The Addict's Dilemna

Old 08-13-2003, 02:49 PM
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Morning Glory
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The Addict's Dilemna

The Addict's Dilemna
Floyd P. Garrett, M.D.

Abstract. Addictive behavior attempts to repair a state of bad feeling but is a Faustian Bargain that perpetuates itself and often asks the ultimate price. Addiction can be compared to an unhealthy, fanatical love. Unnatural and arbitrary hedonic management by substances or stereotyped processes distorts and cripples the psyche and places the individual at a grave survival disadvantage. The addict is double-minded because he cannot really and truly desire recovery until he already has it. Recovery is about restoring natural, spontaneous and healthy regulation of mood and feelings. Because addicts may be seriously impaired in their pre-addictive self-care and self-management they often require prolonged help learning to feel well without resorting to the "tricks" of addiction.

Addictive behaviors such as smoking, drinking, drug use, overeating and other "quick fix" maneuvers aimed at rapidly and dramatically changing the individual’s emotional and hedonic state are natural and common targets for resolutions of reform, whether at New Year’s or any other time, to "do better," to "turn over a new leaf" or to "quit once and for all." And even more than in the case of the typical New Year’s resolution, the solemn promise of the substance(alcohol, nicotine, other drugs, food) or process(gambling, spending, sex) addict is well known by just about everyone familiar with such matters to be, more often than not, ‘writ in water.’ In addiction perhaps more than any place else, "The best laid plans of mice and men gang aft aglay."

Such natural and only too well justified skepticism about promises of reform on the part of those familiar with the addict does not necessarily include the addict himself, who may fervently and sincerely exclaim "I know I’ve said this before – and I know that you don’t believe me and that you are entitled not to believe me. I wouldn’t believe me either if I were in your shoes. But this time I really mean it. I swear it will be for real. Wait and see if I’m not telling the truth!"

But in spite of this and other equally inspired proclamations of intent to reform, in the vast majority of cases of definite and well-established addiction, nothing whatever changes – at least not for long. Or if there is change, it is change for the worse: the addict’s outrageous addictive behavior sometimes seems almost to feed upon and draw nourishment from his passionate promises that "it will never happen again." This phenomenon leaves those who have to deal with the addict in a confused, discouraged, angry and usually depressed state.

It is difficult to change any behavior to which one has grown accustomed unless there are powerful and consistent immediate rewards for doing so or equally persuasive penalties for not doing so. In many cases, e.g. that of commencing and maintaining a physical exercise program, the rewards of such a behavior change are by no means immediate, while the costs of them –the discomfort occasioned by exercise to which one is unaccustomed- are up front and unavoidable. Individuals who succeed in getting over the hump of such habit change usually do so by making themselves look ahead to a future and more desirable state which will be the actual and lasting reward of their present, unrewarded efforts. Everyone knows how difficult it is to do this – and how easy it is to succumb to excuses and rationalizations which permit one to abandon his efforts while managing to save face by telling himself that "I’ll get back to it later" or "Now is not a good time to be doing this – but in the future, when circumstances are more favorable, I will certainly resume my efforts." Addictive thinking is notorious for its smooth and lawyerly ability to "plead its case" and to make the afflicted individual actually believe that he is making a rational decision in his own best interest, when in fact he is simply being yanked around by the addiction like a puppet on a string. "Wait until after the holidays to stop drinking," addiction coos into the ear of the alcoholic who has become seriously concerned about the consequences of his drinking. "That way you will actually have a much better chance of stopping and staying stopped than if you went ahead and stopped drinking right now. This is not a good time to try to stop drinking – but next month will be perfect!"
Old 08-13-2003, 02:49 PM
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Morning Glory
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In the case of addictive disorders all of the usual resistances to habit change are found in full force – but there are other obstacles as well. For in most cases the addict is deeply divided and double-minded about his very desire to change his behavior, even when he is perfectly aware that the behavior is damaging both to himself and others. The addict knows that he ought to want to stop engaging in addictive behavior, but he is powerless to make himself really and truly want to do so. His intelligence and his reason may point him in one direction, that of recovery from his addiction; but the force of the addiction itself points in another, quite opposite direction. The result is a kind of ongoing internal civil war in the mind of the addict, who is thus a house divided against itself, pulled in two contradictory directions and as a result, double-minded to the tips of his toes.

Even to attain such a stage of more or less conscious double-mindedness is for many addicts a sign of significant progress. For in the early stages of addiction, and in all cases in which people are simply unable or unwilling to be honest with themselves, such a definite and clear-cut distinction between the addictive want and the rational should is seldom available to the conscious mind of the individual. Such dissonances as exist are smoothed over and rationalized away by the extensive armamentarium of the addict’s psychological defenses, with the happy and fortuitous result that what the addict wants –to continue his addictive behavior- turns out to be precisely what is both justified and best for him, at least in his own mind. But even here, beneath the threshold of consciousness and behind the obscuring screen of mental defense mechanisms such as denial, projection, rationalization and others, the addict is usually deeply divided against himself.

Addictive double-mindedness means that the addict, even, indeed especially when he has attained a reasonable consciousness of his plight, remains between the proverbial rock and a hard place. He knows that his addictive behavior is not good for him or for those around him; and he knows that the wisest, sanest, most sensible and indeed the only rational thing for him to do is therefore to abandon it immediately and to never look back. But this the is one thing that he is not prepared to do. He might do almost anything else to be rid of his addiction – but he won’t do the one thing needful, and the only thing that counts: desist once and for all from the addictive behavior itself.

Why not?

For the addict the prospect of giving up his addictive behavior and the feelings it brings him activates profound feelings of loss, deprivation and despair. The addict is attached to his addiction in a primitive and pre-rational fashion just like a lover is attached to his beloved – or an infant is attached to its mother. Because there are no longer any clear boundaries between his love object –in this case, his addiction- and himself, each merges imperceptibly into the other so that it is impossible to tell precisely where the addict stops and his addiction begins - and vice versa.

The psychological consequence of this blending, merging and fusion between the individual and his addiction is that any threat to the continued vitality or existence of the addiction is immediately experienced as an equal and corresponding threat to the self. The addict cannot really imagine a worthwhile life sans his addiction – or if he is somehow able to conceive such an existence, he finds it to be unbearably weary, stale, unprofitable and empty, a kind of living death that is more of a curse or a punishment than anything to be valued or preserved. Thus it is perfectly natural for him to say to himself, imagining as he usually does a future free of addiction that is also and as a consequence destitute of every enjoyment and meaning that make life worthwhile, that quantity of life is not so important as quality, hence it is reasonable in his mind to persist in his addiction even if it shortens his life substantially because at least he will be happy during the time remaining to him.

Unless one understands this inability of the addict to envision in any depth and for any significant duration a meaningful and worthwhile future for himself without what to him has long since become the comfort and security of his addiction, he will not be able to make sense of the ways in which the addict is constantly and usually successfully drawn back to his addiction like the moth to the candle flame. Nor will he be able to comprehend why the addict often appears to sacrifice his life, his fortune and his sacred honor –usually in the reverse order- to the demands of his obviously absurd monomaniacal obsession.

Addiction is a process that over time encroaches upon and over time invades the normal, healthy "tissue" of the addict’s personality in a manner strikingly similar to the way a malignant tumor crowds and infiltrates the tissue around it. And just as in many cases the Dilemna for the treatment of a bodily cancer is how to remove or destroy the cancer while simultaneously sparing as much as possible of the nearby non-cancerous and often vital host tissue, so does recovery from advanced addiction require a similar separation of "tissues," with destruction of one and protection of another. The process of recovery from addiction in fact quite often resembles the radiation treatment and chemotherapy of a grave malignancy during which the individual often experiences side effects and feels quite ill from the treatment.
Old 08-13-2003, 02:50 PM
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Morning Glory
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It has been often and truly observed that the addict in many ways resembles a lover with a fatal attraction to an injurious, possibly even a deadly love object. Such destructive and even fatal love of one individual for another is of course by no means unknown. It has many enduring literary representations, from the poems of the Roman poet Catullus to W. Somerset Maugham’s novel "Of Human Bondage." Just about everyone is familiar with this phenomenon of unhealthy love – if not from their own experience, then from that of their friends or acquaintances. Individuals in the grip of such a pathological obsession are "unable to live with" and "unable to live without" the object of their affections. Such relationships are stormy, painful, often violent – and always unhappy. In some cases the lover is perfectly well aware of being abused, misused, deceived and maltreated by the one he loves – but he seems strangely powerless to stay away from a relationship that is obviously unhealthy and injurious to him.

Such lovers, like all lovers, are of course obsessed with the object of their love. They long for it, pine away when deprived of it, and think constantly about ways to reunite with it. The beloved becomes the center of the lover’s mental universe, the center from which all radii emanate and around which all circumferences are drawn. Everything is organized in a hierarchy on top of which the beloved reigns supreme and secure and to which everything, absolutely everything else is now subordinate. Nothing that seriously threatens the beloved object is likely to survive for long – and even everything that does not pay it sufficient homage or which is even suspected by the lover of being critical of it is likely to retain respect or regard that once were unquestioned. Friends, family, traditions, even ethical and moral values once held sacrosanct: all must and do give way if they threaten the continued relationship with the beloved. By means of a "transvaluation of all values" the addict now finds himself truly "beyond good and evil" – at least when it comes to his relationship with his beloved.

If a lover in the grip of such a dire obsession for his beloved is advised by others to give up the relationship "for his own good" or for the good of others –one thinks of the Montagues and the Capulets of "Romeo and Juliet" here- he will recoil in anger and disgust from the very thought of a life without his beloved – and he is surely apt to distance himself, even to regard as actual or potential enemies those who dare to give him such absurd and intolerable advice. He may even declare that since life would not be worth living any longer if deprived of his beloved, he is perfectly prepared to hazard every danger, even if necessary to die in an effort to prevent what for him would be the ultimate and irreparable disaster, the loss of his beloved. And whether his "beloved" is a person or an addiction, he may upon occasion do just that.

Although it is the rare addict who thinks consciously of his relationship to his addiction in terms even remotely resembling those just described, an analysis of addictive behavior and values reveals many remarkable similarities between a certain type of love of one human being for another, and the love of an addict for his addiction. Common to both experiences is what might be called a totalizing tendency to reshape not only the world of the lover but even his very identity in a manner congruent with the object of his love. The very existence of the addicted individual can often be divided, both subjectively and also objectively, into "Before the addiction" and "After -actually during- the addiction." Of the experience of what truly comes "after the addiction," i.e. recovery from addiction, the addict as a rule has no conception whatever beyond the projected state of perpetual mourning and living death described above.

It is worth dwelling for a moment longer upon the remarkable attachment of the addict to his addiction – and upon his profound sense of loss when he is - or even imagines himself to be- deprived of the comfort, solace and sense of security he derives from it. For in a psychological sense this track takes us very close to the lair of the addictive beast itself.

Although breaking the bonds of a serious addiction is actually a huge step toward personal freedom and a richer, deeper and more satisfying life for the formerly addicted person, it is almost invariably experienced by the addict himself as a massive, often a catastrophic loss and resulting state of permanent deprivation. Even the faintest threat of such a potential loss is often enough to activate frantic emergency behavior designed to head it off at the pass. The long habit of addiction has made the addict accustomed to it and caused his other coping strategies and tools to wither from disuse atrophy. In many if not most cases he literally does not know what to do with himself without his addiction.

A large part of the addict’s double-mindedness about recovery results directly from his longstanding intimate relationship with his addiction as a security object –in fact, as a soothing and comforting parental surrogate- and the painful negative emotions that are inescapably connected to the loss of such a familiar and, as the addict sees it, protective relationship. For strange and even starkly opposed to the actual facts of the case as it sounds, the addict actually feels sheltered and protected from danger by his addiction. Without his addiction the addict feels terribly insecure, exposed, and liable to all kinds of harm. For the addict, his addiction is a kind of pacifier that can always be depended upon to produce the feelings associated with safety and security – even though in his case these feelings, because they are artificially derived and thus bear no relationship to the addict’s real circumstances, are dangerously misleading.

Addictive behavior aims to modify the emotional and hedonic(pleasure) state of the individual directly by artificially creating positive feelings and avoiding negative ones. This means that the addict’s own internal guidance mechanism, his "survival compass" becomes progressively disconnected from his actual internal and external environment with its constantly shifting and changing stimuli and cues, and is replaced by the "false compass" of the addiction whose needle is always pointing toward itself and hence bears no relationship at all to what is good or bad for the individual who attempts to navigate by it.
Old 08-13-2003, 02:51 PM
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Morning Glory
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Pleasure and pain, the two "sovereign masters" that the Utilitarian philosopher Jeremy Bentham claimed rule the lives of all men, are obviously instrumental in steering not only human beings but every sentient creature toward certain goals and away from others. One need not be a crude utilitarian nor a rank hedonist to see that a significant disruption in the "guidance system" of the pleasure-pain sensors could have negative, even fatal results. For example, if it felt good rather than bad to thrust one’s hand into a fire there would certainly be a lot of badly burned and permanently crippled people around, still struggling against the temptation to "do it just one more time." And in the other direction, if the sexual reproductive act were an intensely painful experience for all parties involved, it is not likely that the problem of overpopulation would ever arise.

Thus in some rough and certainly inexact fashion the sensations of pleasure and pain seem to act as guidance systems and channel markers to steer the individual in a safe direction and away from harm. And it is also difficult to deny that under most circumstances a feeling of well-being or happiness most often indicates that "all systems are go," i.e. that the individual’s inner and outer milieu is at the moment stable, healthy, and conducive to life and growth. A pervasive bad feeling, on the other hand, or any sustained state of negative or so-called "emergency" emotions(fear, rage, guilt &etc.) suggests that an unhealthy condition exists either internally or externally and that some action is called for to restore the conditions necessary for health and its associated positive feelings.

The syndrome and process of addiction involves what might be regarded as a sustained manual override by artificial means of the "autopilot" of the addict’s natural and interactive hedonic(pleasure-pain) regulation. The addict, that is, learns to take control of his hedonic state by direct chemical or behavioral means, thereby short-circuiting its connections to his actual inner and outer environment and rendering it worthless or even harmful as a "compass" to steer by. By means of a kind of Faustian Bargain he manages to attain good feelings and to avoid bad ones, not in a natural and healthy fashion that is intimately related to the ongoing reality of his life and behavior, but by the manipulation of his addictive substance or process. As time passes he strays further and further from the true path of health and sanity until at last, and usually before he realizes what has happened to him, he finds himself lost in a dark wood of addiction with no guide to show him the way back. For by this time his own "compass" has been so damaged by his addiction that he is very apt to fear and avoid just those things that would be good, even lifesaving for him, while instead steering and steaming with all his might directly into the jaws of the very addiction that is destroying him. His feelings are no longer reliable guides to rational and healthy action but in fact quite often the very reverse. Thus while the motto of addiction itself might be "If it feels good, do it!" the motto of recovery, certainly not in all cases but in more than a few could be "If it doesn’t feel good, do it anyway."

The addict’s Dilemna, then, comes down in the end to this: what he feels like doing is seldom good for him, while what he doesn’t feel like doing, e.g. stopping his addiction, getting treatment, engaging in healthy behaviors &etc. often is. In most cases of well-established addiction the emphasis has long since switched from the so-called "positive reinforcement" paradigm in which the addictive behavior is primarily motivated by a search for pleasure or good feelings, to a "negative reinforcement" model in which the goal is mainly to avoid the bad feelings that the addict knows are in store if he fails to perform his accustomed hedonic manipulations by means of his substance or process of choice.

Such considerations help to explain the fact, well-known to professionals who deal with individuals suffering from serious addictions, that lasting recovery, when it begins, quite often begins in the context of a crisis of sufficient magnitude to overwhelm the addict’s natural and well-entrenched aversion to recovery by an even greater fear such as the loss of an important relationship, a job, health or freedom(the threat of jail for addiction-related offenses).

It is therefore not at all the case that alcoholics and addicts "have to want to get better" before recovery can commence, much less that they must "want to get better for themselves and not for someone else." For the addict’s double-mindedness makes such "pure" motivation all but impossible for the vast majority of addicts. Luckily for the addict, recovery is just as likely, perhaps even more likely if he is in effect marched at bayonet point in the direction of behaviors that are good for him and which he would therefore, owing to his addictive hedonic disorientation, normally avoid like the plague if only he were not afraid that by so doing he would incur an even more unpleasant consequence. For it is one of the many curious paradoxes of addiction and recovery that genuine and sincere motivation for recovery is a result of and not a prerequisite for recovery.

When addictive behavior is suddenly interrupted or suspended –usually by circumstances beyond the addict’s control, but occasionally as the result of a rational decision- there is an immediate hedonic backlash effect as the "bills" begin to come due for the prolonged artificial manipulation of mood and feeling state that is a central feature of the addictive process. The addict suddenly feels worse – much worse. Depending upon the specific substance involved he may undergo so-called "withdrawal symptoms." But regardless of the substance or process involved, when an addiction is suddenly interrupted the addict is plunged into a negative hedonic state that may last days, weeks, or even months. During this period of time –early recovery or early remission- he is obviously extraordinarily vulnerable to a return to his accustomed "old reliable" means of directly manipulating his feeling state, the very addiction that has brought him to the unpleasant predicament he is presently in and is trying to escape from. As he begins to abstain from his addiction he feels bad – but he is doing well. In fact the negative hedonic state of bad feelings the addict encounters as the consequence of suspending his addiction is the very first step in the direction of health and normalcy. For the first time in what is often a very long time his bad feelings have a natural and ultimately healthy origin: his mind and brain are attempting to re-establish their own autonomous equilibrium after the withdrawal of the artificial external mood changers that his addiction has relied upon to manage his hedonic condition. All that is necessary in many cases is for the addict to abstain from his addiction long enough to permit his own resources to begin to take over again. Given sufficient time –usually to be measured in months rather than days or weeks- the natural resilience of the nervous system "works through" whatever abnormal changes or deficits resulted from the prolonged artificial mood regulation of addiction and restores the abstinent addict to his pre-existing, pre-addictive status.
Old 08-13-2003, 02:51 PM
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Morning Glory
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Yet many times this pre-addictive status itself may be an abnormal one, in fact a condition of dampened or diminished mood and pleasure-capacity that may be a precursor of the florid addictive disease that later breaks out as a consequence of the addict’s often unwitting efforts to repair his pre-addictive condition by means of drugs or other behaviors that make him feel better. For in the last analysis, addiction is nothing but a miscarried and often tragic attempt on the part of an individual who does not feel good to feel better.

The newly abstinent and recovering addict therefore is frequently in a kind of hedonic "double jeopardy." For the discontinuation of an addiction always involves "payback time" as the individual’s own internal regulatory systems struggle to get back on line; and the addict’s "normal" pre-addictive state may itself have been significantly impaired – in fact, one of the reasons he was ensnared in the addictive cycle to begin with.

The exact causes of the future addict’s pre-existing abnormal hedonic state –a state of not feeling good- are seldom known with any precision. Most likely a combination of "Nature"(the inborn physical constitution) and "Nurture"(environmental and life experiences beginning at birth) are responsible.

The interaction between Nature and Nurture can be subtle and bi-directional: an infant that was born with a hedonically compromised nervous system may be unusually fussy or less emotionally responsive than average, behavioral qualities that in turn may elicit differing responses from its caretakers and, when older, peers. An almost infinite series of combinations and permutations is possible depending upon individual factors and circumstances. Simple answers in this complex area are frequently misleading.

In fact, thanks to the peculiar emphasis of much traditional thinking about mental health upon origins rather than remedies, even the questions themselves are frequently beside the point. Not "where did this difficulty originally come from?" but "how can it be changed for the better?" is the more pragmatic and usually the more productive question to ask in regard to human beings and their vicissitudes. For in addiction, perhaps more than in any other area of abnormal human behavior, insight is not enough. At best, insight provides a pretext and an inspiration to proceed with the actual behavioral changes required for recovery from addiction. But insight is not really required, at least in the beginning.

All that is usually required for recovery to commence is willingness to perform the necessary work – even if that willingness is partial, incomplete or coerced. As long as the work gets done, the recovery has a chance to begin. In the optimum case both insight and motivation develop later on - as a consequence of the original, frequently grudging spadework of early recovery. "Begin recovery first," the motto here might be, "and ask questions afterwards." Failure to acquire the motivation for sustained recovery and at least a minimum amount of insight may of course predispose the individual to later relapse after a promising beginning. But first there must be a beginning, however it is brought about. And at this stage of things, one method seems to be about as good as another – though those that are most dramatic, painful and undeniable, as well as those with still imminent and even more dreadful consequences if the addiction continues seem to yield the most initial impetus and momentum to the early recovery process.

Although abstinence from the addictive substance or process is the sine qua non of a lasting recovery from addiction, experience with addicted individuals shows plainly that abstinence alone is often not enough. For although a certain number of addicted people do succeed by simply giving up their addiction, a large number do not. What happens to them is reminiscent of Mark Twain’s famous remark about smoking: "It’s easy to quit – I’ve done it a hundred times!" Such individuals stop their addictive behavior, hold on by their fingernails for a while, and then relapse – sometimes with extra added momentum from the negative energy of their "deprivation." This familiar addictive cycle causes shame, guilt, despair, disgust, hopelessness and helplessness both in the addict and those who are affected by his addiction.

Sustained recovery from a well-established addictive disorder requires a major realignment of the psyche away from the artificial, unnatural and over-specialized dependence upon a substance or process for hedonic management, and towards a more natural, environmentally-attuned and above all flexible responsivity to internal and external stimuli. Instead of manipulating his mood and feeling state by the artificial means of chemicals that are completely unrelated to what is actually going on within and around the individual, the recovering addict gradually and often painfully learns to operate on his own resources. And because his own resources are many times inadequate for satisfactory mood and hedonic control, he must also acquire new methods of cultivating good feelings and avoiding bad ones.

The fellowship, interpersonal and social learning, and the spiritual and cognitive resources of 12 Step and other recovery programs can be of enormous assistance in helping the recovering addict to learn such new coping strategies. A kind of Catch-22 frequently develops here, however: many addicts are so impaired in their capacity to take care of themselves and manage their moods in a healthy fashion that even participating in an interpersonal recovery program may initially be beyond their resources. Thus it is often quite a challenge and stress for them merely to begin regular attendance at helpful support meetings – and many people who might benefit substantially from such meetings simply avoid them, offering as excuses for doing so a variety of familiar and predictable rationalizations. The characteristic addictive response is along the lines of "I’d rather do it by myself," an attitude that itself signals what is usually a longstanding difficulty in recognizing the need for help and in being able to request and accept it when it is in the best interest of the individual to do so.

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