“Addictions” or “Addiction”? Willful choice?: A paradox
Thirty-seven years ago this month, I commenced my first administrative job as Director andMedical Director of a 16 bed, hospital-based Addictions Treatment Unit (ATU) in the now defunct New England Memorial Hospital in Stoneham, Massachusetts (Boston area). Back then, we were a little bit ahead of our time for Massachusetts anyway, to call it an “Addictions” treatment unit when most programs were “Alcohol” rehab programs. We were going to combine all the addictions (alcohol, cocaine, heroin etc), including accepting patients with co-occurring psychiatric illness (“dual diagnosis” back then).
This year I left to join a company to manage programs around the country. An addiction psychiatrist friend and colleague, Dr. Michael McGee, took over the leadership of that treatment unit. Over the years we’ve both thought together how to improve awareness and services for people suffering from addiction. We even wrote a paper together-starting to think outside the box on matching services to needs. (McGee, Michael D, Mee-Lee, David: “Rethinking Patient Placement: The Human Services Matrix Model for Matching Services to Needs” J. of Substance Abuse Treatment. Vol. 14, No. 2, pp. 141-148, 1997.)
But that paper and topic is for another day.
In this month’s edition of Tips & Topics, I want to share (with his agreement) some recent “debate” Mike and I have had: What is addiction? What’s the role of choice in relapses – or as I like to call it “flare-ups”, “recurrence of signs and symptoms” or “acute exacerbations of the chronic illness of addiction?”
Before that, let me address one issue we have had some debate about and that is “addictions” versus “addiction”.
Compare using the terms -“addictions” versus “addiction”- when describing what DSM-5 calls the Substance-Related and Addictive Disorders.
If I were to do it over again, in 1981, I would have named the new program the “Addiction Treatment Unit” not the “Addictions Treatment Unit”. I have come to understand the illness, influenced by the definition of addiction by the American Society of Addiction Medicine (ASAM), as “addiction” which manifests itself in various substance-related conditions like alcohol use disorder, tobacco use disorder or methamphetamine use disorder; and in non-substance-related behaviors such as gambling disorder.
ASAM’s Short Definition of Addiction:
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.
When we treat Major Depression, Schizophrenia, Bipolar or Anxiety Disorders, it is not called the “Depressions Treatment Unit”, “Schizophrenias Treatment Unit”, Bipolars or Anxieties Treatment Unit”. You get the picture.
Addiction is the illness/disease, but we must do person-centered, individualized treatment because it manifests itself in many different forms of substance use and other addictive behaviors. In addition, it co-occurs with many different conditions in different people – co-occurring trauma and other psychiatric challenges, chronic pain, risk-taking thrill-seeking temperaments, criminogenic factors etc.
One size cannot fit all.
Consider your attitudes and beliefs about the role of choice when people with addiction use substances.
Michael McGee just had his first book published The Joy of Recovery, which is “a comprehensive guide to healing from all addictions. It lays out a path and a method for recovery leading to a life of joy, free from the bondage of addiction. It is a book about transformation.”
You’ll notice Mike speaks of “healing from all addictions“. When I was reviewing his manuscript we had the discussion I outlined in SAVVY Tip 1 above.
The second “debate” we had was about terms he uses: “readdicting” and “readdiction”.
Here are excerpts from our friendly back on forth on the implications of this terminology:
From Mike to David:
“I’ve been using the term “readdicting” or “readdiction” as synonymous with “recurrence of signs and symptoms of addiction.” I see that you are not comfortable with these terms and wanted to understand better your thinking. I use these terms extensively in my book…”
My response to Mike:
I see addiction as the disorder/disease. For each person, they may have their own mix of biopsychosocial etiological factors. But once they cross the line into addiction as the illness, their relationship with substances and addictive behaviors like gambling, becomes irrational and out of control. I’m not saying they cannot do a number of things to minimize the chances of having a flare-up of their disease. But once it flares-up, it isn’t a conscious choice or behavior to pick up a drug and willfully “re-addict”.
I liken it to Depression or Panic Disorder or Schizophrenia. When someone has a recurrence of depression, I don’t see that as “re-depressing.” They haven’t been cured of depression only to “re-depress.” The individual has depression and despite what they may do (medication, exercise, therapy etc.) it may return; at that point, they are the passive recipient of another bout of depression. They didn’t re-depress themselves. Same with panic or psychosis. If it flares-up, I don’t think of that as “re-panicking” themselves or getting back to psychosis in some willful way. I think “readdicting” sounds like a verb, not a state of being.
I’m always looking for better terminology that sees recurrence of substance use in a person with addiction as a bad outcome to be assessed and treated versus a sign that the person is re-addicting in some willful and active way. The individual is afflicted by a flare-up of addiction (passive tense) versus readdicting (active verb sense).
For example, you write that “We consider episodes of readdicting as opportunities for learning andgrowth“. I think what I am saying is:
- “When there is a flare-up of addiction and the person starts using substances in an irrational and out of control way, that is an opportunity for learning and growth.”
- It takes away from the idea some counselors express like this: “Well there has to be some negative consequence for using (or readdicting), otherwise every other patient will think it is OK to use and this program will be out of control with people using with no consequences.”
“We consider episodes of flare-ups of addiction as opportunities for learning and growth” means:
- We have to find out what went wrong so the person succumbed to the flare-up and had a recurrence of signs and symptoms like substance use, positive drug screens andoverwhelming cravings to use.
- The poor outcome of substance use warrants assessment and treatment plan changes; not consequences for willful readdicting.
I just think that for some, and maybe many, “readdicting” sounds like the client has chosen andstarted willful, out-of-control use of substances or gambling behavior.
“I see your thinking, I think…that people have recurrences of addiction like recurrences of depression, anxiety, panic, hypertension, hyperglycemia, chronic obstructive pulmonary disease (COPD.) These recurrences happen as a manifestation of a brain disease: disordered functioning of the brain’s drive-reward system.
I have concerns about where there may be a mismatch between reality and this comparison. I actually think it is a mistake to compare addiction to any other particular disease process. Addiction is unique unto itself: Addiction is a disease in which there is organized, compulsive behavior, such as in Obsessive Compulsive Disorder (OCD). While behaviors certainly impact upon other chronic recurring diseases, these diseases are more experienced than acted out.”
My response to Mike:
When you say addiction is “acted out” rather than experienced, I think you are saying what many psychiatrists and mental health professionals say about addiction: that the focus is on the behaviors as acted out and that these behaviors cause addiction rather than the behaviors being the result of addiction.
It is a bit like the old question of “Is there an addictive personality disorder?”
- Because the behaviors look the same in patients with addiction, mental health focuses on what it does with other disorders. They describe the behaviors and then give it a diagnostic label e.g., addictive personality; addiction as a compulsive disorder.
- But from George Vaillant’s work -(at least with male alcohol use disordered subjects followed prospectively over decades from college before developing addiction)- it seems clear that “alcoholism was generally the cause of co-occurring depression, anxiety, andsociopathic (delinquent) behavior, not the result.”
- Common clinical presentations of compulsive use, out-of-control behavior and anxiety etc. are the result of addiction not the cause of it.
So when you say diabetes and hypertension etc. are experienced, not acted out, it diminishes the role lifestyle choices and behaviors have on the development of diabetes and hypertension; andon recurrences and flare-ups of those diseases too. So I see a lot of parallels and similarities, rather than seeing addiction as uniquely different.
“I see your point. All these disorders have lifestyle precursors combined with genetic vulnerabilities.”
“In reference to our exchanges and the use of the term “readdicting,” it is important to recognize that indeed there is (almost?) always some degree of choice. Loss of control occurs along a spectrum.
- For example, most advanced sufferers of opioid use disorder make conscious, willful choices, such as to not shoot up where they might be caught. It is because of choice that people respond to contingent reinforcement.
- At some point in the intoxication/withdrawal/
craving/addiction-seeking cycle, people make a choice to go through the cycle again and again.
- At some point in the cycle people can and do make a choice…sometimes to addict again, or to not, maybe to ask for help, go to a meeting, etc.
- If there were no choice, then craving management techniques would never work.
- People often choose to enter the cycle of addiction again because they perceive that they have no other choice.
- It is correcting this misperception that is at the heart of addictions treatment for at least some, if not most people suffering from addiction.”
My response to Mike:
Yes, I fully agree that choice and re-involving with people, places and things can set a person up for a flare-up and recurrence of use. I am not saying addiction is like someone suddenly being overcome by a flu virus and that their choices about people, places and things have nothing to do with the development of addiction and flare-ups.
But I see this with diabetes, hypertension, depression etc. too.
- When people don’t stick with lifestyle change of diet, exercise, smoking, meditation or whatever, they set themselves up for a recurrence of spiking blood sugar, elevated blood pressure (BP), suicidal depression etc.
- So if you mean “readdicting” is about making counterproductive choices about people, places and things, I agree on the term “readdicting” – the person is setting themselves up for another episode of out-of-control use or gambling.
- But I don’t see “readdicting” as the same as “recurrences of signs and symptoms of addiction.” At the point someone picks up a drug and uses, against all their better judgment and promises to themselves and others that they will not use again, that is not acting out or willful misconduct.
- It isn’t acting out or willful misconduct when a person’s BP spikes or they have an asthma or panic attack or become psychotic.
- There are many choices in any disorder where choice and behaviors can increase/decrease chances for a flare-up and recurrence of signs and symptoms.
- But at the point of the actual flare up, I am saying that isn’t a choice for those who have addiction or any other chronic disease.
“Agreed, David. Well said.”
Resources from Dr. McGee:
1. “I write my blog based on issues and themes which come up in my work with patients. Issues include trauma, addiction, recovery, and healing. I write it primarily with my patients in mind, but also for the general public, touching on life themes universal to the human experience. I blend cognitive-behavioral, relational, and psychospiritual ways of thinking about healing and recovery in what I hope is an integrative, evidence-based, and common sense-based approach to healing andrecovery.” My website is drmichaelmcgee.com.
2. “The Joy of Recovery: A Comprehensive Guide to Healing from Addiction”
The Joy of Recovery is a practical “how to” guide to the Being, Seeing, and Doing of Recovery. It uses 12 “Touchstones of Recovery” to guide readers through the process of healing from addiction.
Links to purchase Dr. McGee’s book:
Michael D. McGee, M.D.
So what are some implications of our “debate” over addiction as a disease and the role of choice?
Help your clients see that they have choices; they are not helpless victims of addiction.
“People may not be aware they have choices. This can be corrected by pointing it out–raising awareness. People vary in their degree of awareness, and thus in the amount of control they have over their compulsive drives. If people did not have any control, then they could not choose recovery or ask for help. Many people “wake up” from addicting (compulsivity) and choose not to addict any more. I think awareness is a key factor that mediates the experience of loss of control.
So really we are dealing with a spectrum disease with no clear demarcation between innocuous habits and severe addiction.
- A spectrum of severity among a spectrum of interrelated processes: Pain, Desire, Compulsion to act, and Degree of control (modulated by Awareness of options andalternative motivations).
- “Readdicting” honors that there is a behavioral element of the disease process that is recurring in our brain drive-reward system.
- In treatment, we need to emphasize choice; that is empowerment- through meditative practices combined with cognitive behavioral treatment (CBT) and interpersonal interventions.
- For example, people develop the capacity to Stop, Investigate, Consider the options, andAct with love. We help people to see they always had a choice, but didn’t know it, even if just the choice to ask for help…which people do every day.”
My response to Mike:
I agree with all of the work people need to do to give themselves the best chance of sustained recovery. I think the issue of choice is one that gets mixed up in the public’s understanding of addiction and which is why I am pressing this point.
- The public sees all addiction behaviors as a choice and willful misconduct and so does not have compassion for people with addiction. So I am careful about saying things like “people with addiction had a choice but didn’t know it.”
- Does a person with diabetes have a choice about manifesting diabetes, even though lifestyle and choices contributed to the eventual manifestation of the disorder?
- Then once a person has diabetes, do they have a choice about when it flares up, even though behaviors and choice can contribute to a flare-up and recurrence of symptoms?
Yes, people do have a choice about this: If and how they will involve with people, places and things to advance health and well-being; or whether they will choose people, places and things that do not support recovery.
Understand the paradox of surrender and empowerment.
Patients and clients who cross the line into addiction have their own recipe of biopsychosocial-spiritual factors leading them to lose control of substance use or gambling, against their better judgment.
Here’s how to help clients think about the paradox of surrender and empowerment:
- Once I own and surrender to the fact that I have addiction and that I didn’t choose to re-addict and lose my career, family, values and health, I am now not disempowered without choice – a victim of addiction.
- Paradoxically, now I am powerful – empowered to give up self-defeating guilt for all the crazy things addiction leads to; empowered to stop beating myself up for all the times I broke promises to myself I would quit; empowered to now take responsibility for my life choices and recovery.
- As a person with addiction, it is not that I am re-addicting and choosing compulsive substance use.
- Rather, what I need to do now is take all preventive steps, choices, lifestyle change, new friends, meditation to avoid flare-ups as much as possible.
- If I do all those things, I may never have a recurrence of signs and symptoms of addiction again.
- Or I still may have a flare-up for which I will not condemn myself for re-addicting andmaking bad choices. I will use this as a learning opportunity to tighten my preventive plan.
- At the same time, I will surrender to the fact that despite all I do to prevent addiction flare-ups, I am powerless over this disease. I will not condemn myself just as I would not condemn myself for a panic or heart attack; or hypertension or hypomania.
“David…I see and agree with what you are saying above. Makes sense. I think there is a paradox of choice. I think we agree there is a choice to surrender and ask for help, even in the midst of a “flare up.” I see this every day I admit a new patient to treatment. It is paradoxical and difficult to convey. People do truly lose control and do not have a choice when they have a flare up of readdiction. What you are saying is true. Yet I still observe that people, even in the midst of not having a choice, did have a choice that they did not see or consider…and that choice, as you say, is to surrender andask for help. And to do so is self-empowering.”
Here are more of Dr. McGee’s observations about the paradox of choice and surrender:
- People both don’t have a choice (due to the dysregulation of their brain’s drive-reward system) and they also do have a choice at the same time – to surrender and ask for help.
- Asking for help is self-empowering.
- Some people also have more indirect choices that address the disease of the drive-reward system – by changing the way they live; or even just seeing things differently in a way seems to reinstate the executive functions of the prefrontal cortex like good judgment andrational decisions as top-down control over the drive-reward system.
- We see this all the time in people who “wake up” and just stop addicting because they really “see” that it isn’t working or is harming them too much. But then, did they have a “choice” to wake up? No.
- This is something that happens. The conditions for this experience can be cultivated – using Motivational Interviewing – but people can’t really “choose” to wake up.
- So I guess I see that people suffering from addiction don’t have a choice to addict or not when in the midst of a “flare up”-we are in agreement about that for sure.
- But they do still have choices: To surrender, to ask for help, to weigh the pros and cons, to practice craving and trigger management techniques, to practice more effective, love-based ways of being, seeing, and doing.
I thought the quote was: “A paradox is a truth standing on its head so you don’t recognize it.” But in checking Google, apparently the correct saying is “A paradox is the truth standing on its head to attract attention to itself“. That catchy phrase is attributed to G. K. Chesterton, an English writer, poet, philosopher, dramatist, journalist, orator, lay theologian, biographer, and literary and art critic. Wikipedia G.K.Chesterton
One reference quoted Oscar Wilde as having said that, but I’m going with Chesterton who is often referred to as the “prince of paradox”. Either way, it is an attention-getting phrase that captures the dictionary definition of paradox: “a statement that is seemingly contradictory or opposed to common sense and yet is perhaps true“
- Surrendering to be empowered
- Being powerless to actually embrace your power
- Getting what you want when you don’t need to have it.
These all do seem quite contradictory perspectives that you don’t at first recognize as truth; andthey do indeed grab your attention.
Have you heard of a couple hell-bent on becoming pregnant, spending thousands of dollars andcountless stressful hours with fertility drugs and in vitro fertilization efforts only to give up andadopt a child? Then within a year, they are pregnant with their own biological child. How is that for getting what you want when you don’t need it?!
My kids, when they were more in the active dating scene, verified the truth in paradox too. If you go to a club desperate to hook up, it seems like a desert without a prospect in sight. But then when you surrender to the fact that tonight it’s not going to happen, (so I may as well just enjoy the music and dancing) somehow she or he shows up out of the blue.
Surrendering doesn’t mean meek passivity and taking on a victim position. And embracing your power doesn’t mean aggressive, driven, relentless effort. When it comes to addiction recovery or getting the love or job you want, recognizing the truth in paradox sets the scene for success:
Calm, quiet surrender to your powerlessness to make it happen – balanced with
- Faithful, steady, diligent effort from a stance of powerful confidence.
If that sounds like a tall order, the good thing is that all the power is in your hands, but you have to let go before it really works.
Now that’s maybe a truth standing on its head.