Defining Addiction - the Debate Goes On

Addiction has always been a controversial subject - even trying to define it has given rise to a lot of discussion and argument over the years. The discussion has been particularly lively again recently, as can be seen from the links at the end of this blog.

The American Society of Addiction Medicine, for instance, has just updated its definition of addiction, partly to make more room for behavioural addictions such as sex addiction.

The following is their current Short Definition:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

And here is a brief summary of the ASAM's other main points on the subject:

1. Addiction reflects the same brain changes whether it arises in response to chemicals or behaviors.
2. Addiction is a primary illness. It's not necessarily caused by mental health issues such as mood or personality disorders. This puts to rest the popular notion that addictive behaviors are always a form of "self-medication" to ease other disorders.
3. Both behavioral and substance addictions cause the same major changes in the same neural circuitry: Hypofrontality, sensitization, and desensitization.
4. Engagement in chronic "addictive behaviors" indicates the above brain changes have occurred. Addictive behaviors then become unconscious and habitual.
5. The new definition eradicates the old "addiction vs. compulsion" distinction, which was often used to deny the existence of behavioral addictions, including Internet porn addiction.

Useful, by and large, I think, with a welcome emphasis on the neurological realities of the addicted “state of mind”.

My own current definition is as follows:

Addiction is a progressively tolerated & progressively damaging biopsychosocial adaptation to (and therefore preoccupation with) the intense emotional rewards (pleasure/pain-relief) provided by certain artificially-enhanced activities, and their associated rituals, which require minimal personal investment (e.g. heroin use, gambling, pornography use, etc). As addiction progresses, these Supernormal Stimuli hijack innate motivational systems, leading to a self-perpetuating cycle of compulsive behaviours, which the addicted person sporadically tries to control, with decreasing success, when crisis points are reached, but which they at other times resist acknowledging by the use of various cognitive-emotional defenses.

There are various other points regarding addiction that I have made over the years while teaching on the subject; each of them would find agreement from some practitioners/researchers in the field, and disagreement from others. Most of them tie in well with the ASAM perspective.

· Addictions can arise not just in relation to certain mood-enhancing drugs such as alcohol or heroin, but in relation to any intensely mood-enhancing activity such as gambling, pornography use, eating chocolate, etc. These can all be described as Supernormal Stimuli, a concept which deserves a separate blog post at a future date.

· Addictions occur along a continuum, i.e. they can be mild, moderate, severe. While it is certainly possible for an addiction to develop very rapidly, they more usually develop over a period of time.

· Addictions have biological, psychological and social aspects. The traditional medical approach to addiction focused almost entirely on the biological aspects; psychologists, psychotherapists and counsellors could be over-focused on the emotional-mental aspects; and community and social workers have been understandably most concerned with the socio-political aspects of addiction. Nowadays, more and more of those working in the addiction field are taking a bio-psycho-social approach to the problem.

· Addictions have obsessive and compulsive elements, but they are not the same as Obsessive Compulsive Disorders. OCD does not require an intensely mood-altering object, and can be seen as primarily a self-protective strategy rather than a self-rewarding one.

· Addictions are not always just symptoms of underlying issues, such as trauma or depression. Dependence on a mood-altering activity may begin in response to such issues, but it becomes self-perpetuating.

· Addicts enjoy their addiction less & less as it develops, and are not simply indulging themselves. Addiction is not the same as having a passion for something.

· Quantity of acting out is not always the best criterion of an addiction (“He drinks a lot”). Judgments of quantity are always relative and subjective.

· Drugs, pornography, gambling, prostitution etc. can be addictive; this does not necessarily make them “bad” or wrong in themselves. Of course, we can have valid moral judgments about some of these activities, but this is a separate issue from their potential addictiveness.

· Many different helping approaches to addiction work for different people. The 12-Step approach is probably still the most familiar to a lot of people, but various schools of psychotherapy also have important things to say about addiction; in particular, Cognitive-Behavioural Therapies have been found to be particularly helpful in the early stages of helping people to recover from an addiction.

· Complete, final recovery from addiction is not necessarily possible, in the sense that there may always be a remaining vulnerability (just as with depression etc). This is especially true if the addiction is chronic, and true in particular ways for food and sex addictions, given how central these activities are to our lives.

Finally, as promised, some links for further reading:

http://news.yahoo.com/addiction-brain-disorder-not-just-bad-behavior-215621166.html

http://psychcentral.com/blog/archives/2011/08/16/is-addiction-simply-a-brain-disease-it-is-now/

http://www.npr.org/blogs/13.7/2011/09/09/140307282/addiction-is-not-a-disease-of-the-brain?sc=fb&cc=fp

http://www.psychologytoday.com/blog/cupids-poisoned-arrow/201109/toss-your-textbooks-docs-redefine-sexual-behavior-addictions?utm_source=FB&utm_medium=Link&utm_campaign=RoutAdd

http://www.asam.org/1DEFINITION_OF_ADDICTION_LONG_4-11.pdf

The debate goes on…

Coming out as Humans: Radical Acceptance of Human Nature

“I am human, nothing that is human is alien to me.” - Terence (c. 185-159 BC)

Our evolved human nature is what it is. Just as a mountain climber has to be realistic about the mountain they are tackling, and an artist has to be realistic about the materials they are using, as therapists we need to have as realistic a picture as possible of human nature, because this is the basic material we work with. This doesn’t mean that we yet fully know what that nature is, though we are gaining a clearer and clearer picture.

Ironically, human nature does not equip us well for the task of realistically understanding human nature. It would not make sense for evolution, via natural and sexual selection, to have designed us for that task. Instead, like any organism, we are designed to be good at much more immediate, survival-and-reproduction oriented tasks; as Patricia Churchland puts it, “The main business of our brain is to help us adapt to changing circumstances, to predict food sources and dangers, to recognise mates and shelter, in general, to allow us to survive and reproduce” (Brain-Wise: Studies in Neurophilosophy). We therefore tend to develop a rather practical, partial, parochial, biased, subjective, unscientific view of human nature. In other words, we can’t trust our ‘common sense’ on this matter.

Our individual upbringings rarely prepare us well for the task either; a fully realistic view of human nature is not a comfortable thing, and is therefore not generally encouraged or promoted. Our individual philosophies of human nature are based partly on explicit teaching we received (often including very unrealistic religious views of what it is to be human), and partly on our life experience (which for many of us will have been quite limited, even protected). A remark attributed to bishop’s wife in Darwin’s time seems apt here: “My dear, descended from the apes! Let us hope it is not true, but if it is, let us pray that it will not become generally known.”

I also wonder whether our training as counsellors/psychotherapists prepares us well for this task. None of the main psychotherapeutic theories of human nature is adequate; if nothing else, many of them suffer from the limitation of being based on a single proposed drive/motivator. It is simply not accurate or helpful to think that all of our behaviour can be explained by a sublimated sex-drive (Psychoanalysis), by a drive towards self-actualisation (Humanistic approaches), or by the desire to achieve rational goals (REBT, and indeed much of modern economic theory). Evolutionary psychology, on the other hand, sees human life, like that of any organism, as consisting of strategic attempts to maximise our success along various key axes, such as mating, care-giving, satisfying appetites, staying safe etc. We expect human motivations to be multiple and modular, not unitary.

One of the things that suggests to me that even qualified therapists do not always have a realistic view of human nature is that they are often surprised by what seem to me to be fairly obvious manifestations of how Homo Sapiens is built. One of the examples I am familiar with, having given a lot of training in the area of Sexual Addictions, is the way in which pornography use is often seen as something pathological, and in need of some special explanation, rather than as the behaviour of an animal (particularly the male of the species) who really likes visual sexual stimuli, especially highly enhanced ones.

We shouldn’t be comfortable with a view of human beings as organisms who are always happy about having had children, who always enjoy their free time, and who should be at ease when flying 10,000 feet in the air – though this is the default view presented in much of mainstream TV and film. Instead, we should deeply internalise the truth that a normal human life contains disappointment as well as enjoyment, anger as well as love, fear as well as ease. We are status-driven, comfort-seeking mammals, inherently suspicious of those outside our in-group, obsessed with fairness, and never really satisfied for long.

I believe that therapists especially need to work hard to develop a more radical acceptance of real human nature. By radical I mean a number of things:

• Acceptance that there is a human nature. Our mind is not the proverbial “Blank Slate” that has sometimes been thought (for a discussion of this issue see Steven Pinker’s book “The Blank Slate”).
• Going back to our evolutionary roots (“radix” means “root” in Latin) in our efforts to understand our nature. By this we mean our roots as hunter-gatherers, as primates, as mammals etc.
• Basing our views of human nature on scientific evidence as well as on personal and clinical experience. The findings of science in this regard are not always what we want to hear, but once they are well established, we must take them on board. A well-known example is Milgram’s classic and shocking series of experiments on obedience to authority figures (http://en.wikipedia.org/wiki/Milgram_experiment).
• Taking the compassionate view that our struggles with a variety of life challenges are normal, not exceptional; relationships often don’t work, drugs are often tempting, etc…
• Being politically radical if necessary. A realistic view of human nature will not necessarily be in line with the current consensus view, and as therapists we may need to take on some role in raising awareness and changing opinions. One example of this kind of shift in thinking is the move that has taken place from seeing children as gender-neutral until they are socialised, to seeing boys and girls as having innate differences in interests, behaviour etc.

I do not mean by radical acceptance of human nature that we should see all human behaviour as morally acceptable, or that there should be any general absolving of responsibility for our actions. We can accept that human nature is what it is and still be morally judgmental with regard to specific behaviours when necessary.

So what does developing such a radical yet real view of human nature require of us?

For a start, it demands a high level of critical thinking in relation to the ideas we already have - again, this is something that does not come naturally to Homo Sapiens, but we can do it with effort!

It also requires a broad and deep study of the sciences and humanities which have something relevant to say (both Freud and Jung, for example, were polymathic in this way). Along with keeping up-to-date with relevant psychological findings (developmental, comparative, experimental, neuropsychological etc), studying some anthropology can be useful, as it helps give us a broader view of both the variety and the consistency of human nature. The same applies to reading good literature, watching good history documentaries, and travelling (at least outside of areas familiar to us). We are talking here about a process of personal development as well as professional development, and if it doesn’t challenge us at some level then it probably isn’t working!

Reading, References:

Patricia Churchland, (2002) Brain-Wise: Studies in Neurophilosophy. MIT Press.

Pinker, S. (2003) The Blank Slate: The Modern Denial of Human Nature. London: Penguin.

“My Brain Made Me Do It” – The Problem of Free Will and Choice

If we take Naturalism as a starting point, as this blog does, then the question as to when, how and to what extent we freely choose our behaviour leads us in directions that are at odds with everyday thinking.

As I previously quoted in my introductory Psychotherapeutic Naturalism post

(http://psychotherapeuticnaturalism.blogspot.com/2011_01_01_archive.html)

“Naturalism holds that everything we are and do is connected to the rest of the world and derived from conditions that precede us and surround us. Each of us is an unfolding natural process, and every aspect of that process is caused, and is a cause itself. So we are fully caused creatures, and seeing just how we are caused gives us power and control, while encouraging compassion and humility. By understanding consciousness, choice, and even our highest capacities as materially based, naturalism re-enchants the physical world, allowing us to be at home in the universe.”

Thomas W. Clark, quoted in: Fully Caused: The benefits of a naturalistic understanding of behaviour. 2008 Ken Batts. http://www.naturalism.org/Fully%20Caused.pdf

Once we see every aspect of our thinking, feeling, behaviour and physiology as part of a web of cause-and-effect, it simply doesn’t leave any room for free will in the way most people think of it. The most common everyday view is probably still the dualistic one, namely that there is a mind distinct from physical brain processes (and therefore separate from the universal network of cause-and-effect) which does the choosing. However, there seems to be no good evidential basis for this view, nor indeed is it clear that this is even a coherent, meaningful notion (I will address the issue of mind-body dualism at more length in a future blog).

Of particular interest are the findings of neuroscience. Think about this, for instance:

A pioneering experiment in this field was conducted by Benjamin Libet in the 1980s, in which he asked each subject to choose a random moment to flick their wrist while he measured the associated activity in their brain (in particular, the build-up of electrical signal called the readiness potential). Although it was well known that the readiness potential preceded the physical action, Libet asked how the readiness potential corresponded to the felt intention to move. To determine when the subject felt the intention to move, he asked her to watch the second hand of a clock and report its position when she felt that she had felt the conscious will to move.

Libet found that the unconscious brain activity leading up to the conscious decision by the subject to flick his or her wrist began approximately half a second before the subject consciously felt that she had decided to move. Libet's findings suggest that decisions made by a subject are first being made on a subconscious level and only afterward being translated into a "conscious decision", and that the subject's belief that it occurred at the behest of her will was only due to her retrospective perspective on the event.

http://en.wikipedia.org/wiki/Neuroscience_of_free_will

So the fact that we subjectively feel like we are making a choice is no guarantee that it really is the case…

But where does that leave us in relation to responsibility, freedom etc? These questions have a particular relevance for us as therapists, because issues of choice, influence, and responsibility for change are so central to the work we do. It’s clear that we do have desires, beliefs and goals, and that the process of choosing between alternative courses of action arising out of these does occur. However, it’s also clear that we have, at the very least, less free choice than we think/feel we have.

Some useful points for us as therapists might be:

We can at least assume a lessened role for free choice in human behaviour, with more attention paid to what goes on automatically outside of conscious awareness, to what we do habitually, and to the causal role of environmental stimuli.

We can remember that people can have full responsibility for their actions without necessarily having full control of them; we don’t have full control of our dog’s behaviour, but we are fully responsible for it nonetheless.

We can remember that emphasising the supposed role of willpower in achieving change is not actually particularly helpful (see also Integrative CBT blog from January 2011: http://integrativecbt.blogspot.com/2011_01_01_archive.html )

While we will no doubt continue to feel as if we have free will, we will probably have to make even greater shifts in our thinking about the issue as time goes by.

Hopefully, this is a start - for those who would like to read further on the subject, here are some suggestions:

http://www.psychologytoday.com/blog/hot-thought/201101/how-free-is-your-will

http://www.psychologytoday.com/blog/mind-brain-and-consciousness/201101/mind-brain-and-consciousness

http://www.psychologytoday.com/blog/dont-delay/201101/external-supports-your-willpower

Dennett, D.C. (1985) Elbow Room: The Varieties of Free Will Worth Wanting. Oxford: OUP.

Dennett, D.C. (2004) Freedom Evolves. London: Penguin.

Elster, J. (2000) Strong Feelings: Emotion, Addiction and Human Behavior. Massachusetts: MIT Press.

Evatt, C. (2010) The Myth of Free Will. Kearney: Morris Publishing.

Stanovich, K.E. (2004) The Robot’s Rebellion: Finding Meaning in the Age of Darwin. Chicago: University of Chicago Press.

Thagard, P. (2010) The Brain and the Meaning of Life. Princeton: Princeton University Press.