Addiction NOT a disease…
MD Lukens, Ph.D. © 2016
Not a Disease
The way I see it, addiction is NOT a disease. It’s something else entirely.
However, as is the case with alcohol addiction, it can and it often does result in secondary disease processes like wet brain and cirrhosis of the liver. Obviously addiction can be a “progressive process” and lead to death, but these facts, even taken together, do not make it a disease. The key is to explain what happens to the mind without having to resort to presuming something is diseased inside the brain. I think that can be done.
Addiction is something we do.
It’s not something we have. An organic disease, which is something we ‘have,’ cannot start in the mind, lead to behavior, and then go on to produce the original disease in the body. In other words, you can’t have the disease happen after the behavior and after the mind has gotten the ball rolling and say it was the disease that caused the the ball to get rolling; The disease process is not the “force” that drove the mind and the behavior.
We have to be able to explain dependency, compulsivity, cravings, moral decay, developmental arrest, obsession, and volitional behavior if we are to adequately explain addiction. Unless you buy the idea that the nature of the diseased brain changes are responsible for all the above, you don’t have a concept that is comprehensive enough or sufficiently coherent in terms of explaining cause-effect relationships.
The hijacking of the pleasure center at the expense of sound judgment is not due to a disease. It is due to an explainable motivational dynamic, that once understood, helps addicts and helpers orient themselves to the right kind of work to be done.
What have been called Mental Illnesses are, for the most part, better defined as behavioral problems that do not stem from a faulty body or body part..
Thomas Szasz argued that “the term ‘mental illness’ is only an inappropriate metaphor and there are no true illnesses of the mind.” By way of contrast, Alzheimer’s is an actual disease that starts in the body and then destroys the mind. When there is brain deterioration we have a body problem that often kills off the mind first, sometimes long before dying.
Addiction is a mind problem first, not a brain problem.
This mind problem leads to volitional behavior that eventually takes a toll on the body, including the brain. The ‘disordered’ mind can kill the body this way; and the ‘diseased’ body that results from lengthy addiction or severe addiction can kill the mind and the body. We can conclude that addiction is the mind eventually killing the body, not the other way around. Suicide is factored in as most addicted people have only a partial love of life, or no love of life at all. They start out depressed, use addictive behaviors to relieve depression and eventually due to the vicious circle end up far more depressed as a result.
Not a Moral Failing
Addiction is not a moral failing either
As it was traditionally defined in the early 20th century. Nevertheless, despite the fact it does not ‘begin’ as a moral failing, in most cases of addiction some significant moral slippage does occur. So we can’t be too surprised that people have historically defined it as such. It sort of is, isn’t it? Don’t you think addicts have a lot of guilt in addition to their shame and self loathing? Severe addicts tend to hurt lots of people. Or sometimes they hurt only a small handful, but they hurt them really bad.
But addicts aren’t bad people who have a “natural” predisposition to doing bad things.
They are people, period. They start doing things to self medicate psychic and emotional wounds and in the process of doing so they eventually come to do some bad things so they can keep their self-medicating going. They feel the need to keep it going so that the emotional pain can continue to be fully or partially controlled. Unfortunately, addiction is painful and demoralizing itself, causing additional emotional and interpersonal damage, so this would-be solution to their pain backfires on them.
It is only after a de-evolution of character occurs in support of the ongoing priority to control emotional pain that the average addict becomes “amoral” or sociopathic. Some addicts start out somewhat sociopathic — they were already folks who had chips on their shoulders — and get worse after they develop an addiction; but for most, the decay in their character is a side effect of their living “on behalf of” their addiction.
Addiction doesn’t start out as a brain/body problem,
but as it progresses it does become a problem for the body, and as the process progresses it almost inevitably also becomes a moral problem as well. But it’s beginning — the genesis of addiction — comes from some other place. There is some other source from which every addiction develops.
Addiction isn’t a Choice Either?
I say it’s not a choice because according to my philosophy of science and my view of the design of the human being as a living system. I assume that all volitional behavior is determined. Thoughts are determined, even as they are volitional. Feeling states are determined as they are clearly volitional even if they don’t ‘feel like’ they are. Perception of reality is likewise determined, as it is our structure at any given moment that ‘permits’ us to perceive what we do.
So what we tend to call “choice” or we experience as having a “choice” is merely an epiphenomenal artifact or contrivance of our languaging. We made up the idea that there is choice because it “feels” like there is, much like we made up the idea of ghosts and spirits and supernatural meanings to things, because it feels like there is such stuff. The rationale for these ideas is more fully developed in “The Physics of Emotioning” book.
Then What is It?
ADDICTION IS A PRIMARILY A MORALE PROBLEM
I’ve been treating people with various addictions for quite a while (25+ years) and I have to say I’ve never met a single addict who has not experienced some form of demoralization prior to the beginning of their addiction. Addicts start from a state of low or ‘lowered’ morale. Some of the them have been “swimming” in a pool of damaged morale their whole lives, and some “tipping point” event sends them down the addiction rabbit hole. They get a serious or sudden case of the “Fuckits” and down they go.
Even if it’s a prescription drug addiction we’re talking about that began with “appropriate” opioid treatment for legitimate physical pain there is demoralization that moves them from a place of diligent physical pain management into the more reckless addictive mode involving the additional agenda of emotional pain (feeling states) management.
Physical pain doesn’t just hurt, especially when it’s chronic it can thoroughly trash one’s morale.
It’s been clear to me for quite some time that there is this cause-and-effect link between morale deflation and addiction. I don’t see diseases per se as involving this kind of pattern.
I myself have Type 1 Diabetes, and it’s been demoralizing to me at times. But despite there being some speculation that stress may contribute to its development, it was not a “mind based” problem initially. I “have” diabetes, I don’t “do” diabetes.
Of course I have lots of diabetic self-care I need to do, but my volitional behavior was not involved in my “contracting” diabetes. Addictive behavior IS volitional. It has to be willed by the living system (rat or human). Without the Will there is no addiction that can happen.
I have diabetes, and I do have to handle it, as a person must do with addiction, but I didn’t give it to myself due to my behavior. On the other hand, in some cases of Type 2 diabetes the emotional acting out that causes the person to over eat and/or to neglect self-care does start in the mind and produces the diabetes secondarily, assuming some genetic or heritable predisposing influence factor that makes inadequate self care and diabetes cooperate in constituting the disease.
My demoralization response is a side effect of my having diabetes; on the other hand, the Type 2 diabetic may, in fact, start with a mind problem that “triggers” the disease process. But diabetes did not cause the instigating behaviors or patterns that led to teh deterioration of the person’s fitness or self care. The disease may have resulted from it, but it has no power to make the person act out with food or decline to exercise.
So if you feel a need to retain the idea of addiction as a disease and you’re willing to stretch the disease metaphor more than a bit, then this kind of “hybrid” problem with mind – behavior – disease interwoven as it is in the case of Type 2 diabetes, then feel free.
Addiction does at least resemble one common disease.
As far as I’m concerned this is the only parallel I can find in the organic disease category that could possible apply and it still is not a full parallel since the addiction disease is said to give rise to the behavior and thoughts and feeling states and motives and “choices” that led to its genesis. The reasoning goes this way: I’m Irish Catholic by birth, so my alcoholism is lying in wait as a predisposition inside my DNA just waiting for a triggering event. I say Poppycock.
But even still, if we concede to the wish of other ‘experts’ to stretch the metaphor in order to keep the concept and label, I still must object to the concept and the label. What does the disease based definition really add to our ability to understand and treat addiction? Very little that I can see, and, in fact, I think our settling on this notion has stalled the inquiry into cause and effect prematurely. Are we looking to fix brains in order to have people behave without the disease “getting the last word?”
Should addicts wait for science and medicine to produce a cure in liquid or pill form?
It’s not a useful way to promote useful understanding. In the end I consider our settling for this idea to be a mistake, and a mistake that causes some significant problems.
The brain and its processes don’t account for one’s addictive behavior.
If we adopt this disease premise based on this kind of reductionistic view of brain-behavior relationships, then all forms of acting out will potentially end up being defined as a disease: the 4 year old’s tantrums, adult criminal behavior, conflicts in relationship, general unhappiness, job dissatisfaction, racial prejudice, underachievement, etc. What will prevent us from recognizing all of these behavior based problems as diseases. You see, it’s a bit of a slippery slope to start characterizing volitional behavior as disease based.
It is not a matter of the brain determining what’s going on for the addict; it’s a matter of the mind determining what’s going on with behavior relative to the addicted person’s felt need to alter unwanted or overwhelming negative (emotional) experience. I repeat:
Addiction is something we DO, it is not something we HAVE
Addiction is the whole set of behaviors people engage in that make the “need to control’ feeling states almost biologically obligatory. If a person “feels” highly anxious it may seem that feeling safer/better is the only priority. Some itches are just too itchy so we feel very strongly motivated to do some scratching.
But this strong need and “compulsive tendency” to DO addictive behaviors and GET addictive payoffs (and costs) is not some diseased change in our wiring, it is a change in our wiring based on meaningful interactions, it is a change based on how we are defining the world and relating to it. It is a matter of our motivational “template” — the entire array of motivational forces acting on us or “through us” at any given point in time.
Addicts are people who changed along their way in life, making addiction take place as an expression of volitional behavior and “willful” engagement in the world.
The changes that preceded “allowing” addiction to happen are morale changes. People are ambivalent about living an addiction-centered existence. Addiction doesn’t happen to them because of chemical interactions; when people do addiction they’ve already changed ahead of time so addiction is “permitted” to take place according to the set of motivations they bring to the table. There’s already in place at least enough wanting or desiring some dissociated change of state, or there would be no payoff from being “high.”
Addiction takes shape for them in a way that fits “well enough” inside their relationship to the self and the world. When it stops fitting so well, they begin to talk about and experience some motivation to change “back” or change “forward.” Don’t be too sold on their early stage promises and declarations, or by the initial talk of change no matter how loud they speak. Talk is very cheap at this level.
Wishingg I wanted something else, or wishing I didn’t still want something that was “bad” for me . . . well I’m still wanting it. Why can’t addicts just stop doing the addictive behaviors? Actually, some do just stop. But most of the people who spontaneously give up a drug or stop drinking find themselves substituting some other symptom for the one they gave up. So long as there’s the sense of demoralization there is the drive to dissociate, to disclaim feeling states and meanings. Some do achieve the “home run” recovery where they stay straight and pretty much love life on their own. Those people’s’ stories should be more closely examined for the “secret.”
The addict does not have some random mood disorder generated by faulty internal chemistry that then “hijacks the will” and “makes him” use drugs or engage in addictive behaviors. That’s not how it works.
It’s clear when you interact with addicts and have them speak about their process that they don’t experience their addiction this way. They “know” the addiction is something they are doing. They may be puzzled as to why, but they’re pretty sure about the “who” and the “what.” Of course, they also talk about times when they are in a kind of trance, where use is taking place on auto pilot, without much awareness.
This is still volitional activity. It is engaged in, in response to the unwanted experience by “checking out” and going “semi conscious” so the deeds could get done without the more fully aware alter ego interfering. If you’re living a conflict in which something you want to do that is also something you really don’t want to do, you might subconsciously help one of the “two halves” of you, one of the sides of the 2 sided coin, come out. If the “prohibiting” side of you is put to sleep, the “hungry’ side can take over. Disinhibition supported by dissociation. Awareness manipulations to have the dark side temporarily win sort of thing.
It is true that anxiety and depression often accompany or precede addiction, but these are concomitant or co-occurring conditions that are themselves also just further signs of a demoralization process taking place. I don’t see these mood disorders as diseases in the conventional sense either . . . but that discussion will have to wait for a future paper.
In letting your guard down or shrinking your connection so you can cloud awareness you have “permitted” a dark side visit, a la Jekyll and Hyde, and you’ve done this in reaction to the underlying “need” to disconnect from awareness of a meaningful agenda. It may be that you feel fully justified in going down this path, fuzzy as it is, perhaps not believing things can improve, or there is any way to uplift your own morale. Something is being disclaimed or avoided, and perhaps the right hand does not want to know what the left one is doing. Demoralization, by definition, is giving us reason to avoid, even if acting out is required to support the dissociation efforts.
In addition to concluding that the origin of addiction has something to do with demoralization, it’s also been apparent to me that there’s always a notable drop in morale at junctures in addicted individuals’ lives when their use or dysfunctional behavior pattern escalates or spirals significantly further out of control. There’s always this identifiable deflation of morale that occurs as a triggering “event” prior to the adoption of addictive patterns of behavior in the first place, and it can similarly be discovered in retrospective review occurring prior to the escalation of the pattern over the course of time.
The addicted person’s public conversation about their problem and their desire for change are much like New Year’s resolutions. The percentage of people who keep their word, or who know themselves well enough so when they say they’re going to do something, they do it, is not that high. People are spin doctors of their own processes; they are not very good informants on any thorny issue of substance, their predictions about the future are heavily biased, and the strong and common face-saving commitment influences self report especially in relation to topics that are very sensitive or that threaten them with face loss.
The fact that addicts who are “trying” to recover fail so often is not a sign of the power of the disease. It’s a testament to the underexamined power of under acknowledged ambivalence.
If we divided the addict in two, and had the two commitments talk to each other (a therapeutic exercise often done in treatment with eye opening results) they would argue until the cows come home. As long as there is some sliver of motivation to keep dissociating to ward off pain there will be “cravings.” They are not impossible to resist. They have no magic power. They have regular power . . . but that’s still powerful enough to have a say in the middle of someone’s living. It’s still enough to tilt the playing field. If you disclaim parts of your ambivalence hard enough you can turn yourself into someone with multiple personality disorder. When that happens no single part can speak for the whole anymore.
We lie. We lie to ourselves, and others. We just do a whole lot more of it when we are operating in addiction mode. We don’t invent lying just for the sake of keeping an addiction process secret from particular persons in our lives, we’ve been doing some lying all of our lives. But it comes in handy in the throes of an addiction process that we are committed to continuing. Sometimes we do the lying knowing we are lying . . . and sometimes we have fooled even our selves.
The moral decay that accompanies addiction is, as I’ve said, a side effect of the willful commitment to “DO” addiction.
Lying and the increasing need to do more and more of it sits at the center of the character erosion. Think of the challenge in reconciling the conflicted ambivalence linking demoralization and the felt need to continue to live honorably. Stealing and other sociopathic actions are a byproduct of some combination of the following: (1) pre-morbid sociopathy, (2) the expense of some addictions, and (3) the illegality of some drugs of choice.
Defining and Understanding Morale
Webster defines morale as “the level of individual psychological well-being based on such factors as a sense of purpose and confidence in the future.”
When the eight-year-old doesn’t get picked for the little league team and he becomes very upset (that is, demoralized), his is an obvious situation-based emotional reaction that negatively influences his mood. His morale is damaged. His positive feeling about baseball and his interest in fitting in with the team are abruptly and “rudely” removed from him, and so important expectations for his future are trashed.
His reaction to this set of circumstances is obviously not just a matter of randomly fluctuating mood or feeling states. His failure to make the cut for the baseball team means something to him such that he experiences a significant diminishment in his sense of well-being relative to his investment in and his “hope” for this image of the future. He is demoralized. This is why and how he develops a mood problem. It could be such a severe case of demoralization that he finds himself hoping his team loses, plays badly, or a star player gets hurt.
If as an eight-year-old he finds that junk food or videogames help to distract him from feeling lousy about not making the team, or to ease the “pain” of his negative mood, we then have enough of the beginning dynamics that we could label this an incipient addictive process. If the same eight-year-old gets bullied on the playground later that same week, he comes home and feels more compelled to use food or video games and feels an even stronger need to take the edge off of those hurts, then we have an actual addiction beginning to take hold. Since he’s only 8 he may not have drugs or alcohol available to “use” but he does have access to food or video games instead.
This is what has led me to refer to food as the “original gateway drug” — it’s a matter of limited access for the child; but the dynamics are the same for adolescents and adults who find drugs or alcohol or sex or gambling or work or exercising or shopping are “needed” to combat demoralization.
The behavioral response to the initial demoralization provides some soothing, some comfort, perhaps a distraction, or a kind of numbing — this sets the stage for a pattern of negative reinforcement to become habitual. Negative reinforcement is defined as a situation in which a behavior is learned and becomes more of a habit over time when it reliably (subjectively determined) leads to escape from pain. The willful engaging in these behaviors becomes adopted as a perceived viable life strategy to intentionally self medicate in response to demoralization.
Nicholas Cummings, a noted psychologist and former APA president, was speaking about this idea a long time ago (1979) in his article published in the journal American Psychologist titled “Turning bread into stones: Our modern antimiracle.” In his article he argued that it is just this sort of demoralization reaction that occurs when the addict’s dream or important life goal doesn’t turn out; how instead of life cooperating by fulfilling those very important dreams we may have, life kicks us in the teeth and our dreams get squashed. His theory was that this was the underlying, but often overlooked source of the motivation for addiction. Nick was a really smart and insightful guy and I believe he was onto something even back then. Too bad we didn’t take his ideas more seriously at the time; instead, we got sidetracked into other speculative conversations about the causes of addiction, including the medical model’s reductionistic notion of chemical causation.
As Johann Hari has pointed out recently, this latter unfortunate idea led to the utterly misguided “war on drugs.” Vincent Felitti, the lead researcher on the ACE study project, has concluded that the chemical “pull” of addictive substances relates to the “mechanism” of addiction but not its “cause.” He and Dr. Anda, his co-investigator on the ACE study, have presented convincing evidence that adverse childhood experiences have a causal influence on the development of a host of problems, addiction included, later in life. These “ACEs” are obviously sources of high levels of demoralization, beginning in childhood, and in lieu of healing, having negative “after-effects” potentially lasting a lifetime.
In the end it appears that the Medicalization of addiction treatment and addiction definition has been most unfortunate.
The brain is not the source of the problem: The chemicals inside the brain are not the source of the problem. The chemistry of the substances are not the source of addiction. Instead, it is the “demoralized mind” that is the cause of addiction.
The broken spirit, the disillusioned soul, the disenfranchised human being – – this is where the action is, this is where addiction begins. This is the “demand” side of the “supply-demand” equation, that is, the source of the need for the drugs in the first place.
Demoralization: How is it Remedied?
Ask any dog owner what they think would be most helpful in the effort to heal a rescue dog that had been abused and they’ll tell you: a warm, loving, safe setting where the doggie’s well being is now a top priority, being provided by someone who knows how to “love well enough” to get the job done. In other words, substantive re-moralizing for the dog that needs it, served up in a way that works, by someone who can do whatever it takes. It is this same set of ingredients that are required for the addict to fully return to life and heal from an addiction.
Some of the major implications for treatment stemming from the demoralization premise should be readily apparent. First of all, we have the prevention efforts to address demoralization ahead of time — helping to fortify our children and ourselves to be more resilient or prepared for these inevitable negative experiences. Secondly, we can strive to immediately and effectively respond after it happens so the eight-year-old (or his older equivalent) comes home after being bullied and instead of keeping it to himself and doing some self-medicating, mom and dad take note of the emotional and behavioral signals and signs and find out what went on.
Then if they are aware enough, educated enough, and psychologically savvy enough they know how to provide sufficient comfort and support to their son. If they don’t know how this could be done, they should ask some expert professionals. This might then also mean the parents may try to take some corrective action in relation to the school environment. These last steps may have the added benefit of helping other children in the school. All of this could potentially obviate the “need” for the video game or food addiction treatment that would come later on, long after the addictive problems have been given time to flourish.
Treatment for addiction must involve some form of re-moralization, finding some way to substantially improve morale. Healing the wounded psyche, the diminished spirit, and undoing the emotional damage – – this is what effective treatment consists of, so this is what needs to be addressed. The person who remains in a demoralized state is very unlikely to “recover” fully from addiction. For me, this explains why the relapse rates are so high and treatment outcome studies continue to show dismal results. The wrong problem is being worked on, while the real problem goes virtually unidentified and largely unaddressed.
Treatment is not simply a matter of working on sobriety directly, and certainly it should not be about working on “staying sober” exclusively. Addiction is a kind of “side effect” of demoralization, a symptom of a larger problem. Why do you think addiction is more rampant in the impoverished and disenfranchised segments of the population? How come adolescence is a time that is so “ripe” for the development of drug and alcohol addiction? Why would it be so prevalent among the elderly? Why are relapse rates so high? Why is treatment so often only marginally effective, if at all? And how can we explain the fact that so many people recover on their own?
Certainly it helps treatment to be successful if a person brings a strong commitment to sobriety or abstinence; but the real important changes don’t come from a focus on the side effects of the problem alone. What is required if there is to be a full recovery, in the larger and more longer term sense, is a restoration of morale. Or, in the case of people who have been demoralized since early childhood, the initial achievement of sufficient morale.
I’ve seen this again and again as a treatment provider over the years: the people who have truly been successful and fully recovered are those who achieve this critical mass of morale repair or what we might call a high level of morale rejuvenation.
They don’t just get sober, they come back to life completely. They change a ton. They get their lives back, and in many cases they end up with better lives than they ever had before.
Filed under: Uncategorized