Addiction
I’d like to discuss addiction with you and how it relates to psychotherapy. Addiction is a quite common understanding by client and therapists of various substance abusers such as alcohol and drugs. The commonly conceived nature of addiction is the disease model. This is that
1. Once a person had a sufficiently large amount of a drug they are addicted, and have to have their drug to avoid withdrawal symptoms
2. There is something about the person that compels them to their drug, the addictive character
3. The behaviour is progressive, you require more and more of your drug of choice
4. There is a loss of control when taking the drug
5. Persistence, even in the face of negative effects
So the essence of the disease model of addiction is people are predisposed through genetics to addiction, it is a disease and people are not responsible for their action as they are being physically controlled by their disease.
The standard treatments in this area are total abstinence for example AA or drugs that make the taking of the addicted drug unpleasant, e.g. antabuse.
It is also noteworthy that addiction is now applied to many things, shopping, sex, gambling to name but a few.
So the path I’d like to take is, does the disease model of addiction make sense, is it a valid and true concept, and is it useful to believe.
The etymology of the word addict says it comes from two Latin words addico which means devote, surrender, give yourself, and ad which means towards. So an addict is someone who surrenders themselves towards something. Modern usage of the word came around 1904 in reference to Morphine usage. The modern day sense of addiction as a disease is derived from thoughts about alcoholism and so I will start my investigation there.
In Colonial America we have a time just before addiction, in its modern sense was born, Increase Mather, the influential colonial pastor, spoke of rum as “the good creature of God” . Where people had unacceptable drunken behaviour then it was ascribed to keeping bad company and being in bad environments (Levine 1978; Fingarette 1988). That people were habitually drunk, was seen as a sin, and an abuse of the gift of god.
The industrial revolution at the end of the eighteenth century was a cultural, economic movement from a generally agrarian subsistence mode to a mechanistic way of life. The move in thought effectively was one from nurturing and responding to nature to quantifying, atomising and mechanistically utilising through repetition. Humans were starting to be understood mechanistically and the notion of disease was prevalent. Benjamin Rush, a prominent eighteenth century physician, first defined drunkenness as a disease, stating it as alcohol is the causal agent, which creates a loss of control in the drinker’s behaviour, such that it became a compulsive action and therefore it is a disease. In short he didn’t describe a disease he defined one (Levine 1978, P152; Schlaer 2000). He also stated that the only cure for it was total abstinence.
The temperance movement latched onto Rushes notions of abstinence. Their notion was that alcohol destroyed the will and that once you had succumbed to it you would lose control. The drunkard being the person with a weak will such that they would take the first drink that would destroy their already frail will, leading to a loss of control, and chaos. The temperance movement that ended in the Prohibition saw alcohol as a force that would deprive someone of their freewill, and those that used it, were sinners for taking the first drink, and victims of disease thereafter.
In its modern guise we can see the temperance movement alive and well in Alcoholics Anonymous. The only change being that AA don’t see alcohol as being universally addictive, only that some people who have the alcoholic “gene” or “character” are inevitably addicted and therefore you must seek help. The help is to acknowledge you are powerless to help yourself, as you are the mercy of a physical effect. It requires you to turn your will over to that of a higher power, i.e. God, as drunkenness is a sin, and you need saving.
So I guess that’s where our generally perceived notions of addiction come from. So let’s have a quick look at some of the aspects of it.
1. Addiction means a person’s will isn’t sufficient to say no to the physical effects of drug withdrawal, thus they are compelled to take the drug
If you smoke a pack of cigarettes a day, or have a wrap of heroin every day for a week, then stop, at the end of the week you will have some physical symptoms that will change if you smoke or take heroin. These are what are commonly known as withdrawal symptoms.
So let’s be a bit phenomenological about this. Ironic given I am smoking regularly at the moment, and I haven’t had a cigarette and have these physical symptoms. So what are they, hmm well slightly hard to describe. I’ve got a little tightness in my stomach, I know I want a cigarette, but that’s because I can see myself standing in the garden, blowing smoke out of my mouth and that’s what I do at this time. Okay I haven’t given you very much all that I’ve really said is I really want a cigarette, but haven’t given you any physical substance to this. All I’ve said, is I want to carry out a habit, something that I do frequently and without thought, a sedimented behaviour if you will.
Being a 21st century boy, I googled the nicotine withdrawal symptoms and found the following physical symptoms of nicotine withdrawal symptoms:
1. An intense craving for nicotine
2. Tension
3. Irritability
4. Headaches
5. Difficulty in concentrating
6. Drowsiness and trouble sleeping
7. Increased appetite and weight gain
So all of these things can be explained by not being able to do my habit, if I’m stopped doing what I always unthoughtfully do, then sure I’ll want to do, be tense and irritable, which will provoke headaches and I’ll find it difficult to concentrate. There is no physical aspect of nicotine withdrawal that can’t be ascribed to a psychological cause, i.e. not being able to carry out my sedimented behaviour.
In short there are no physical symptoms that you could solely attribute to a loss of nicotine. The best I could give you is a knotting in my stomach, but hey that’s a sort of anxious feeling that can come from my life generally, in fact it could well be that I am trying to use cigarettes to counter this anxiety. Rather than cigarette withdrawal causing the anxiety, it could be that cigarettes are used to combat the anxiety, in fact even worse it could be that the smoking causes me anxiety through doing something that quite disgusts me, and caught in the turmoil of being disgusted at my action, I get anxious.
The fact that cigarettes don’t have physical compulsion over you can be seen by how smokers can sleep soundly at night, if it was a physical addiction then they must wake during the night to take their drug, its only when you’re awake that you have these “compulsions”.
So Heroin provides a stronger case, for physical compulsion. Here when we stop taking heroin we have some very strong physical outcomes, shakes, spasms, nausea and anxiety again, which again can be changed if we take heroin.
So here there are strong physical symptoms, the issue with heroin “withdrawal” is that the user doesn’t just want the physical symptoms to go away, as there are different ways to do this, for instance methadone. Rather they want heroin, why because they like feeling like that, they want to feel like that, and they want to repeatedly feel like that.
What we see here with both cigarettes and heroin is choice and desire. Indeed the complexity of behaviour that a heroin addict can display to get their drug would strengthen the idea that this is a deeply volitional behaviour. The absent mindedness with which a smoker smokes, they are generally not that aware of smoking, or they would be more averse, to sucking foul smelling, burning smoke into their lungs, would indicate an activity that is done for reasons other than smoking. When you eat food, often you savour the taste, as you enjoy eating. When you don’t you can often over eat and find yourself using food as a comfort. Likewise with smoking, you don’t savour the smoke you inhale, running its delicious taste around your mouth, rather you are doing it for other reasons.
At this point the argument could return that an addiction is made up of two parts a disease of the will and a disease of the body as Benjamin Rush initially declared it. The disease of the will gets the person to take the first dose, and then the physical addiction kicks in after that.
So what could this disease of the will be. When originally defined, it was mans nature to sin, drunkenness was a sin, therefore the drinker is a sinner, who does things contrary to the dictates of God. In modern parlance whilst we still have this moral trait, there is the character of an addict.
In general parlance, I think it’s fair to say, that an addict is seen as someone who has a weak will. However they show remarkable resilience in getting their drug of choice, indeed an iron will that subordinates all other goals to this one.
A couple of other aspects are prevalent, firstly their moral fibre:
“From the standpoint of psychosocial generalization, addicts lie, cheat and steal. They are deceptive, sneaky, secretive and a bit paranoid. No matter whom they are, or who they present themselves to be, they have only a single motivation - securing their next fix.”
http://www.psychologytoday.com/blog/enlightened-living/200806/understanding-the-continuum-addiction-and-the-addictive-personality
Whilst it seems utterly reasonable to attribute this to an “addict” the same could be true of anyone who is single purposed, the top athlete, who wants only winning, the CEO of a multinational who doesn’t let anything stand in their way.
The last aspect of the addictive personality that I want to mention and then question is the Freudian take:
“We contend that in the case of an addictive character a particular kind of archaic narcissistic fantasy serves unconsciously to organize the subjectivity of such an individual. More specifically we have discovered that at the unconscious core of an addictive character lies a fantasy of being a megalomaniacal self and exercising illusory control over the psychological world of human emotions[..] having control over his or her emotional life through the use of a symbolic magic wand”
The self psychology of addiction and its treatment: Narcissus in wonderland by Richard B Ulman
In this instance the addict then uses their substance to control their emotional life through their magic wand.
There are certain problems I see with this approach, firstly it needs to posit theoretically unproven concepts such as the unconscious, and secondly and in this instance more questionable, is to apply the same theory to all addicts. When heavy drinkers drink, their emotions can be amplified as well as deadened. From the dead drunk to the roaring drunk, to the angry drunk. Substance abuse is behaviour, and as such has all the myriad varieties it does as with any other human behaviour.
The final aspect of addiction I’d like to look at is its characteristics of progression and loss of control. The commonly held wisdom is that as we get more used to our drug, then we need increasingly bigger doses leading to a loss of control. This is an essential aspect of the disease model, as without it, how could anyone claim that they cannot help themselves, and the drug is controlling their behaviour.
There was a study done by Merry in 1966, that is reported in Schlaers Addiction is a choice. 5 people all who had chronic alcoholism, which was described as involving loss of control. The people were in a hospital environment, and had unlimited access to alcohol. However if they drank less they would get better living conditions, if they drank over a certain level then would get worse living conditions. If alcohol is a drug which overcomes the will and forces of loss of control, then this “contingency management” would have no effect. The subjects however did adjust their alcohol intake to take advantages of the rewards. Their relation to their drug, was one based on the standard, albeit complex psychic economical thinking.
Thus there is logic and will involved within an “addicts” world, but we are still confronted by behaviour which from the outside doesn’t make sense as well from inside, where the “addict” may talk of being a victim to their drug, or being controlled. What sense can we make of this?
I would look to Herbert Fingarettes book Heavy Drinking for some illuminating answers. Here he comes up with the observation of central activities in people lives. A central activity is one which a lot of the rest of your life revolves around, which provides you with a viewpoint to the world. So I have worked with computers for many years, so in my house there are a lot of computers, there are computer books, and software, I have many contacts in the computing world and many relations to people through computers, I fix them, or buy them etc etc. Indeed some of the ways in which I see the world, are influenced by the logical structures that I have learnt and used in computing. Thus this has been a central activity for me and it guides how I see the world It has taken a long time to get here, a lot of decisions have been taken to get where I am, where one decision is based on another. In short then there has been a complex set of behaviours that have resulted in my now central activity. To understand my world of computers then you need to sift through the complex decisions that brought me to seeing and behaving in the world as I do.
The same is true for an “addict”; they have arrived at their central activity, say drinking, through a complex set of decisions and judgments. They do things that are harmful to themselves but they do it for the reasons that have brought them to that point and not the fact that they have engaged with an addictive substance, which now force them to make illogical decisions. An addict isn’t weak willed; in fact they show the strongest dedication to a cause known to man. An addict isn’t mad. Their behaviour might seem illogical and bizarre to us, but there is the same sets of decisions and judgements going on in their world as ours, it’s just a different central activity that is at play and different values.
There are several reasons why addiction is still seen as a disease, in spite of the contradictory scientific evidence of the past 40 years. They are as follows;
1. If it’s a disease there will be a cure, there is a magic bullet
2. Certainly in the case of alcohol, most Para-professionals are “recovering alcoholics”, who promote the values of their cure, even if there is no scientific community
3. Money. There is a huge business in helping addicts and that to have the scientific justification of a disease gives them credibility. Also the drinks companies, prefer it this way, so that the attention is focussed on the smaller minority of alcoholics, as opposed to the larger majority of drinkers, who drink too much, which is injurious to their lives, but would be classed an alcoholic, in fact I can at times fit into this category myself
The disease model of addiction I don’t believe to be helpful as it says that the person who suffers from this. It states that they are not responsible for this rather they have a disease. To say someone isn’t responsible for something however gives them no incentive to make the effort to change their behaviour, as they aren’t responsible for it.
If we take away the disease model of addiction where are we left with treatment? Well in a lot more of a complicated place, but also a lot more real place. Gone are the treatment centres, whose claims to efficacy are highly dubious. Indeed there was a large scale test in the 1970’s at the Maudsley Hospital that took two groups, one who were given a range of alcoholic treatments, one nothing. The results from the two groups were similar in terms of success. Which shows that having treatment for alcoholism doesn’t help.
Working with people with addiction, means working with people with sedimented behaviour. The approaches I believe to be useful here would be a phenomenological one. What is the behaviour like for the client? What values does it show? Is it still useful for the client? From here the answers may come, that the client neither likes of values their behaviour yet they still do it and they ask where they can go from here? At this point you come back to the perennial human condition the struggle, between the life thats wanted and the life thats lived. It can be tough. So whilst the potential cure of the disease is a lot simpler, the reality is different and a lot more involved.
Monday, September 28, 2009
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