Category: Connect

Hi All. I just got back from a week in the French Alps. I know: poor me. But I spent the first day trying to snow-board, and fell on my ass with bone-jarring impact about once a minute. And I thought I was past the suicidal thing…

But while I was away, my US publicist sent me the link to a New York Post article, for which I was interviewed by phone in depth the week before. Most newspaper and magazine coverage of the book has been pretty good, despite various factual errors. But this article had some of my words and convictions turned completely upside down. For example:

Along with many other leaders in the field, Lewis believes that the recovery model needs an overhaul, that addiction should be treated as manageable disease, akin to HIV, rather than a curable one.

I don’t think of addiction as a disease at all. Sure, the disease metaphor resonates with aspects of addiction. But whenever I’m asked (as I was this time), I describe addiction as a form of learning. It’s a kind of learning that’s vastly accelerated and self-reinforcing. But it’s not a disease. And I would never, in my wildest dreams, compare addiction to HIV — there is NO VIRUS at work here.

But I don’t blame this columnist for trying to fit addiction into a familiar mould. The gist of her article was about inadequacies in the 12-step approach, and we were in synch on many points. In fact, her aim was to find a simple answer to a complex question. What the hell is addiction and how do we “cure” it?

My book and my other writings highlight the commonalities among addictions and among addicts. I emphasize a “common pathway” of addiction in the neurochemistry of dopamine, the role of the ventral striatum in craving, and the sculpting of synaptic pathways (in the orbitofrontal cortex) that imbue drug, drink, or whatever it is with value. Other neuroscientists also believe in a common pathway for all addictions. Along with ego fatigue, and a few other well-documented findings, these neuropsychological realities reveal something universal about addiction.  So a lot of my message is that we share the same brain — with its characteristic frailties — and when we fall, we fall down the same rabbit hole, and share the same challenges when we try to climb out.

And yet…what I have learned, not only from the addiction literature but from you, dear readers, is that people recover in vastly different ways.

First come the statistics. About 5% of alcoholics stop for good on their own every year  (see this opinionated but fascinating review). The rate of spontaneous recovery appears to be far higher for narcotics addicts (see the recent book by Gene Heyman. Though I disagree with some of Heyman’s arguments, his statistics on spontaneous recovery are informative.) Second, harm reduction really works: many people don’t stop using but they slow down or clean up enough to stop destroying themselves — another natural process of healing. Third, comments on this blog clearly demonstrate that, as difficult as it is to ignore craving, many of us manage to resist it or outsmart it until it becomes manageable, on our own, or with friends, or with family, or with our partners, or in the care of recovery programs (12-step based or not), or in therapeutic communities, or with private therapists, or, or, or…

I’m continuously blown away by how much diversity there is in how people get by and get out.

So what do I tell journalists who want to know the answer ? Yes, brain characteristics are fundamentally relevant to the addiction process. Yes, finding a “common pathway” in the neuroscience of addiction is critical, both for addicts and for those involved in helping them. But no, there is no common pathway to recovery. Some of us take comfort in following rules. Others abhor them. Some of us need to feel cared for before we can stop. Others need to feel more independent. And there are all those shades of grey, those mixtures and variants, among them. We are each individuals, with unique experiences, capacities, affinities, and aversions, and our creativity is probably the most important element in our recovery.

That doesn’t sound at all like a disease.

Last post, I emphasized an assumption of incompleteness as the foundation of craving. This feeling was referred to by readers as a hole, or pothole, or just plain lacking something. There is a lot to that, for those of us who put things (like booze or drugs) into us, in order to fill us up. But recent comments from readers struggling with anorexia or bulimia should make us think about craving more broadly. For some people there’s a compelling need to get rid of something.

What’s the common denominator?

As mentioned time and time again: relief from suffering, and I still think this translates to feeling complete. To be protected against suffering you have to be complete. For some that means filling holes, for others it means getting rid of excess. Either way, we want to make ourselves ideal, coherent, whole, and thus safe from suffering.

Let’s start with those of us who need to put something into ourselves.

This is not the time to review Freud in detail, but a hundred years of psychodynamic (e.g., post-Freudian) theory point to the infant’s need for milk or food, and the relief it provides, as the primal experience of taking something inside ourselves – something we need in order to be okay. One psychodynamic theorist, Melanie Klein, thought that young children experience a profound longing, which she called “envy,” for the mother’s breast or the mother herself. The infant seemed to know, beyond any doubt, that he or she needed something outside the self, in order to be complete. Maybe the first few times you got high, or drunk, or laid, you were reminded of how that works.

But what about those of us who need to get rid of something? There may be a feeling that we are too much, too dirty, too big, too fat, too needy, too greedy. I think even those of us who tend to shoot for more rather than less can identify that feeling. We want to trim ourselves so that we can be pure. Clean and nice. Maybe the common denominator is something really simple, like feeling “good,” which translates to lovable in cuddly mammals like ourselves.

Psychologists try to measure craving, or desire, using verbal information. For example, Hofmann, Baumeister, and colleagues (2011) got 200 people to participate in an experiment in which they were beeped at random times throughout the day and asked to record whether they were presently experiencing a desire…among other things. To make a long story short, participants reported at least one current desire on 50% of the occasions they were beeped. “On average, desires were actively resisted on 42% of occasions and enacted on 48% of occasions.” Well, I’m not sure that puts us much further ahead. Desire is a fact of life,  and a lot of desires have to be inhibited. That psychological datum fails the Grandmother Test: my grandmother could have told me that.

Which is why I turn to neuroscience: the biological basis of mind. I recently heard a very succinct account of what dopamine does in the striatum. It decreases “noise”. There are always a number of competing motor plans — plans of action — vying for enactment. That’s the normal noise in the system. What dopamine does is to inhibit the weaker plans and disinhibit (augment) the strongest of the competing plans. It’s a biological mechanism, sort of like focusing your eyes. So what dopamine does in the striatum is to narrow the field of potential actions, from many down to one. And that’s the basis of craving: a narrowing of focus and motivation to one thing and one thing only.

How could it be so simple?

A “cue” in psychologese means a reminder, an association. According to the research, drug and alcohol cues (like clinking ice cubes or round yellow pills) immediately increase dopamine flow for addicts, drawing our attention to those cues and away from other things. Thus the “plan” to acquire the thing being cued (the drug or drink) is strengthened. Then internal cues — remembering, wishing, imagining — join whatever cue came first, and each of those mental cues also increases dopamine flow to the striatum. From a trickle to a torrent. So, before long, there really is only one plan of action, one intention, one goal, that feels worthwhile. And whether or not it’s forbidden, it overtakes the prefrontal cortex with its urgency: the need to get the one thing that will make us feel complete. Or get rid of the one thing that makes us feel incomplete.

That’s how brain science makes addiction make sense. Craving…addiction…an aberration, according to the ideals of our society. But a very natural process for a part of our brain whose job it is to motivate us to make things better.

I have been thinking a lot about craving lately. What is craving, really? What’s it all about?

Craving seems to amount to a fundamental sense of being incomplete. When we crave, we want something to fill us up. We want to fill a hole, by taking something out there in the world and putting it into ourselves.

We’ve talked about ego fatigue and delay discounting lately. These are phenomena that strengthen the impulsive urge to take something – now! But where does that urge come from? What’s its origin, and what form does it take in our inner worlds?

I’ve long thought that most people who become addicted to something have been badly hurt or scarred while growing up. This view is shared by many others, including Gabor Maté, our Canadian addiction specialist. So we’ve been shamed or rejected by parents or close friends, punished when we didn’t expect it or understand it, bullied, raped, or abandoned, or maybe we’ve lost someone dear to us, maybe more than once.

Yet these wounds don’t explain the craving for something else. They explain why we suffer.

The thing is that suffering is part of life. Many many people in the world accept suffering as inevitable. Many who suffer do not become addicts. But for those of us who have been addicted, there seems to be a fundamental expectation that’s truly flawed: the expectation that we can be made complete by something out there in the world. What made us think that? What made us imagine that we could relieve our suffering in that way? Or does addiction reflect some crazy optimism, a hope for relief that never gets extinguished?

Addiction must start off with the very real experience of getting relief from something outside ourselves: a substance (like booze or drugs) or an act (like gambling or sex). We naturally stumble on such experiences in adolescence or young adulthood. (And note that addictive “acts” also put something into the self: a feeling of triumph or pleasure that was not otherwise available.) Then the thing that provides relief becomes a goal with greater and greater draw. Hence, we crave it when we have to go without.

Yet the conclusion that we become more complete when we have that thing…that can’t just come from a few arbitrary experiences of intoxication or pleasure. We must come prepared — predisposed — to feel that way. And then we find the key that fits the hole.

The belief that we are incomplete without that thing seems like a fundamental, bedrock assumption at the root of craving and pursuing addictive activities. What could be its origin?

More soon…but I’d like to hear your thoughts first.

Okay, where were we? Ego fatigue. The empty-tank syndrome, losing your resolve when you’ve been trying too hard or for too long or both. The comment thread has been really valuable: Many of you know exactly what this feels like. And we seem to recognize that this phenomenon is critical when it comes to relapse.

The classic ego fatigue test was developed by a psychologist named Baumeister and published in a 1998 article in a standard psychology journal. He put hungry people into a room and left them alone with two bowls in front of them: a bowl of radishes and a bowl of chocolate-chip cookies. Half were instructed to have some cookies but no radishes; the other half were instructed to eat radishes only – no cookies. After only five minutes, the participants were asked to perform some cognitive tasks that require self-control. Those who’d had to resist temptation (cookies) performed more poorly or quit earlier. The interpretation was that they had “depleted” a resource needed for self-control.

In the same paper, another experiment was reported, one that’s at least as relevant. Participants watched a 10-minute video clip that was very emotionally arousing (either humorous or tragic). Half were asked to show no emotion on their faces, and the other half could behave normally. Those who had to suppress their emotions performed more poorly on subsequent tasks. Once again, something had been depleted.

These studies have the “toy” quality of many psychology experiments. But they seemed to tap something important. In the past 12 years, ego fatigue (or ego depletion) has been studied in many other labs, sometimes with very clever procedures and strong results. In the field of addiction research, there has been increasing recognition that ego fatigue is a serious problem for recovering addicts. But I’d say that those of us who have been addicts are the real experts.

If 5 minutes of resisting temptation actually lowers your cognitive control, what’s the impact of 5 hours? If 10 minutes of suppressing your feelings saps your cognitive reserves, imagine the impact of suppressing those feelings (deliberately and consciously) all day long, day after day. You know what I mean, and reader comments on the last two posts fill out many of the details. Rather than repeat them here, let’s move on.

Ego fatigue is not simple and it does not act in isolation. Many of us have expressed immense relief, triumph, or joy when we finally give way to temptation. At least for a while. Next post, I’ll write more about the “multiple personality” issue that I think is involved. For now, I want to mention one other psychological phenomenon that is joined at the hip with ego fatigue.

Delay discounting is the common finding that people (and animals!) will prefer an immediate reward of lower value to a later reward of higher value, even though there’s less overall gain. People who are naturally impulsive are the most prone. Delay discounting has a lot to do with dopamine’s short-sightedness. Dopamine enhances the draw of immediate goals, and that’s all it cares about. Your higher brain processes are supposed to look out for the future. So the dopamine rush of craving and the urgent pull of present opportunities are intimately linked in your brain. And the higher brain processes…well that’s the problem.

The following video, of kids in the “marshmallow test,” shows how agonizing it can be to fight present temptations.

The Marshmallow Test

This video also shows how we try to fight against delay discounting, especially when we know how DUMB it is to give in to immediate temptation (and when there’s a moral imperative to hold out). But what I really wanted you to see is the gyrations these kids go through, trying to resist. The whole task brings on massive ego fatigue for any 3-4-year old. It’s hard to keep resisting what’s right in front of you! And the ones who make it all the way sometimes seem to suffer most.

What’s different about the successful ones, if anything? They sniff it, fondle it, smell it, even kiss it, and then they look away. They scrunch up their little noses and they look away, or look down, or pretend it’s not there. That’s the point: they distance themselves from it, before ego fatigue overcomes them.

We addicts often “discount” the value of sobriety, because the payoff is in the future. Instead we break down and choose the immediate reward. We lunge for the marshmallow — sometimes after ego fatigue has already sapped our strength, and sometimes when we just want to skip the whole, familiar, gruelling process of self-denial.

But there is a way out. We can learn something from these 3-year-olds. Look away, look away. In fact, because we’re adults, we can go one better. Don’t just look away but get yourself out of the room, or out of the neighbourhood, or get the wine out of the house, before the “humming” takes over.

The 11th Commandment: Avoid temptation.

There were a lot of comments on my last post. Any of us who have been there know about the pivot point, and some readers felt that this was a critical moment, a key to the whole cycle of addiction and readdiction. I gave it a name, ego fatigue, from the psychological literature. And I promised another few posts to explore this topic more deeply. So while I’m working on those posts, trying to incorporate all the articles Alese keeps sending me, I thought I’d fill the gap with a couple of pages from my book.

This excerpt is from the chapter in which I deal with ego fatigue, called Night Life in Rat Park. But the part I’m including below doesn’t get into the neuroscience — not yet. It’s just a read-out of the fantasies, the self-talk, the loosening sense of self-control that all start to slip and slide as you approach the pivot point. Or maybe it’s more like an accelerating ride over the crest of the toboggan run. Either way, from then on you’re lost. And the lesson, as several readers (and I) commented, is to not let yourself get into that state of “simmering” — the protracted, agonizing wrestling with the temptation to do it, pitched against the need to stop yourself.

This excerpt is from my life as a late-blooming undergraduate, working late at night in the rat lab:

I went in. I hung up my coat. I unlocked the door to the inner sanctum and made my way to the cages. My rats were all there, busy doing nothing, as usual. Scratching and whispering, scurrying, hiding, perhaps talking to each other in little rat voices. They paid me little attention. I was a familiar sight, or more likely a familiar odour, and we’d have time enough to visit as the night wore on. “Hi, little guys. Who wants to go first tonight?”

I pulled a cage out from the middle of the grid, just to make life interesting, and carried it to the procedure room, whispering all the way in my rat voice… I filled the pellet tray. I filled the water bottle. I made sure everything was perfect. On a fresh data sheet I recorded the date, February 12, 1977, the subject number, and his weight—before supper. Then I picked up the rat and placed him in the left wing of the experimental chamber… Finally, I lifted the slide between the two sections of the box and watched, horrified and amazed, that this little rat obeyed so perfectly the commands issued by his brain and his stomach. He did what he was programmed to do. Flawlessly.

I went through a dozen more animals, and I was still only half done. I wouldn’t arrive home until nearly midnight. Another long, lonely, boring night. And it was particularly lonely because Sharon and I had been fighting again. Always fighting… When things got difficult, as they had again now, I pleaded for her understanding, for her strength, or if those weren’t forthcoming, I pleaded for her to lay off. I didn’t want to feel that I was recalcitrant, naughty, unkind, unfair. I wanted her to put her arms around me when I got back, even if I got back at 2 a.m. No more fighting.

But now, as I shuttled about the lab, the angry, wounded wrinkle of her brow floated above me, behind me, and the resonance of her nasal voice rose from the hum of the fridge. The old lab fridge. Sitting in the corner of the procedure room. Would I? Should I? No! Once was enough. Somebody would find out. No they wouldn’t… Nobody is saving it up for the rats, that’s for sure. It’s going bad. It’s probably five years old. Yeah, but it works. It still works. Oh, does it ever. Yeah, and it’s probably toxic. You’re probably going to die. If you do what you’re thinking of doing. Don’t even think about it.

But I am thinking about it. I can’t stop thinking about it. And there were no ill effects last time . . . The bell went off and brought me back to reality. If this was reality. My first reaction was a rush of shame: it was vile. Shooting some undefined liquid into my veins. Okay, it was morphine. Morphine, the wonder drug. Morphine, the perfect narcotic. The pure essence of which everything else—even heroin—is a derivative. But it was disgusting to shoot that stale stuff in the fridge. A familiar glare from somewhere inside.

I picked up my now well-fed and well-exercised little beast, and it seemed as though he was smiling at me: I know what you’re thinking. No you don’t! I weighed him again, a bit more roughly this time, then put him back in his cage. You don’t know what I’m thinking, you dumb rat. It’s not your morphine anyway. To get my mind off the fridge, off Sharon, I put the next rat into the box and picked up my novel, plunked myself down on the musty sofa and started to read. Nobody was around. Not only the lab but the whole subbasement was deserted. No sound. Except for the scurrying of those rats still awaiting their moment of glory. And the others, the sated ones, licking their fur contentedly. A sound that grew louder in my imagination: soft tongues scratching and scraping as they cleaned their soft white fur. They were at peace. Like I would be if I . . . No no. Don’t go there. Not again.

I’m a big boy. I’m studying to be a psychologist. But I still like to read horror novels sometimes. Especially lately. And Anne Rice evokes the most compelling images. A newcomer has entered the parlour. One of the older vampires crosses the room so swiftly his movements are invisible. He grasps the visitor fondly by the lapels. He whispers to him, part seduction, part warning: “So you want to become one of us? But are you strong enough to bear the curse of isolation that will be yours forever? With a taste of my blood?” And I’m thinking about the morphine in the fridge again, because it is like the vampire’s blood: dirty, poisonous, yet offering me its singular powers. It will plunge me into the land that is inhabited by the few, the outcasts, those who prowl by night and sleep by day, whose business is the sating of a shameful hunger. And now other images are awakened. My memories of [old Berkeley friends, part-time junkies], both fond and repugnant. Ralph putting Jim to sleep with a shot of Seconal, a drug that would one day kill him. And my childish wish to be one of them, despite the foreshadowing of destruction that hovered there.

Only fifteen or so rats to go. I’ll never make it. Too long. Too tempting. Don’t think about it. Don’t think about the little bottles in the fridge. You might never have noticed them if you hadn’t been searching for a can of pop. And don’t think about the syringes lying so neatly in their paper wrappers in the cupboard. Don’t think about them! But I look at the vein in my arm, so rapidly I can’t stop myself. Up until a week ago, I hadn’t shot drugs for over two years. That’s all over. A youthful folly. With its share of horrors, to be sure. Nobody knows the trouble I’ve seen. Nobody knows . . . but Jesus. I’m actually humming this as I get up to replace one rat with the next. I’m humming this and I’m smiling a little to myself, smiling with a sneaky little smile, a sneaky little rat smile. A smile for no one. A smile no one can see. But there is a quickening in my pulse. A part of me has given up.