Part 2: Treatment for addiction, not disease

As promised, here’s Part 2. But note that this section (on implications for treatment) is based on eight and a half chapters you haven’t read yet. To distill some of the main points is tricky, but here goes:

handinjectionAddiction is maintained by an entrenched set  of connections between the striatum — the part of the brain that generates goal-directed desire and thrust — and regions of the prefrontal cortex (e.g., the orbitofrontal cortex) that hold the goal in mind, embellish it, imbue it with value, and “remember” it as the salvation you hoped it to be. My argument about recovery is that you can’t turn off the striatum — the motivational engine. You can’t turn it off because it’s at the very center of who you are, it is the pulse and drive that moves you from one moment to the next. So, if you can’t turn off the “biology of desire”…then you have to connect it with different goals, goals that can also be consolidated by synaptic networks contentin the prefrontal cortex. But to do that, you need to engage yet another part of the prefrontal cortex that is critical for perspective change — the part of the brain that can make choices (the dorsolateral prefrontal cortex) — what I call “the bridge of the ship.”

Sounds simple—re-engage the bridge of the ship, and get it to take on a new set of goals, goals that will synch up with the motivational engine.

Only two problems:

Problem #1. These goals for future wellbeing can only be achieved through long-term plans, not the short-term plans for immediate relief that have been central in addiction. And these long-term plans are supported by a different set of synapses than those that supported your addictive goals. Different but overlapping! As with the webbed fingers example, goals for future wellbeing and immediate relief have become fused together in addiction — but now these two synaptic patterns need to be allowed to separate. This requires thinking and feeling differently — a shift in perspective — at least for awhile. What fires together wires together, and what fires apart wires apart. The long-term plans and goals have to establish their own distinct connection with the motivational engine, with desire.

Problem #2. The goals for achieving short-term relief are highly compelling, very much in your face, hard to disengage from, because the dopamine pump continues to activate them — rapidly! I call that “now appeal” (technically, delay discounting)– and it’s a well-known obstacle to quitting. And by the way, it completely bypasses “the bridge of the ship,” the part of the prefrontal cortex necessary for perspective change.

So how do you shift the beam of desire from highly practiced short-term goals to much less practiced long-term goals — what might be called the assembly of a future self — and then reinforce the new roadwork? First, you need to avoid killing the motivational thrust that comes from you and only you. Yet becoming a “patient” (in a doctorpatientdisease-model-based treatment environment) is very likely to squelch that motivational thrust…. I mean, doing what you’re told is not the same thing as doing what you really want. Second, you need to act fast, strike while the iron is hot. Because the brain gets so quickly caught in the dopamine-powered pursuit of short-term relief — in now appeal — you have “catch” it when it’s looking toward something different. In other words, you have to catch it just when the “bridge of the ship” gets activated — so that desire and future wellbeing make contact. That’s when a different synaptic channel between the striatum and the prefrontal cortex can open up. addict in mirrorLike an arc of static electricity leaping to a new target. And that channel is there, and it does light up.  At least sometimes. Like when you wake up feeling zonked, shitty, shaky, with withdrawal symptoms revving up, looking at the deterioration of your face in the mirror, and running to the toilet — and for the next half hour you want like anything to quit. You want to choose a future. Right then, you want to quit.

So there’s a condensed lead-up. Now I wish I could provide a brilliant new design for optimizing treatment for addiction — one that sits like a crown on this neuro/experiential modeling. But I can’t. I don’t know enough, and I think that job really belongs to people within the treatment world, not “science writers” like me. But here are a couple of paragraphs, from the last section of my book, showing where this kind of logic might lead us. And again, my thanks to Matt Robert and Cathy O’Connor, who helped me see things from this perspective.


What alternatives might stem from a developmental approach to treatment, applying the power of momentary desire to a personal time-line for quitting? Most important, there is no single strategy, organization, method, or philosophy that commands center stage. Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because there is no fortress wall that needs to be scaled, no line-up at the door, and no financial minefield that needs to veryworriedbe crossed. Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future.

Community-based groups, including SMART Recovery and progressive AA groups, can provide a kind of narrative scaffolding, a concatenation of stories about addiction and recovery, that can help addicts work on their own future “stories” — their personal narratives — addicts who are ready to move on. Group meetings are frequently inserted into institutional treatment as well, but whether they’re available when addicts really need them and can use them is entirely hit-and-miss. And while group processes can be helpful, they are certainly not always helpful, nor are they the only way forward. Treatment only requires the attention of one other human being who can hold, possibly distill, and hopefully extend the vision of a future self energized by an individual’s desire to change.

brainfigure2What will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change. This can be the presence of a friend who accompanies you to your first 12-step meeting, as was the case for Brian at the very point when he’d had enough. Or the attention of a therapist who really gets where you’ve been and where you want to go, as was the case for Donna at the fulcrum of her despair. It dialoguecan even be the horrific embrace of a jail cell where you see your options with brutal clarity, as was true for Natalie. (To read these hair-raising accounts in full, I’m afraid you’ll have to wait for the book.) It can be a month on your uncle’s farm, a book that captures your heart when you think you’ve lost it, or the stuck window opened by meditation, romance, or antidepressant therapy when you’ve been buried in your cave for too long a time.

Quitting requires a merger, perhaps a collision, between desire and perspective­ — again, what fires together wires together­ — yet it doesn’t demand any particular brand of intervention.

Nevertheless, next week I’ll describe a radical treatment initiative that I think exemplifies a right-minded approach to recovery. And I hope that, through your comments, you might also provide some ideas for how to awaken the treatment world.












35 thoughts on “Part 2: Treatment for addiction, not disease

  1. Gary January 29, 2015 at 8:59 am #

    Hi Marc….very interesting material!~
    Change is certainly and inside job and can happen instantaneously or perhaps a “process’ and not an “event”. I don’t believe it’s who you are that poses a problem and/or perhaps a solution but who you “think” you are. Who we are, in my opinion, cannot be grasped. However, in attempting to find ones identity can pose problems especially if I identify as being an addict, alcoholic etc…

    In the self-help movement there are many helpful sayings or proverbs such as Think Think Think, First Things First and you have to name it to “tame” it. For many its only when they admit honestly that they are alcoholic or that they are an addict that change begins to take place. I guess in embracing the truth about ones’ circumstances or perhaps seeing with “clarity” the nature of their problems only then can change take place.

    Denial, blaming, poor me poor me pour me a drink syndrome only creates and disguises the real problem.

    I’ve mentioned many times that “Long before I developed a “Drinking Problem” I developed and “Thinking Problem” about drinking. Thinking and/or its construct is fairly complex from person to person and isn’t only developed from a biological perspective but environmental factors play a significant role.

    Its not necessarily the story of my life that matters but the life or importance of that story that will matter with regards to behavior and perhaps actions taken.

    Change, in my opinion, is moving out-of-the-center of my perceived world or my perception of life. My or mine can also create problems and may be donminated by one’s ego. Deflating the ego is a humbling experience which allows for a wave of clarity and awareness to embrace you physically, emotionally, and/or spiritually. Its a true knowing without naming where one can truely feel and be part of the greater whole. Deep within every human being, beneath the labels of modalities, evidence-based research etc… exists that which cannot be named only known and felt in the heart. Perhaps real change is not changing at all just becoming aware of how we are all connected to each other in the whole of the universe.

    • Donnie Mac January 30, 2015 at 7:31 pm #

      JLK ? Is that you ?

    • Marc February 16, 2015 at 6:29 am #

      Hi Gary. Your comment captures some of the “positives” of the AA approach, and there are many. Yet 12-step groups vary enormously, and dogma can interfere with the freedom to discover and activate your future self, whether that dogma is from the medical world, from AA, or from any other source.

      I think we are very much in synch. I particularly like your phrasing, which I’ll paraphrase here: “It’s not necessarily the story of my life that matters but the life …of that story.” That captures what I’m trying to get across: the critical step of energizing one’s life story — a story that leads to a future self, free of addiction — with the engines of desire.

  2. Jeffrey Skinner January 29, 2015 at 12:03 pm #

    I’m looking forward to the book. I’ll have to read this again before I could respond because the argument is unavoidably dense.

    One thing you might consider: the “bridge of the ship” metaphor. A bridge implies a (homuncular) captain in control. I assume that’s not at all what you intend.

    • Marc February 16, 2015 at 6:32 am #

      True, that’s not what I want. Yet there is such a thing as deliberate, conscious self-direction, and there are brain areas that are structured and connected up for exactly that function. The bridge of the ship is just a part of the ship — it’s not at a different level of existence. But it’s the part of the ship in charge of steering.

      • Jeff Skinner February 16, 2015 at 12:31 pm #

        Excuse the epistemological nitpicking. I do know what you mean and you do too. I really want to see the whole book!

  3. Marcus January 29, 2015 at 3:02 pm #

    So how’s the “war on drugs” working out for us in all of this???

    • Matt January 31, 2015 at 8:46 am #

      I think it’s where all the money is, now in the form of the prison system and innocent people’s broken lives…

  4. Matt January 30, 2015 at 5:33 am #

    I think we quash things like desire and perspective when they need to be flipped or redirected. They’re too basic to our human make-up. As you suggest Marc, desire needs to be reframed, redirected and replenished. So do things like denial, which has a fixed negative connotation of keeping one stuck in addiction. But the dictionary definition of denial is “An unconscious defense mechanism characterized by refusal to acknowledge painful, realities, thoughts or feelings.” [American Heritage Dictionary] It can help someone get sober and avoid sapping their willpower and resolve with shame and regret over the damage caused by the addiction. That can be addressed later when in a stronger, sober state of mind.

    • Marc January 30, 2015 at 11:38 am #

      Hi Matt. This is such a beguiling idea. Do you want to say more about it here? Or…..should you save it for a guest blog-post?

      • Matt January 30, 2015 at 12:57 pm #

        This is unclear. Maybe I blog blurted prematurely. I’ll try to explicate a little later, but it may need a post to adequately clarify. The point is we have a lot of fossilized language and ideas around recovery, it being such a charged topic… and that tends to lead us away from more effective diagnostic treatment models as people throw up their hands and say it’s too complicated.

        • Janet February 2, 2015 at 8:27 am #

          Yes, Matt. The language we have fails us at time. Well put.

  5. Richard January 31, 2015 at 2:25 am #

    Fossilised language is so true. I think I understand where you’re coming from Marc – my next question is HOW ?

    • Marc February 16, 2015 at 6:35 am #

      Indeed, Richard, that’s the question. I don’t claim to have a single, brilliant answer, but see the next post for an example…of a treatment approach that embodies the principles I’ve gleaned from synching up the mind and the brain in addiction.

  6. Matt January 31, 2015 at 12:40 pm #

    Okay, here goes:

    Desire and motivation are always there in us in some form. If they weren’t, the species would have disappeared long ago. If desire gets more acutely focused on the relief-giving behavior, then negative consequences get ignored, and future goals and dreams vanish. If desire gets focused on the goal of wanting a better life, future goals reappear and are reintegrated into our present selves. So desire itself is neutral: it can lead us to harm or lead us to a better place.

    Some would say that denial is similarly neutral. It can harm us or help us. When our desire is totally focused on the relief given by the addictive behavior, we deny the negative consequences that are accruing. “Problem? What problem?” When the desire shifts to wanting a better life, denial helps us focus on that goal by helping us ignore or “deny” the boatload of negative consequences caused by the addiction. Otherwise, early in recovery, the shame, despair and regret associated with confronting those consequences may be too much to bear. In acute recovery, the siren call of immediate relief is too strong, and the body and mind are still weak. So the positive side of denial can crucially help us manage the minefield of early recovery. It can focus our desire for a better life on staying clean, and that tunnel vision can help us keep out the temptations on the periphery that would serve to distract us and pull us back in. It helps us manage the transition to a new habit.

    • Marc February 16, 2015 at 6:42 am #

      Matt, I love your conclusion that desire is neutral. Indeed, as with nuclear power, it’s a form of energy, of thrust, that can be used either for good or evil, so to speak.

      As we’ve discussed, I don’t see denial exactly the same way. But I know exactly what you mean. And what you’re calling “positive” denial is what I’d call attentional control. Or to in the unbelievable stuffy, unappealing, and abstract phrasing of present-day psychology, “attention bias modification.” Or to put it more simply, you have to be clever and oh so quick to divert your “desire” from the siren song of drugs or booze or whatever. And yes, it becomes a trick, and hopefully it becomes automatic…and then you can get on with your life.

  7. Margot Tesch January 31, 2015 at 4:13 pm #

    I guess in your first book, the day you realised you could say “no” to drugs for EVER … not just for a while, that was when you started to rewire your brain and make new connections in your prefrontal cortex. You plastered “no” on the wall (or was it the positive “YES”, can’t quite remember), either way you started to strengthen your belief in your recovery which is effectively re-wiring the things that had disconnected. This is really powerful. It’s about taking practical everyday steps that help you re-engineer your belief system. Thanks you Marc for your inspiration. Can’t wait to read the book.

    • Matt February 8, 2015 at 4:33 am #

      Hi Margot

      I totally have the same sentiments. And short and sweet, keeping Mr. Midbrain from coming in and dashing plans for recovery and beyond. I envisioned the yes/no thing as 3 stages: saying “yes to no”(affirming desire to quit); saying “no to yes”(whacking back urges in early recovery); and saying “yes to yes” (when the positive habit gains a foothold and starts to establish itself).

      • Marc February 12, 2015 at 6:22 am #

        That’s a rather brilliant synopsis, Matt. Captures it so nicely.

    • Marc February 16, 2015 at 6:53 am #

      Thanks, Margot. Yes, that was the moment for me. And my memory of that moment continues to inform my intuitions about recovery. The word was “No”. Matt covers the process perfectly in his response to you.

      The other thing (owed again to discussions with Matt) that I’m thinking about these days is the role of anger. Anger is an “approach” emotion, just like desire. It’s goal oriented and it focuses attention and drives behaviour…just like desire. In the “No” strategy, I was channeling a lot of anger. What was new was that the anger was directed at my addiction, not at my self. So with anger pushing and desire pulling, so to speak, you can direct yourself to this future that’s so different from your present. And you practice it, and get better at it, but it has to continue to be energized by powerful emotions.

      I wonder if this principle helps explain why people tend to relapse once they feel they’re over the hump of their recovery: because they’ve lost the passion to change…because it’s no longer a direction, a goal, they have to strive for. You are so much more vulnerable when you’re standing still than when you’re moving…

  8. Matt February 5, 2015 at 5:53 am #

    I think this is why detoxes can be such a seminal transformative opportunity— to link the person’s desire to a viable method with realistic encouragement. It’s not that we don’t do that already, but it’s not as focused and individualized as it needs to be. This is when people are sufficiently defeated, fed up, and are the most malleable and direct-able. Detoxes should be a reminder to people that they are not at the bottom, but at a way station to a new life.

    And actually pointing this concept out to people in detoxes is a place to start– while their spirit is roused, and and there is available motivational encouragement.

  9. jasmine February 15, 2015 at 3:43 am #

    Dear Marc:

    As someone noted above, the excerpts you have shared are dense indeed. I’m sure it wasn’t easy to distill such complex ideas etc. with brevity. At the same time, I felt awestruck by your post. I think that what you have shared is ground-breaking, instructive and just darn fantastic! I have no doubt the practical applications of your work will be challenging, if not arduous, though it is clear that – because of your efforts – a new discourse will ensue…one backed by research while accounting for the individual and particular paths of each person struggling.

    If I couldn’t wait to read the book before, I now add multiple exclamation marks!!

    Bravo – and thanks to all the contributors here for such a rich and honest dialogue,
    Jasmine 😉

    • Marc February 16, 2015 at 7:00 am #

      This is very heartening, Jasmine. Thanks so much. And yes, the dialogue is really central. I feel like we are thinking together and discovering new ground as we do. Here I’ve highlighted specific contributions from Matt and Cathy. In the next post, I highlight what I’ve learned from discussions from another person in the treatment world, Peter Sheath. But every comment and question helps me to formulate and revise productively. For example, your comment here tells me that the density of the modeling is not necessarily an obstacle to “getting it” and being inspired by it. That’s an important bit of feedback, because I constantly have to steer between abstraction and accessibility, and this helps me adjust the balance. Again, thanks!

  10. Dr. Basim Elhabashy February 17, 2015 at 12:45 am #

    I would like to praise you for sharing such a nice thought. Now, there are so many rehab centers available for addiction treatment.

  11. Jaclyn Claire February 24, 2015 at 4:36 am #

    Your article gave us more information biologically that how an addiction starts and how you get addicted to it. Drug addiction displays as an irresistible drive to take a drug even with serious adverse consequences. This a typical behavior has been traditionally viewed as bad ‘choices’ that are made freely by the addict. I appreciate your thoughts for sharing with us. As the Doctor said, there are a number of rehab centers available.
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  12. Laura Judge February 25, 2015 at 12:08 pm #

    Hey Marc!

    I really loved this article, it is one of the best explanations of focusing on long term vs. short term goals through treatment that I have come across. I have recently just finished . treatment myself, and constantly have to remember my long term goals when going about my day-to-day activities.

    I also loved that you emphasized that “there is no single strategy, organization, method, or philosophy that commands center stage. Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward.”

    This post is great food for thought and I’ll definitely be reading future posts.


    • Marc February 26, 2015 at 5:20 am #

      Hi Laura, That’s great to hear. I’m glad these ideas are speaking to you. When the future feels welcoming and soothing, the whole process becomes much easier.

      More to come….

      Very best,

  13. Richard February 27, 2015 at 11:32 am #

    When I look back now and realize that yes! when I was in jail I did have a vision of my future self. It was of a time when I was young, innocent, exploring nature, a time I wanted to regain in what I could see as me in the future. Today I’m here and each day is a love and joy of the next to come. When people would say, “What do you want for your future”, “Where do you want to be?” For me it was all about growing down, growing up was not fun anymore when their was so much confusion, Drugs, alcohol, that redirected me from my path. So as a child again, I have a new start and today its my choice what and where I want to go…
    Thanks Marc

    • Marc March 1, 2015 at 6:02 am #

      What a lovely comment. That captures the “future self” concept in its full richness and beauty. This is a clear portrayal of the connection between heart and mind that’s so necessary to make recovery a discovery…and not a horrendously difficult chore.

  14. Kristie March 23, 2015 at 11:49 am #

    A couple of quick questions: first, how do you educate an addict who is is treatment that the disease model is not the only viable and valuable model out there. I have a family member in a rehab that swears this is all a disease and that he isn’t responsible for the chaos he caused. Is there even a point in trying to educate? It seems he has checked his brain at the door.

    Now onto the other things: what part does trauma play in addiction, do you think that there is room for a trauma based treatment model in addiction therapy and in addressing the physiological changes that occur in the brain as a result of addiction, do you think neurotherapy could play a part in brain re-wiring?

    • Marc Lewis March 24, 2015 at 10:14 am #

      In regard to question 1, I’m going to paste in a paragraph from my upcoming book. This should do the trick, but if it doesn’t, just read the rest of the book:

      “Yet, after reading thousands of comments and emails from former and recovering addicts and interviewing dozens of them for hours at a time, I’m convinced that calling addiction a disease is not only inaccurate, it’s often harmful. Harmful, first of all, to addicts themselves. While shame and guilt may be softened by the disease definition, many addicts simply don’t see themselves as ill, and being coerced into an admission that they have a disease can undermine other—sometimes highly valuable—elements of their self-image and self-esteem. Many recovering addicts find it better not to see themselves as helpless victims of a disease, and objective accounts of recovery and relapse suggest they might be right. Treatment experts and addiction counsellors often identify empowerment or self-efficacy as a necessary resource for lasting recovery. And, in a statistically rigorous but highly provocative study, Miller and colleagues found that the only pretreatment characteristic that predicted relapse, six months after concluding outpatient treatment for alcohol dependence, was “the extent to which clients endorsed disease model beliefs before entering treatment.”8 As well, once they’ve beaten their addictions, many former addicts choose not to spend the rest of their days walking on eggshells lest the disease return. While re-addiction is clearly a hazard for some, others achieve a realistic and lasting confidence that they’ve outgrown their addictions and it’s time to move on. In fact, survey research published over the last thirty years indicates that most addicts eventually recover permanently.9 For them, the disease label may be an unnecessary, even harmful, burden.”

      Your second question is a bit too big to try to answer here, but I strongly recommend Gabor Mate’s book, In the Realm of Hungry Ghosts. There are many treatment experts who strongly feel that it is necessary to re-examine and reprocess the past in order to move on. My book deals with that as well.

      • Kristie March 26, 2015 at 12:00 pm #

        The reason I ask the first question is because said loved one is highly endorsing that he is sick and as a result, dismissing and responsibility for the damage that he caused to his family making reconciliation extremely difficult. if the addict absolutely believes he is sick with a disease then there is no ownership over the damage that his actions caused because he couldn’t help it after all, it was the disease not him.

        Which leads me to the next question: I am a trauma therapist and highly believe that unprocessed trauma is often the root of many mental/emotional issues. And knowing this family member’s life, unprocessed trauma ran rampant. He is a textbook case of avoiding the guilt and shame of his addictive actions by adopting the disease model. However, there is a ton of guilt and shame from the trauma and the two combined became overwhelming. Is it even possible for someone like that entertain that it is not a disease? When confronted with some of these truths, he refuses to have a discussion because it will “jeopardize his recovery”

        Which leads me to my next point, the brain is a plastic (not static) entity. Trauma and addiction both re-wire the brain. Would not neurotherapy, which would again re-wire the brain back to its natural state, then be an effective solution?

        • Marc March 27, 2015 at 1:10 pm #

          Too many questions for me to address right now. It does sound like his defence system has thoroughly embraced the disease model. What a marriage — made in heaven.

          Yes, trauma and addiction both rewire the brain. So does major league baseball, but to a lesser degree.

          And I have no idea what neurotherapy is.

  15. MarvinCarr March 29, 2015 at 10:19 pm #

    Hi Marc! Nice article. I found your article while I’m browsing about treatment addiction. According to another I article I read before, there are more complications that can affect the addiction to the brain. Sometimes, it affects those important areas which can damage the normal functions of the brain. Like your article, they show some examples and facts about this matter. Until now, it’s a nonstop searching and finding more ideas and studies about addiction and the brain. You know what, every time I read about this kind of topic/article, I feel that someday I will share those ideas and knowledge to other people, particularly to those suffering from addiction in better hope treatment place wherein I am a volunteer. I never thought that I’d become more curious and interested in this kind of topic. I wish I’ll get more information here to share with others. Thanks again.

  16. Carlton October 10, 2015 at 1:42 am #

    Addiction, not Sobriety, is what is maintained.

    It is rarely talked about, but this fact; “Addiction is maintained” are the first words of this post.

    This is one of the realizations that many people probably have during the recovery process.
    The realization that goes with it, is that Sobriety is the natural default of all living things.

    Tis is easy to say, and to comprehend, but during the struggle with an addiction, it can seem
    a near impossible thing to realize and feel.

    But these are the types of realizations that indicate that a freedom, not a limitation, may lay ahead.

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