Thursday, July 17, 2008


The area of addiction and substance abuse is challenging for me.

One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.

The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so

One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.

I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.

Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.

In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.

Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.

One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).

Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.

There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.

A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:


Anonymous said...

"The communicative power of metaphors: an analysis and interpretation of metaphors in accounts of the experience of addiction."


Anonymous said...

Can you elaborate on your first sentence.

GK said...

I believe that active addictions prevent other forms of therapy from being effective (e.g. medications, various types of psychotherapy, etc.). Sometimes, dwelling on these other types of therapy can be "enabling" with respect to the addiction, in that they delay a focus on a core problem, while (because of the addictions swamping out their benefits) not being very helpful in themselves.

Therapeutic progress is metaphorically similar to building a new structure, perhaps like a carpenter (the patient) building a new home, with wood, nails, concrete, etc. (Here the therapist could be like an adviser or assistant). Addictive behaviours are like having your new structure be cut or burned down every few days or weeks, or having your carpentry team deprived of food. It dampens the morale involved in continuing the construction project, and leads to repeatedly having to start from scratch. It may foster the belief that it is not really possible to construct the home.

So, as a therapist, it is hard to commence therapeutic work without having a clear plan around ending addictions. If there is no plan around the addictions, I don't believe this is sound therapy, in the same way that it would not be a sound construction plan to continue on building without finding ways to prevent your structure from being torn down in the middle of your work. In fact, such a therapeutic plan could become part of the addictive cycle rather than part of the cure (addictive forces in the mind seem to love it when a new structure is toppled town).

I guess part of the good news, for me, is to learn more about addictions medicine, to know that addictive problems are just as solvable as anything else; but we must never underestimate the difficulty and challenge involved.