The most common question I get in my work and sometimes from my friends is “Am I an alcoholic?” This is usually followed by “Does this mean I have to go into rehab? Will I ever be able to have a drink again?” I believe that treatment for addiction should be individualized to take into affect each person’s individual needs, complexity and readiness to change. Every case is different. Sometimes the answer is undeniably “It’s complicated” I was trained to apply systematic screening and assessment in order to determine if say Alcohol Abuse vs Dependence is present based on DSM-IV criteria and make treatment recommendations based on the ASAM placement criteria. You can learn more about them here and here.
But sometimes I encounter cases of addictions that do not fit either.
After the tragic death of Amy Winehouse there was a lot of speculation on the web, even by professionals in the addiction field, as to who is to blame. There was actually one article I read which seemed to imply that if she had been able to drink in moderation maybe she would still be alive. I honestly can not comment on that either way. I will say that the harm-reduction model of treating addictions is not popular among people who advocate for abstinence as the only acceptable treatment outcome and people who support the 12-step program approach. Having worked at a methadone clinic for years and witnessed powerful positive change, I am not a big fan of one size fits all treatment approaches nor am I into labeling.
There is however one view on addictions that I have found very helpful, especially lately, in helping clients who do not seem to fit the traditional medical model of addiction.
That’s the Staton Peele approach.
Here’s a summary of Dr. Peeles’ view on addiction “addiction is not unusual, although it can grow to overwhelming and life-defeating dimensions. It is not essentially a medical problem, but a problem of life. It occurs for people who learn drug use or other destructive patterns as a way of gaining satisfaction in the absence of more functional ways of dealing with the world. Therefore, maturity, improved coping skills, and better self-management and self-regard all contribute to overcoming and preventing addiction. Addiction is a way of coping with life, of artificially attaining feelings and rewards people feel they cannot achieve in any other way.” Stanton Peele, “Cures depend on attitude, not programs,” Los Angeles Times, March 14, 1990.
Peele is a big advocate of the harm-reduction model. I think harm-reduction does not work for every one, in fact in can be detrimental to one’s recovery. But that’s subject for another article.
One area I find Peele’s theory to be applicable is in explaining how addiction and intimate relationships are so closely interconnected. Jim always ends at the bar drinking after a fight with his wife. Anna’s drinking always gets out of control after a break up. John had experimented with pain pills on and off in college but did not get addicted to them until after the devastating loss of his long time lover and best friend. Travis’s sex addiction gets worse after feeling rejected by a love interest. In the words of one of my clients “I was lost before I found love. I was on a path of self-destruction with drugs, alcohol and women but with my wife I have found what I was always missing, I have been clean and sober since. Now I’m high on life”
Staton Peele wrote Love and Addictions in 1975. Poets and writers have written about drowning love sorrows in wine since the beginning of time, from Rumi to Pablo Neruda to Shakespear to Bukowski to rock and roll and so on…
Amy Winehouse wrote:
“The man said, “Why do you think you here?”
I said, “I got no idea”
I’m gonna, I’m gonna lose my baby
So I always keep a bottle near
Ryan Adams, a singer song-writer from NC and my all time favorite, who battled alcoholism and addiction for years and sang relentlessly about sad, impossible, troubled love affairs, wrote:
“And I hold you close in the back of my mind
And raise my glass ’cause either way I’m dead
Neither of you really help me to sleep anymore
One breaks my body and the other breaks my soul”
Luckily he’s still alive and well and sober.
Addiction is a way to respond to unsafe relationships.
And by unsafe I don’t mean physically violent although that is the most obvious case. Unsafe means threatening to the ego as much as threatening to the body. What I’m talking about here is emotional safety. When we feel loved, accepted, nourished, protected and part of someone else we feel safe. That safety is often threatened when we feel unloved, uncared for, betrayed, lied to, yelled at, abandoned, neglected, rejected, violated.
To understand where we are going we have to understand where we come from.
Safety and the Primitive Brain
Let’s start with the evolution of the brain. In the base of our brain we have the reptilian brain. We share this part of the brain with animals including alligators and lizards. The reptilian brain takes care of those things we don’t usually think about: heartbeat, digestion, and breathing. It also is concerned with survival, and if it’s dangerous, it will help us respond in one of 5 basic ways: fight, flight, freeze/play dead, submit or hide. These are also the 5 basic survival skills of couples. Couples with fight, flee (leave), play dead (stare right through their partner), submit (OK, whatever you want, just stop the nagging!) or hide (go to another room).
On the other hand, if the reptilian brain is safe we will do one of 5 things: play, nurture, mate, work and be creative. Remember when you first met your partner? How you played, nurtured each other and had more sex? Do you remember being more creative and productive at work? As animals evolved, a second part of the brain developed called the mammalian brain. This brain developed when animals began to live in groups and take care of their young. This is the part of the brain where feelings are stored. That’s why most animals experience some feelings and live in groups.
Several million years ago a third part of the brain developed: the cerebral cortex. In humans this part of the brain is 5 times bigger than the other 2 parts combined and this where all logical processes happen: speech, writing, logic thinking, math, etc. The three parts of the brain work together simultaneously. If a tiger is coming at you your logical brain says “That’s a tiger”, your mammalian brain says “I feel scared” and your reptilian brain says “Run!” or “Freeze!”
But in relationships is often hard to articulate or identify who or what the “tiger” really is. We know something is not right but all we are left analyzing is the behaviors we can clearly see but can rarely understand. Like, how is it, for instance that when Jim and Linda fight he ends up getting drunk at the bar even though he knows that is not going to help the situation at home but only confirm Linda’s insults that “he’s nothing but a loser”? Sometimes fighting, fleeing or hiding involves addictive behaviors particularly sexual behaviors like masturbation, pornography, but also gaming, internet addiction and alcoholism. Often past experiences with these behaviors make a person more susceptive to going back to (if they have stopped) or increase the frequency of these behaviors. This explains why people engage in addictive behaviors even against their logical thinking. It appears that the primitive reptile brain has taken over the cerebral cortex. This is why people logically know it doesn’t make sense to engage in behaviors that often make the already troubled relationship even worse. They are “thinking” with their primitive reptile brain, which often means they are not actually thinking at all.
Sometimes we are not simply chasing a drink or a drug. Sometimes using is a maladaptive way of coping with unsafe relationships. In this cases treatment should focus on the relationship and reestablishing safety more than on changing addictive behaviors themselves. I have found that establishing safety and learning to evoke mental images of safe places/mental states is crucial in learning to calm oneself down and coping with highly stressful situations, which in return helps the addictive behavior dissipate.
This should also be the main focus of relapse prevention in more traditional addiction treatment.
Also read http://www.goodtherapy.org/blog/love-drugs-primitive-brain/