Category: Connect

Hello all. I have to admit I’m becoming addicted (again!) — this time to addiction memoirs. I’ve read four in the last four months, all written by alcoholics:

Drinking: A Love Story — Caroline Knapp.

Drunk Mom — Jowita Bydlowska.

Drunkard: A Hard-Drinking Life — Neil Steinberg.

The Couch of Willingness — Michael Pond & Maureen Palmer.

I’m still finishing the last two. I pick them up in my spare time, packed up on my Kindle for train rides and class breaks, or late at night when I’ve got time to myself. I really like them. I find them delightful, suspenseful, fascinating, epochal, and redemptive — redemption seems to be a big word in this genre.

But really, why do I like them so much? First, I’ve written one of my own. I know how the story goes from inside out. Second…okay, let me reconsider the list of adjectives I just used:

Delightful. Really? These are without exception intimate portrayals of people who are living horrific lives, cutting out hunks of flesh and soul without knowing how to stop, committing reprehensible acts and then choking on shame, guilt, and remorse. Why is that delightful?

Suspenseful. I already know that they are going to keep drinking until they finally quit. And then they’re going to feel better. Where’s the suspense?

Fascinating. Ditto. The stories are remarkably similar, as though they are simply variations on a theme — sitcom formulas. I mean, right down to the details. They hide bottles all over the house. They get rid of empty bottles in the neighbours’ trash cans. They feel embarrassed going back to the same liquor store day after day. Then they go to another store. How is this fascinating?

Epochal. That’s a word used to describe Greek myths, classic tragedies, and so forth. These folks just get drunk a lot. How epochal is that?

Redemptive. Well, they do finally quit. (I’m still not sure about Neil Steinberg, having not gotten to the end. But I’d be surprised if he didn’t). But “redemption” seems like a pretty strong word for finally behaving in your own best interests rather than continuing to torment yourself and everyone around you.

 

So here are my best guesses at why those words came to mind:

Delightful. They are such human beings. Such an unpredictable, ever-changing mixture of strengths, weaknesses, suffering, defeat, pride, shame, and even humour. A fair bit of humour in the last three for sure. Because you have to laugh if you’re not going to cry. Or at least get some of each. These memoirs epitomize the complexities and virtues of humans facing and eventually overcoming astonishing challenges.

Suspenseful. When are you going to quit?! How are you going to do it?! You have tried so many times without success (often), I just can’t see how you’re going to pull it off, and I’m waiting for it with every page turned.

Fascinating. See “delightful”. But let me add that these are war stories, dramas, tragedies, and they describe unimaginable extremes of human desperation, depravity, creative problem-solving, and determination. So you really held an airplane bottle of vodka to one nostril, blocking the other, to inhale the fumes?  Snorting booze? You poured your wine into baby bottles as camouflage? You really grabbed that bottle off the bar counter while the bartender turned her back? Unbelievable!

Epochal. But they really are epochs. Each and every one. Just as Shakespeare’s tragedies all followed the same formula, and yet each came across as unique, profound, one of a kind. Each one (at least each good one) carries us effortlessly along classic story lines constructed from the basic components of suffering, self-deception, and the inexplicable capacity — the heroic capacity — to come back from the jaws of defeat with your dukes up. Or to reshape your personality until that becomes possible. Addiction memoirs seem an obvious extension of classical drama into our modern age.

Redemptive. Well, what is redemption, anyway? I think it must presuppose the idea of sin, moral failing, finally overcome through some sort of penance that one endures voluntarily to become clean or whole once again. In his recent book, Lance Dodes mentions this assumption as built into the AA-inspired notion that you have to hit bottom before you’re ready to quit. But very often, you do. People fight like crazy to quit. And the most agonizing part of that fight is turning your back on the one thing that provided relief, support, and comfort. As Steinberg puts it, “attending the autopsy of someone you love.” That’s pretty damn courageous.

 

Addiction memoirs seem to tell the same tortuous story, often starting in the same place and ending in the same place, but with the incredible diversity, the unexpected creativity and novelty, the unanticipated twists and turns, partial victories, temporary failures, redoubts and stupidly courageous counterattacks, that derive from being one of an infinite variety of suffering humans. We are so different. And though addiction pulls us through roughly the same line-up of torture instruments, like those tours you can take through torture chambers in medieval castles — adults, 18 euros; kids, 8 euros — it does so in ways that never cease to surprise me, mesmerize me, and make me proud.

 

Here’s most of an email I recently received:

 
> Subject: why does the addiction resurface when we least expect?
> Marc,
>
> I really enjoyed your memoir. In so many ways I feel I can relate….
>
> So… Here’s my question…
>
> Why, after being sober for 7-months, did my craving for alcohol become
> that much more intense? Gave up alcohol in August 2013… Started
> drinking again in February 2014… It’s like….. thought I was on my
> way toward a happy peaceful sober life, and then, BAM! Drinking more
> and in ways that I see are perhaps more self-destructive?
>
>
> What’s up with me?

 

Here’s most of my reply:

Hi  _____, Thanks for your note. I find it thought provoking, and really very moving, partly because I had similar experiences when I was taking drugs. Also, your note goaded me into writing this long-overdue post.

This is what happened to me: In 1979 or so, after several years of struggling to abstain and remain abstinent, I finally quit “successfully” for a few months, and then BAM! — I fell back in. Just as you describe. I had quit taking any and all opiates in late December, at the same time as extricating myself from an extremely painful marriage — many strings, much guilt — and making binding promises to myself. Now I was living in my own apartment, I’d given up trying to influence my wife’s state of mind, I was getting good grades in my first year (of graduate psychology), and I was thoroughly delighted to be “unhooked” physically and, so it seemed, psychologically.

Then I went to a party at someone’s home in April, about four months later. I went to the bathroom to pee, and while standing in front of the sink I impulsively opened the medicine chest. And there, staring me in the face, was a large-size bottle of Tussionex — about 1/4 used up, so…. ideal for taking a few sizable gulps without anyone being the wiser. (Tussionex is a cough medicine whose main ingredient is hydrocodone.) Soon after that night, I began using again regularly, and breaking into medical offices again regularly. I guess I was so upset with myself for ending my fast that…well you know how that one goes. Then, one night, three months after that, I climbed out of the basement window of an enormous medical centre, my pockets stuffed with drugs and needles, and walked directly into the waiting arms of several officers of the law. Ironically, I was working as a psychology intern at the time. In other words, I was supposed to be one of the healthy ones. Six weeks later I was given a suspended sentence. But far worse than that, I was kicked out of graduate school, essentially black-listed from all psych departments in Canada, at least for a few years, and I ended up washing windows and house painting to make ends meet.

So what goes on when we are sailing, in the clear for months, and then BAM! — we suddenly find ourselves in the throes of our addiction, as bad or worse than ever?

I figure the two most important brain changes that go with addiction are (1) the rewiring of the striatum, from ventral (nucleus accumbens) to dorsal striatum, and (2) the rewiring of prefrontal areas responsible for self-control, decision making, and so forth. The striatal change takes drug-seeking from an impulse to a compulsion, so that the behaviours we engage in to get/take substances or engage in other addictive acts become at least partly automatic. This is an example of classical (Pavlovian, i.e., stimulus-response, i.e., S-R) conditioning. Stimulus now leads directly to response. The prefrontal change blunts our capacity to think flexibly and switch goals as needed, so that addictive goal-seeking is no longer harnessed by cognitive control.

If those two brain changes are central to addiction, then ongoing brain changes in both systems — essentially in the opposite direction — are probably central to recovery. We recover some cognitive control, and those prefrontal networks become more efficient once more, but slowly, and mostly because we work on it like hell. We practice cognitive control daily, and thereby awaken the synapses that got too sleepy. In fact, a study I recently reviewed on my blog shows that we grow extra synapses in cognitive control areas after several months of abstinence. These function like a suit of armour that protects us from addictive impulses….until the automatic S-R response finally weakens.

But here’s the problem: On any given occasion, the cognitive control network is slower to power up than the impulsive/compulsive network, and this is especially true while the cognitive control network is still being “tuned up” (so to speak) during the recovery phase. So the synapses in the striatum and its close neighbour, the amygdala, get activated extremely rapidly by drug cues — even during recovery — compared to the prefrontal control networks. Approximately one-fifth to half a second faster (my speculation based on EEG findings). So these “control” networks (which Kahneman refers to as System 2) are not only intrinscally slower to begin with, they’re even slower (and more deliberate) than usual because they’ve gotten rusty with disuse.

So when I opened that medicine chest, my slow deliberative control mechanisms did not have a chance to act BEFORE the rapid, automatic, Pavlovian-style response took effect — as soon as I saw that bottle. Stimulus = Tussionex. Response = Grab and drink. Reflective self-control doesn’t even power up until half a second after the sight of the bottle. And that’s another important point:  action tendencies break off and have a life of their own. My whole brain was already set into a response mode (triggered by the stimulus) that was extremely hard to interrupt once it got started. All those striatal synapses were already singing in choral unison: “fuck it”, “just do it”, “I have to get this inside me”, “do it now before anyone (including myself) can stop me”. Those synapses were still functioning as a coherent, efficient network — the net result of all those yeas of addiction.

I don’t know if this explanation works for you. You mention increased craving. But that could be a sort of byproduct. I’d say that many people slip because they’ve let down their guard, they’ve stopped concentrating very hard on beating back those action tendencies (and maybe even imagined they could experiment a bit) — simply because they’ve been sober long enough to believe they’re out of danger — at a time when they actually need extra effort while cognitive control networks are just beginning to blossom again. They figure they’re safe. They open up medicine chests on a whim, or sip a glass of bubbly at an office party. And, as you say, BAM! Down you go again. And this ride really is more self-destructive than the last, because you are terribly angry at yourself for letting it happen. What an ideal time for a self-destructive feast!

 

 

In the comment section following the last post, a fruitful dialogue sprang up between Matt (the author of the post) and Cheryl, a reader. In a comment following his post, Matt admonished us (addicts, ex and otherwise) to remain aware of our vulnerabilities (like fluctuating willpower, loss of perspective), to not get too cocky, to continue to remind ourselves that we still think and feel and even act like an addict. Cheryl’s response was a sort of call to arms in the other direction — an invitation to shut down the voices of self-doubt and take stock of our strengths instead. To trust in those strengths, to dive into that pool of self-trust without looking back. These approaches to recovery sound almost diametrically opposed. Yet it seems to me there is  some crucial truth in the space between (or stretching to include) both of them. In fact, this could be one of those magical tensions. Like wave-particle duality, or the impossibility of life without death, or the fact that humans are both totally selfish and totally altruistic — the kind of tension that gets you thinking more deeply about a topic than any one perspective ever could.

The sort of self-trust that Cheryl mentions is, I think, similar to what I was trying to emphasize in several posts, including this one, nearly a year ago. I was pointing to a special kind of power in self-trust that turns up its nose at the reminders of past failures, to the shame and guilt that go with them, and to the moralistic (and sometimes, hate to say it, but realistic)  judgements of others, those judgements that bounce round and round inside our minds in self-defeating rumination. That kind of total self-trust is a lot like hope, in that it’s at least partly irrational, maybe even deluded in the grand scheme of things, but absolutely essential to moving forward, potently, effectively, without looking back, eradicating that massive tangle of self-defeating habits in one giant twist rather than a bunch of little adjustments.

And yet — hey, we’re not idiots! — after what we’ve been through (i.e., addiction) we’ve learned a thing or two. We know the value of staying on top of the little things, continuing to evaluate just how vulnerable we might be in certain contexts (like the aftermath of rejection or loss, driving past a particular neighborhood) and situations (like parties, especially when things get a little late) where the dangers lurk. Even little dangers, because they can easily blow up into big dangers. We’ve learned to remain cautious so that we can avoid those dangers before they spring up in front of us. Like a dog suddenly caught in the headlights of a speeding car, it’s too late for the dog, given that we didn’t start slowing down half a block away. This view has a lot in common with the concept of “self-programming” that I got into a few posts ago, and that Jeff Skinner and Shaun Shelly have also remarked on in different ways.

I quote my esteemed self from that post:

Proximal intentions don’t matter. By the time you are getting close to the point of action, the dye is already cast. Setting up intentions in advance is called “self-programming” by [a philosopher named…] Slors, and I think that’s a great name for it. You are indeed programming your own future, by changing contingencies, determining circumstances, setting up non-negotiable outcomes. You are programming your life, and your brain, and your environment…

As Matt says, it is really crucial to stay ahead of the game, i.e., to adjust your speed, or pick a different route, before you hit the dog, before the urge (and/or the opportunity) to use is staring you right in the face.

Come to think of it, both those strategies — total self-trust and vigilant self-monitoring — so seemingly opposite, are resolutions to the fundamental problem of delay discounting…or to put it more colorfully, the problem of being stuck in our over-the-top attraction to the IMMEDIATE FUTURE, at the expense of long-term contentment. If you’ve followed this blog, you might remember how I went on about the role of dopamine — which geysers in our nucleus accumbens when addictive “rewards” become present, possible, available. I claimed that an unfortunate side-effect of dopamine is to exaggerate the (perceived) value of immediate rewards (e.g., a few lines of coke in half an hour; a chocolate cheese cake for dessert) while “discounting” the importance of future outcomes (e.g., being broke, fat, and/or increasingly addicted).

So….isn’t that cool? These opposites — whose tension feels creative, productive, maybe even necessary — are both good answers to the same question: how do you free yourself from the fierce and unpredictable tug of the immediate future? Do you trust yourself and thereby project yourself directly into the future you really want, or do you slow down and turn up the vigilance dial by remaining painfully aware of your past?

I could try to collapse this tension by saying something like: trust yourself to be exactly as cautious as you need to be… But some tensions are more creative when left alone.

Here’s another guest post, and it’s a winner. Sincere thanks to Matt Robert, a  SMART Recovery facilitator I met last June in Boston….

 

I’ve been spending a lot of time these days going in and out of locked detox units. And it’s interesting because, in most important ways, they haven’t changed very much at all. But I’ve changed, and the reason for my going into them has changed as well. Now I go into them because I want to, and I leave because I can.  I go into them now to talk about recovery.

There is a particular flavor of desperation endemic to detoxes.  The atmosphere is rife with anger, self-loathing, guilt, shame and defeat. People seem to bounce around among acceptance, denial and hair-trigger reactivity, along with the emotions that trail behind all three. The writing is on the wall everywhere: that one is about to lose everything, and that the way to arrest this decline is clear. Yet alongside these realizations is the feeling that one cannot stop, that one must find again the solace the addiction once provided but is now decimating, one day at a time.

Into this mix come representatives from recovery programs, telling the patients definitively that they are powerless and that they have to accept that.  Or that “you are not powerless, you always have a choice.”  Both ideas, either taken together or separately, can pave the way to recovery. But when they’re presented as diametrically opposed approaches in a marketplace of recovery programs, they may do more harm than good. Especially in early recovery settings.

It’s confusing when someone who is struggling sees all this wrangling about what’s the best method.  And probably most proponents of a particular approach would admit, if pressed: not everything works for everyone.  In the wake of actor Philip Seymour Hoffman’s death of a heroin overdose, the New York Times convened a panel of experts for an Op-Ed piece entitled “What Is Addiction?” Their views: It’s a disease and needs to be treated as such. It’s a choice and legitimate options need to be made available. It’s a form of learning. It’s a lack of the spiritual development needed to build inner strength. Or…what?

The recovery enterprise is a classic example of humans being human.  “If it worked for me, it has to work for you.”  But it’s those in the early stages, in detoxes and other harsh settings, who will be most negatively affected by the unintentional arrogance of the well-meaning recovery groups whose method is the “only way” that works. And all the rhetoric about powerlessness, choice, and whether or not it’s a disease may be nothing but a distraction that serves to impede recovery, not bolster it.

In every recovery group there are hardliners who argue that their way is the only way.  But there are often others who use their chosen framework to meet people where they are.  Although some in SMART Recovery emphasize its difference from “non-scientific” methods, most recognize that everyone is an individual with a unique development, and background, and set of needs, and that the recovery that works best is the recovery that works best for ourselves–even if it’s not in SMART.  It will be different for everyone, and the journey to being free of one’s addictive behavior involves discovering the unique combination of things that work. There is no “one size fits all” in recovery.

The beauty of support groups is that they provide a safe place to work on recovery—in fact, many safe places.  There is now a great array of alternatives to choose from.  But as SMART Recovery founder Joe Gerstein said in a 2010 interview with the The Guardian, “the coercion of people into AA, SMART, or other support groups…is ethically wrong, medically wrong and psychologically wrong.” Not to mention pragmatically wrong.  And it is in early recovery where this coercion is most likely to happen.

If we could stand up on a mountain and look down at all the different recovery groups, we’d see that, although they differ in some obvious ways, they’re all aiming to do the same thing. Their objective is identical.  And that is to achieve and maintain sobriety. Period. Not to advance some treatment agenda, or get funding for research, or compete ideologically. It’s not that the exigencies of funding shortfalls are unimportant. Or that changing the attitudes of the powers that be is a trivial enterprise. Or that there is no merit in identifying a scientifically grounded road to recovery. But for the lonely person staring out a window on the locked ward of a detox, this contentious posturing is just a distraction from the dire situation at hand, and from the task of piecing together a recovery that works.

 

The following is a guest post, composed by Julia Hammid. I’m grateful to Julia for her thoughtful and sensitive reflections…..

Judging by the volume and intensity of the discussion around Harm Reduction (HR), both here and in many other venues, it seems to be a flashpoint for identifying some of the core issues driving policy, research and personal opinion in regards to addiction (even as the term addiction is still being defined). In the spirit of promoting an illuminating and productive conversation around addiction, recovery and treatment, here are some of my thoughts on HR. Just for the record, I am in favor of HR as a concept, though I may not agree with every version of how it’s provided.

So, why the brouhaha around HR? Doesn’t it just describe a broad variety of strategies to counteract the damage of addiction, short of complete abstinence? The question is not so much whether HR should exist. It’s going to exist no matter what we say. The question is whether or not we like it and support it. For example, we dispute whether the powers that be should fund programs that provide clean syringes, safe spaces to use, and even the (uncontaminated) substances themselves.  In my mind, HR includes a lot more. In fact, I would claim that most, if not all, recovery includes some form of HR, even if complete abstinence is the goal.

While addiction includes a vast array of substances and behaviors, abstinence can only be applied to selected substances, mostly illegal ones. How are we to define abstinence from addictions that are not measurable with a blood test? And even where abstinence is the only goal, where HR is most controversial, those who are abstinent from the identified substance often end up substituting or relying on (dare I say becoming addicted to?) other substances or behaviors, which fly under the radar. For instance, there’s a joke around AA about being addicted to the donuts and coffee that are ubiquitous at meetings.

I am not saying that addiction cannot be overcome or that one thing is always replaced by another or that any of the above is bad. I am just saying that I think, with few exceptions, recovery is always a continuum and always includes some form of HR, in the fullest sense of that term. More often than not, there is a period of shifting of dependence from the target bad thing to other less harmful (or simply legal and more easily obtained) things. Even seemingly positive things can be pursued with some of the same desperation that the original addiction carried, including socially approved addictions such as, coffee, sugar, TV, running, the internet, or even “dependence” on therapeutic treatment, religion, etc. I  know some people who are so immersed in their 12-step community that their whole lives revolve around meetings, the literature and the people they know in that community. I’m not saying that’s a bad thing. I’m just saying that it should be recognized as a form of HR.

To some, HR connotes state-supported addiction. But that is nothing like the actual goals of HR proponents. The controversy is kept alive by discrepancies such as these. In contrast, I think the word “abstinence” carries its own social and psychological baggage and may misrepresent what the opponents of HR are arguing for. Abstinence is not a term I personally find appealing. For me it connotes ascetic monks trying to rise above earthly existence by denying themselves much of what makes life worth living. Abstinence puts the focus on what one is not doing, rather than looking forward to what is truly worthwhile. In some ways, full blown addicts are abstinent from life, foregoing all its richness in pursuit of their addiction. Most agree that abstinence from a particular drug or behavior is far more precious.

A story was shared in response to a post on this blog, about a relative being instructed to just apply a cool cloth  to the addict’s forehead and in a few weeks they would “be good as new.” As any recovering addict will tell you, it takes a lot more! And much of what it does take I would classify as HR. Even if you quit the identified addiction, there are still a mountain of other issues that need to be addressed, such as recovery from the trauma that may have been driving the addiction, employment, reputation, how to create/repair a life, a family, a community. From the addict’s point of view, support for those tasks is as essential as stopping using.  And much of that work can begin while engaging in “official” HR services.

Society sees addiction as a drain on its resources (unproductive individuals sucking up services) and a source of harm to others (crime, disease, embarrassment, etc.). So, from society’s perspective, fully abstaining from the addiction removes all the above negative consequences. But from the perspective of addicts (and those who are able to step into their shoes, whether family or treatment providers) it’s not at all that simple.

Abstinence and recovery are not one and the same. As opposed to simply stopping using the target substance, “complete” recovery is as varied as are humans. Life is, by its very nature, imperfect, and applying definitions of things such as addiction, abstinence, sobriety, and recovery to real people will always be approximate.

The core arguments I’m hearing are about who pays for what services and strategies, what the authorities endorse, and what is socially and ethically acceptable.  We can, and should, argue about specific programs, policies and laws, but trying to agree on one “correct” way to recover from addiction ignores the valiant struggles and triumphs of so many who have recovered, one way or the other. I was bulimic for over 15 years (many years ago), which was as intractable, self-abusive and life threatening as addiction to any drug. And I am quite certain it would have killed me had I continued. As with other less clear-cut addictions, recovery for me is a continuum, one which involved plenty of what I would certainly call Harm Reduction.

Julia Hammid

PS. I (Marc) highly recommend this Time article by Maia Szalavitz.  It is just excellent, and it provides some very dependable statistics that argue for the value of various Harm Reduction programs and policies.