried to push them out of his mind. This didn't always work of course, and even when it did he regularly drank later. But he was still pleased that he was "putting up a good fight" against his enemy - his terrible drive to drink. He asked me if I agreed with his plan, and whether I thought that his intermittent success was a sign that he was making progress. I was sorry to say I did not. Pushing away thoughts of performing addictive actions is, in fact, a terrible idea. His technique was not just doomed to failure but actually interfered with ever mastering his addiction.

Addictive thoughts are never random, so the moments when they occur provide critical opportunities to learn what drives an addiction. Whatever event, circumstance, interaction, thoughts or feelings that occurred just before the appearance of addictive thoughts will be a clue to the issues for which addiction is a solution. To distract oneself at just that moment is the last thing to do if you hope to gain control of addictive behavior.

Naturally, paying attention to any single episode of thinking about drinking or another addictive act may not be sufficient to see the underlying theme behind all one's addictive acts. But the more occasions spent focusing on the precipitating circumstances behind that first instant of addictive thought, the easier it becomes to solve the mystery.

Focusing on these key moments when addictive thoughts first arise also has an immediate value. Even if the precipitating factors are unclear, just thinking about them at these times creates a helpful separation from the helpless feelings that always precede and precipitate addictive thoughts. After all, to think about oneself is to stand beyond one's inner world and observe it, not be immersed in it. Self-observation is an antidote to feeling helplessly trapped.

Suppressing addictive thoughts is also part of another problem. The man I'm describing tried to squelch his addictive thoughts because he viewed his addiction as an enemy to be stamped out. But seeing addiction as his enemy kept him from seeing it as a part of himself: an attempt to resolve intolerably helplessness feelings by taking an action that would restore an immediate sense of power. Instead of thinking of his drinking, or even his thoughts of drinking, as the enemy, he would have been much better off seeing his addiction as a symptom with an understandable emotional purpose and drive. Instead of looking away from his problem, he could have looked toward it and learned about it.

Working to suppress thoughts involves yet another mistaken notion: the false and destructive idea that addiction can be mastered through willpower. The idea that people can control addictions just by trying hard is a longstanding myth that has led to denigration of people with addictions as "weak" or lacking in "character." Of course, people with addictions have as much willpower as anyone else. Like every other psychological symptom, addiction arises from internal, at least partially unconscious, emotional issues and is an attempt to deal with them. Emotional symptoms (which we all have to one degree or another) are not treatable simply through conscious effort. People with addictions can no more stop their symptomatic behavior through willpower than can people with depression, anxiety or phobias. And beyond the unwarranted criticism directed at people with addictions, those who themselves believe that their addiction can be "defeated" by force of will (for example, suppressing addictive thoughts) are setting themselves up to feel worse about themselves when willpower inevitably fails.

It does take work to deal with addiction, but not the work of pushing away thoughts. It is the work of observing one's complex feelings, motivations and conflicts, especially at the time of first thinking of performing an addictive act. Self-observation is not easy for anyone, and is especially hard if thoughts are quickly followed by strong urges to act. But this is where learning about the underlying issues precipitating addiction pays dividends down the road. Once you have identified the specific emotional factors leading to feeling overwhelmingly helpless - and then to addictive thoughts - it becomes possible to predict in advance when these thoughts will arise. That allows time to find ways to deal with these emotional precipitants before feeling flooded by them, not by crushing your own thoughts, but by understanding them.

Is addiction really a disease? And if not, what is it?

A new look at an old idea.

Published on December 17, 2011

For many decades it's been widely accepted that alcoholism (or addiction) is a disease.  The "disease concept" is taught in addiction training programs and told to patients in treatment programs.  It is unquestioned by public figures and the media.  But is it true?  And if it is not true, is there a better and more helpful way to define addiction?

Let's start with a short history.  In the bad old days, before the disease concept became widely popular (about 40 years ago), our society was even more prejudiced against people with addictions than it is now.  "Addicts" were seen as different and worse than "normal" folks.  They were thought to be lacking in ordinary discipline and morality, as self-centered and uncaring.  They were seen as people who were out for their own pleasure without regard for anyone else.  They were viewed as having deficiencies in character.

Then came the idea that addiction is a disease: a medical illness like tuberculosis, diabetes or Alzheimer's disease.  That meant that people with addictions weren't bad, they were sick.  In an instant this changed everything.  Public perceptions were less judgmental.  People were less critical of themselves.  Of course, it wasn't welcome to hear that you had a disease, but it was better than being seen as immoral and self-centered.  So, the disease concept was embraced by virtually everyone.  With all its benefits, it's no wonder this idea continues to attract powerful, emotional support.

Widespread enthusiasm for the disease model, however, has led to willingness to overlook the facts.  Addiction has very little in common with diseases.  It is a group of behaviors, not an illness on its own.  It cannot be explained by any disease process.  Perhaps worst of all, calling addiction a "disease" interferes with exploring or accepting new understandings of the nature of addiction.

This becomes clear if you compare addiction with true diseases.  In addiction there is no infectious agent (as in tuberculosis), no pathological biological process (as in diabetes), and no biologically degenerative condition (as in Alzheimer's disease).  The only "disease-like" aspect of addiction is that if people do not deal with it, their lives tend to get worse.  That's true of lots of things in life that are not diseases; it doesn't tell us anything about the nature of the problem.  (It's worthwhile to remember here that the current version of the disease concept, the "chronic brain disease" neurobiological idea, applies to rats but has been repeatedly shown to be inapplicable to humans.  Please see earlier posts in this blog or my book, Breaking Addiction, for a full discussion of the fallacy of this neurobiological disease model for addiction.)

As readers of this blog or my books knows, addictive acts occur when precipitated by emotionally significant events, they can be prevented by understanding what makes these events so emotionally important, and they can be replaced by other emotionally meaningful actions or even other psychological symptoms that are not addictions.  Addictive behavior is a readily understandable symptom, not a disease.

But if we are to scrap the disease concept and replace it with something valid, our new explanation must retain all the beneficial aspects of the old disease idea.  It must not allow moralizing or any other negative attributions to people suffering with addictions.  In fact, we'd hope an alternative explanation would have more value than the disease label, by giving people with addictions something the disease concept lacks: an understanding that is useful for treating the problem.

Knowing how addiction works psychologically meets these requirements.  Recognizing addiction to be just a common psychological symptom means it is very much in the mainstream of the human condition.   In fact, as I've described elsewhere, addiction is essentially the same as other compulsive behaviors like shopping, exercising, or even cleaning your house.  Of course, addiction usually causes much more serious problems.  But inside it is basically the same as these other common behaviors.  When addiction is properly understood to be a compulsive behavior like many others, it becomes impossible to justify moralizing about people who feel driven to perform addictive acts.  And because compulsive behaviors are so common, any idea that "addicts" are in some way sicker, lazier, more self-centered, or in any other way different from the rest of humanity becomes indefensible.

Seeing that addiction is just a compulsive symptom also meets our wish for a new explanation: unlike the "disease" idea, it actually helps people to get well.  As I've described in this blog and my books, when people can see exactly what is happening in their minds that leads to that urge to perform an addictive act, they can regularly learn to become its master, instead of the urge mastering them.

Despite all its past helpfulness, then, we are better off today without the disease idea of addiction.  For too long it has served as a kind of "black box" description that explains nothing, offers no help in treatment, and interferes with recognizing newer ways to understand and treat the problem.

And there is one more advantage.  If we can eliminate the empty "disease" label, then people who suffer with an addiction can finally stop thinking of themselves as "diseased."

How To Tell Who is Right about Addiction

Examining the arguments.

Published on September 2, 2011

We all know that there are vastly different, widely-disseminated views about the very nature of addiction. When I give lectures about addiction, I am sometimes asked, "With all these opinions, how can I tell who is right?" It turns out that there is a surprisingly straightforward way to figure this out.

To set the stage: as I've discussed and illustrated in this blog and my books on addiction, addiction is a psychological symptom like other common symptoms that we call compulsions. While physical dependence is quite real, it cannot explain the clinical picture of addiction: the recurrence of addictive behavior years after physical dependence has faded, the frequent substitution of non-drug addictions for drug addictions, and so forth.

Now, when two sides debate, we judge which side to believe based on their expertise - their knowledge and experience of the issue at hand. If a chef debates a nuclear engineer about nuclear physics, we believe the engineer. If the topic shifts to the best way to cook a duck, we believe the chef.

We also want to know whether each side has studied the other's position. Generally speaking, if Side A doesn't know the basis for Side B's viewpoint, we should dismiss Side A for basing its conclusions only on its own perspective. How believable are they if they aren't aware of the errors or limitations others have identified?

On the subject of addiction, let us first consider the question of expertise. Neurobiologists who study drug effects on the brain have devoted their professional lives to studying just that. They have both training and experience in the anatomy and physiology of brains, and their work largely consists of conducting laboratory experimentation on animal brains (mostly rats). It is therefore reasonable to believe what they say about how these animal brains work and how they are affected by drugs. But these scientists typically have little or no experience treating people, and their training is not mainly devoted to human psychology. (Even those neurobiologists who are psychiatrists have chosen this career path largely in place of clinical work with patients.) This has resulted in a fundamental problem with the neurobiological theory: it takes findings with rats and generalizes them to humans. It is a leap that would never be made by people who have training and experience with addictions in people.

To those familiar with addiction in human beings, it is obvious that the "addictive" behavior observed in rats is nothing like the behavior of people with addictions. When rats have long-term exposure to opiates, they increase seeking behavior in response to cues associated with the drugs, just as in Pavlov's famous dogs. But the changes in rats' brains that lead them to automatically seek drugs when exposed to cues either do not occur in humans, or if they do occur, do not produce addictive behavior. As I have described elsewhere in this blog, a massive body of evidence has proven that exposing people to drugs for long periods does not turn them into addicts as the "chronic brain disease" theory would predict. And addiction in humans looks very little like rat behavior in a number of other important ways:

• Addiction in humans is not thoughtless or instantaneous or automatic. People often wait hours to get a drug supply, or to drive to a casino, or to pick up a bottle of liquor.

• Acts of addiction in humans are virtually always precipitated by emotionally important factors, not simple external cues.

• Humans can substitute non-addiction compulsive behaviors like cleaning the house for drug addictions. That cannot be explained by the "chronic brain disease" model.

• Once people with addictions understand how their addictions work psychologically, they are regularly able to control or stop their addictive behavior.

Let's now consider the question of expertise on the psychological side of the debate: people who treat human beings with addiction. For myself, I have trained extensively in human psychology, first as a psychiatrist and then as a psychoanalyst. I have devoted my career to treating people, as director of major addiction treatment programs involving thousands of people where I treated and supervised the treatment of many of them myself, and in my individual psychotherapy practice for over 35 years. I have written many academic papers and books about the psychology of addiction. This is the training and experience behind my views about human addiction.

But what about the other big criterion we use to evaluate an argument: understanding the other side's facts and logic? Although my interest is in human psychology, I read the neurobiological literature. In 2009 I published an academic paper on the respective roles of neurobiology and psychology, referencing and describing the neurobiological view and explaining where it is applicable and where it falls short.

It is possible that some of the leading neurobiologists have read the psychological literature, but I can tell you that I have not found any sophisticated consideration of the psychology of addiction in any of the neurobiological addiction literature (and I am a reviewer for more than one addiction journal). What passes for psychological insight (if it appears at all) is questionnaires about general traits like "interest in risky activities." This absence of sophistication quite simply makes it impossible for the authors to recognize or meaningfully engage the psychology behind addictive behavior.

So, who is right? I offer this rule of thumb: for questions about how drugs affect brains and where in the brains drugs act, believe the scientists who study those issues. For understanding addiction in humans, believe those who have experience and training with humans. If still in doubt, remember that human addictive behavior is vastly different from the behavior called "addiction" in rats which is the basis for the neurobiological view.

One final point. Some authors like to split the difference and say addiction (in humans) is both psychological and neurobiological in origin. This approach tends to make everyone feel good. However, since the "chronic brain disease" idea doesn't apply to people, it isn't good science to include it in the explanation.