Author: Marc

This video was sent to me by Shaun Shelly, a frequent contributor to this blog. It conveys how a well-practiced “mind set” can end up being so much more than a momentary wrong turn. It can be an inescapable ride on a vehicle that’s about to crash. And it can have a vast nonverbal dimension that is entirely  invisible. Like an iceberg, most of its mass is probably below the surface.

I’m talking about addiction, of course. We want to understand how we can shift from one “you” to the other “you.” That was the theme of my post a couple of weeks ago. But the craving self is so thoroughly sculpted in brain tissue, so overpowering in the moment, that it’s difficult if not impossible to just shift out of it. We want to turn it off like a buzzing light bulb, and we keep flicking the switch, and nothing happens. You can’t switch it off because it is a stable, learned pattern that arises in mind and brain whenever drugs or booze are present.

Okay, so watch the video, then we’ll talk. (The creator, whose name sounds like “Destin,” comes across pretty manic, but don’t let that stop you.)

Destin has learned a pattern of motor responses triggered by the sensory information that comes from getting on and riding a bike. As have most of us. The trouble is….it’s the wrong pattern for his particular bike. Every time he tries to ride, the sensory information (feel of the handle bars, changes in the visual field with motion, tilting of the bike with gravity) triggers his well-learned motor response pattern — without his say-so. Even his intense cognitive efforts can’t change it: “Knowledge is not understanding.”

But it’s the “wrong” pattern. So he continues to fall.

There are a few places we can go with this.

(We could consider his weird bike to be analogous to addiction…..In which case we’d say it took him a long time to  get addicted — and once he got it, he found it hard to unlearn. He finally manages it 6 minutes into the clip.)

But let’s keep it simple. Let’s imagine that the way he learned to ride a normal bike all those years is like learning an addictive mental habit. It became ingrained. When he wanted to shuck that habit, he couldn’t. It was too well learned.

For Destin and for addicts, the ingrained habit comes to life in a matter of moments. The cues for the bike rider are the sensory inputs I mentioned above. For the addict as well, sensory inputs can be hazardous. That’s why you don’t drive past the liquor store or chat on the phone with your former dope partner if you’re serious about staying abstinent. But addicts don’t need to experience that inflow of sensory information. All they have to do is bring the image to mind. Remember how great it felt, fondle that memory, taste it, and then the craving explodes to the surface.

We could consider how anxiety itself amplifies the cascade that leads to the fall for Destin — how the first glimmer of imbalance is enough to propel the motor movements that will rapidly defeat him. Not much different from addiction at all. To paraphrase Frank Herbert’s Dune, anxiety is the mind-killer.

What holds the pattern so firmly in place for the bike rider is the urgency of turning the handlebars to offset the first hint of imbalance. That urgency is the middleman that sends the messages to the muscles…turn the handlebars this way, which is sure to complete the disaster. For addicts, what holds the pattern in place is also urgency — but it’s entirely mental, not physical (except in the case of physical withdrawal symptoms). The addict doesn’t need physical uncertainty to propel the wrong moves, just emotional uncertainly, which accelerates to urgency, which rapidly calls up habitual responses: I want it, yes, I really do, just this one time, I deserve it, I’m going to do it, and it’ll be all right.

In addiction, the urgency, craving, desire, whatever you want to call it, is the psychological product of dopamine flooding particular synapses in the striatum. But I’ve told that story elsewhere. For now, what’s most important is that, once the habitual pattern arises on each occasion, two things happen:

1. We are lost, at least this time around, we’re going to fall — unless we’re really clever and we’ve already been practicing bail-out techniques.
2. The pattern, having overtaken our nervous system yet again, is reinforced in our synapses, and thus more likely to arise in the future.

There’s one more point that I hope you’ve noticed: Destin finally did learn to take control of his riding pattern, to rid himself of the habitual response set that led inevitably to a crash. But it took practice! Five minutes a day, for eight months! The moral is simple: well-learned brain algorithms need not be permanent. You can change them, especially if they’re not working for you. But it takes time and it takes practice.

When I said I wanted to move further into the psychology of addiction, I didn’t mean I was about to forget the brain. The subtleties of your thoughts and the cellular activities of your brain might seem like different planets, impossible to gaze at simultaneously. Yet both are going on at exactly the same time in exactly the same place.

Addiction is usually characterized by two psychological states: craving and loss of control. But when we look very closely at the flow of time leading to each occasion of using (or drinking, or whatever it is), there seems to be a blurring of the two. Giving in (loss of control) starts to look like a well-worn path, initiated by craving. Can we reconceptualize the relationship between craving and giving in? So that it makes sense? — at least more sense than the notion of falling through a trap door that was bolted shut? What if craving and surrendering are not two processes but one? Just a single time-line, a building momentum, leading from a state of determined abstinence to a headlong plunge?

Imagine that you can be two different people. That’s not such an absurd idea. It’s been around in psychoanalysis for a century, and even the cognitive science of the last three decades finds it reasonable. Not multiple personalities, but something subtler. The you that screams for vengeance when your favourite player gets tripped from behind and the you that turns off the TV and tucks your kid into bed can easily be seen as two distinct yous. So let’s imagine that the you who anticipates how wonderful it will feel to get high is simply a different you than the one that knows that’s insanely stupid.

Of course this isn’t an original idea in addiction studies. Twelve-step fellowships continue to broadcast warnings that your addiction is waiting to get you, doing push-ups in the parking lot, and even the more contemporary cognitive-motivational tactics of SMART Recovery might counsel you to ignore the addict voice — as though it weren’t your own voice at all.

So let’s think about the two yous differently, by aligning the psychology of wanting versus abstaining with two distinct brain states. That’s not difficult. When we anticipate getting high with excitement and attraction, the striatum, which is the part of the brain that initiates goal pursuit and powers it with desire, is strongly connected to the orbitofrontal cortex (OFC), a region of the prefrontal cortex on the border of the “limbic system” that encodes the value of things — good things like a friend’s smile and bad things like sour milk. The striatum and OFC are quickly linked (an “orbitostriatal” bond is formed) in anticipation of a valued outcome, and that’s when you become the child, yearning, anticipating, and falling forward into the treasure trove at your feet.

But what happened to self-control? A much smarter part of the brain — called the dorsolateral prefrontal cortex — often oversees the impulses generated by your striatum. The dorsolateral PFC is where judgments are formed by comparing possible outcomes and making conscious decisions. We can call the dorsolateral PFC the “bridge of the ship.” Its job is to steer.

But addiction and other impulsive acts are accompanied by a “loss in functional connectivity” between the orbitostriatal alliance and the bridge of the neural ship. A loss of connectivity simply means that activity (measured by an fMRI brain scan) in one region becomes less correlated with activity in the other region. This disconnect is exactly what is observed in addiction. When pictures of drug paraphernalia are flashed on a screen, addicts show a surge of activity in the orbitostriatal region and reduced activity in the dorsolateral PFC. Some studies show this disconnect to become more severe with the length of the addiction. Other studies show the same disconnect when “normal” people surrender to tempting (but dumb) impulses. The disconnect is real. And when it happens, you become the unfettered, unconstrained child.

Craving is simply desiring what feels attractive, and surrender is the natural order of things when desire is unconstrained.

So you get high, you start drinking, you click on a tried-and-true porn site or you call that forbidden phone number. An hour later you are bored and you know you didn’t get what you wanted. Two hours later the regrets pile up like unanswered mail. Three hours later (if it takes that long) the child’s excitement is replaced by self-reproach, recrimination, and perhaps a determined commitment to never do it again. You are no longer thinking or feeling the way you were a short time ago; your values have locked in again. And your brain is no longer functioning the way it was functioning a short time ago. The orbitofrontal cortex (occupied now with something like sour milk) is reconnected with the dorsolateral PFC, its overseer. Because desire is now just a memory, an empty husk. With desire slaked, no matter how unsatisfactorily, your brain changes back again. It’s just the way it works.

Let’s say you’d been abstinent for weeks, maybe months. How could you have done something so stupid? Again?!

The answer is simple: it was a different you.

Hi all. I’ve taken a little break from blogging. The final send-off of my book manuscript gave me a chance to catch up with email, reading, and some other writing projects. I even sneaked in a novel. It’s called The Humans, by Matt Haig. I picked it up at an airport bookstore on my way to Budapest, where I gave a talk at the International Conference on Behavioral Addictions. Beautiful city, great conference, and a really engaging novel: it’s about an alien who comes to earth on a mission to kill a math professor whose discovery threatens the entire universe. Humans might now acquire the technological capabilities to wreak havoc on a cosmic scale. But against his better judgement, he actually learns to like us, and before long he wants to be one of us. Sweet, funny, and often wise.

Anyway, I’ve thought about where I want to go next in blogging. I want to move on. Through this blog and my writing, I’ve arrived at a place in my own understanding of addiction which I think covers the basics, so to speak: the neural, psychological, and experiential elements that converge in addiction. I’ve shared all this with you: the neuropsychological basis of craving, the cycle of seeking and losing that accelerates learning, the narrowing window of desire and attention and its biological foundation in the dopamine system, the critical importance of self-narrative, of connecting desire with a self-defined future rather than remaining stuck in the present. And all the rest of it.

This leaves me with the sense of having built a good solid foundation for a model that makes addiction comprehensible without shovelling it into a pat category — like disease, or choice for that matter — and filing it away for the experts to dissect.

But there’s a lot farther to go. I want to build more floors onto this model. I want to make it as big, comprehensive, articulate, balanced, and realistic as possible, using the tools I know: psychology, neuroscience, others’ experience, and my own self-honesty.

I think the next level has to do with the way we talk to ourselves — the running dialogue or monologue through which we organize our thoughts and orchestrate our feelings. The hells and heavens we create for ourselves in imagination and reality. We all know that drugs and other addictive substances and acts can have tremendous appeal, or they can feel like relentless attackers. We sometimes pursue them even while we revile them, and sometimes we shun them even when they call to us in their sweetest voices. Our ruminations, our internal rebellions against real and imagined authorities, our construction of plans, limits, goals, and rules all have a great deal to do with whether, when, and how we pursue these angel-demon entities. Whether we remain addicted or break free.

I think these psychological processes are critically important for understanding addiction in a more detailed, more intimate, and more realistic way. And I think we can access them, bring them into the daylight of examination, and work with them — in ourselves, our loved ones, or our clients — in order to gain mastery over addiction.

So that’s where I want to go and I want to bring you with me. We learn a lot from each other. We’ve graduated from Kindergarten; now let’s move on.

Those of you who remember record players probably recall the infamous “broken record” — which kept repeating the same sounds over and over. Maybe that’s me, but I thought I’d share a few more words of thanks. I finally finished editing the copy-edited manuscript of my book, a horrific chore that took three weeks, nearly full time. Now the book is really, really, really finished — entirely in the hands of the publishers And my last task was to compose the dedication, which goes at the front, and the Acknowledgements, which go at the end. Here they are…

Dedication

For the members of my blog community, who have generously shared their experiences and insights, and for the five who trusted me to tell their stories here.

Acknowledgements

After writing a book about my own passage through addiction, I needed to learn what my experiences had in common with those of others. So I began a regular blog that attracted a bright, boisterous, and empathic community populated by former and recovering addicts. The many comments following my posts and the guest posts contributed by members provided a wealth of insights and information that I could not have hoped to find elsewhere. I want to thank each and every one of the people who’ve engaged in this conversation with me. You inspired me to write the present book, and you helped me understand addiction well enough to feel I could make a worthwhile contribution.

The five former addicts whose stories I tell deserve the gratitude of everyone attempting to comprehend addiction by combining private experience with other forms of knowledge. The people who volunteered for this project donated many hours to respond to my questions, and they did so with unstinting energy and honesty, dredging up details from experiences they might have preferred to forget. When wearing my interviewer’s hat, I often felt like a dentist drilling deeply, painfully, until I unearthed every chunk of my respondent’s past. They bore up bravely, shining the beam of self-examination wherever I asked them to look. I am deeply grateful.

Lisa Kaufman, my editor at PublicAffairs, helped me upgrade my understanding of the rehab world, past and present, until I’d acquired the perspective I needed to portray it sensitively and accurately. But I’m most grateful to Lisa for encouraging me to follow the implications of my own model from theoretical abstractions to concrete directions for practice. She convinced me that, for many readers, that’s where the book had to land. And she was right.

Tim Rostron, my editor at Doubleday Canada, has now been my writing guru through two books, and I continue to celebrate my good fortune. Tim’s mastery of the deep and subtle currents of English and his dedication to transparency and flow have nursed my growth from scientist to writer.

I benefited hugely from the seasoned perspective of two unpaid editors, Matt Robert and Cathy O’Connor. As a pioneer in the rehab community and a sparkling commentator on current trends, Matt took me behind the scenes of the rehab/recovery world. He read most if not all of these chapters, showed me what I was missing in both form and substance, and helped me smooth out terms and concepts that might otherwise get caught in the reader’s throat. Cathy generously dipped into her editorial talents to guide me through the no-man’s-land between what I thought I was explaining clearly and what readers were likely to grasp. There were jagged craters everywhere, most in places I would not have checked. Cathy pointed them out with patience and precision and helped me figure out how to fill them. I am so very grateful to both of you.

Other treatment experts came to my aid. I am particularly indebted to Shaun Shelly, who kept pace with every conceptual step I took, in the book and in the blog, and harvested examples to help support our shared understanding of addiction. And my thanks to Peter Sheath, who spearheaded the Birmingham Model described in the last chapter and infected me with the courage, creativity, and optimism he has brought to the treatment world. [Both of these men have been frequent contributors to this blog.]

My most generous and dependable editor remains Isabela Granic, my partner for eighteen years. Your steady supply of gist was the mortar by which my details could cohere and settle. You continued pointing me toward what I’m good at and reminding me of its worth. And you stoked the fires whenever I got discouraged or just tired. This book could not have existed without you.

Finally, Ruben and Julian, thank you for letting me work all those hours when I should have been playing with you. Ruben, thanks for adjusting my chair. Julian, thanks for the cuddles. I’ll try to make it up to you both now that the book is finished.

To Matt, Shaun, Peter, my five interviewees, and all the rest of you — Thank You!

…by Peter Sheath (lightly edited by Marc)…

Here is a more detailed account of the community-wide treatment approach being implemented in Birmingham. Thanks very much to Peter for stepping up to the plate. Note that this post is a response to the questions and concerns raised by blog members following my last post.

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I’m pretty much overwhelmed by your positive messages and support. It’s taken some time to get to this point. Now we are about to take the quantum leap of helping people begin to deal with addiction problems within their community — as a community. The program has much in common with policies implemented in Portugal, where there have been dramatic reductions in almost everything negative associated with drugs. If it works, and many of us firmly believe it will, it will be a real game changer for the way we approach health care in general. It will help move us away from the “deficits approach” — needing an “expert” for just about every problem we encounter within our societies — to a more co-productive community-based “expert by experience” model, whereby people can take responsibility for resolving their own problems.

Jasmine makes some great points, and we have thought long and hard about almost every one of them. The only one I don’t get is her query, “how the heck could this not create a sense of stigma, othering, and sense of hierarchy?” Much of the model is already happening in a very informal way all across Birmingham.     The city is probably the most diverse city in the UK, with lots of communities where English isn’t the first language — communities that just wouldn’t dream of looking for outside help. Part of my role has been to find out what goes on in these communities, how they deal with addiction, and if there’s anything we (ROR) can do to help. Most of the time all I’ve found are very dedicated people doing it for themselves, having developed some astonishing networks involving community elders and local businesses. Far from stigmatizing addiction, these networks have served to normalize it and, in many ways, make it the responsibility of the community.

Note that the start date of our project is March 3, and the leaflet that Jasmine is referring to is intended for interested parties, professionals and commissioners. Once we launch, we intend to consult with service users to develop a pamphlet that’s both user friendly and accurate.

Most of the people we will be working with are already engaged with community resources on a daily basis. Nearly 5000 are in receipt of opiate substitute prescribed medications, which they pick up most days of the week from a community pharmacy, and around another 1000 are accessing the various needle exchanges delivered by community venues. Most people with alcohol problems presently go to either their general practitioner or a community pharmacist as a first point of contact. But most of those professionals have little or no support, supervision and/or training, so they simply refer them on to the alcohol team. That usually causes further delay in getting the necessary help — a problem that could have been resolved at first point of contact.

We have gone to great lengths to ensure that professional help, when needed, is easily accessible and readily available. Clinicians, keyworkers, and structured group activities are never more than a short bus ride away and available within community centres, libraries, etc. The ROR outlets, pharmacies, retail premises, eventually taxi drivers, and many other participants will know exactly where and at what time help is available. All sorts of on-line/telehealth support will be available as backup. We are hoping that, as the community develops and community champions come forward, professionals can begin to focus on people with complex issues and those who have become dependent on the treatment system for years. Anyway, as you can no doubt imagine, I have work to do, please watch this space for further updates.

Thank you very much, Richard, for your support. I agree with everything you’ve said, and your words resonate with my experience, both as a person who couldn’t deal with life without substances and as a person who has dedicated his life to try to make things better. I believe the answer lies just where it always has, in the community. We, the treatment industry, have in many ways created a monster: we have persuaded people that they are sick and they need professional help to get better. Just as the great Bruce Alexander, Carl Hart and Marc have been saying, addiction is what happens when people try to soothe away things like dislocation, marginalization, poverty, and dissatisfaction. Yet these come about because of the systems or communities people come from. If we create an environment where communities can begin to heal themselves and their members can take responsibility for each other, then maybe change can happen. Up until now, focusing on individuals, isolating them, and treating them as sick has not taken us where we need to go.