This article belongs to Addictions Anonymous column.
Earlier I mentioned dark feelings and this, I think, is a common factor running through all addictions of whatever sort. Knowing how to live with, control and even eliminate unpleasant emotions is a survivor skill that people have in different amounts. Those who become vulnerable to addiction always seem to lack skills for handling emotions, but these simple skills are neither complicated nor difficult to learn.
We can sympathize with someone in severe physical pain, but when someone is suffering from intense and constant unpleasant emotions we may not even notice it. Even if someone we know complains of feeling wretched, we are at a loss to make helpful suggests, so we simply tell them to cheer up, get over it or go see a shrink.
As you may have noticed in a previous column, about half the items on the list of addictive triggers are activities, not substances. Gambling, collecting stuff and heavy exercise are potential dependencies or addictions that, until recently, were not seen as addictions at all. And who knows what innocent practice we engage in today will become tomorrow's new addiction? Distinctions become blurred: for example, is sun tanning a substance addiction dependent on light waves, or is it a behavior?
It is easy to make up different classes or types of addiction, types such as substance abuse verses activity addictions. Or, we could divide up the addictions in terms of mood elevators(uppers) and tranquilizers (downers). Still other classifications could be made on the basis of what particular emotions seem to drive the individual addict. What is difficult is to see are the underlying characteristics of all real addictions. At the most general level, unpleasant emotions are evident in every case. Setting up different classes is easy, but I do not think very helpful. Seeing the underlying unity in various addictions is more difficult, and will take willingness to think at a very broad level.
Most likely, there is little point in making a substance versus activity distinction when we have at hand other reliable ways of deciding when any addiction exists in an individual.
Most of the addicted clients in the hospitals where I worked wanted to think that they were just like normal people except for their particular, self-identified dependency. They thought that if they could just learn to stop using their favorite addictive, life would be back to normal. That, of course, is one of the most popular delusions among addicts. They think, If I could just stop doing X, life would be wonderful again.
I don't want to destroy the hope some addicts have, but there are two problems with this thinking. First, there is some likelihood that, without special care, a new addiction will be substituted for the old one. Call it cross-addiction, but this is very common in someone starting to abstain from a primary addiction. They almost always want something to fill the void left by the old addiction. Second, life has probably never been normal for most fully developed addicts, especially if they started early. They often have little desire or skill for normal living, and when they practice being normal it seems dull or frightening at first. Worst of all, they don't know how to deal with their darkest feelings, emotions that overtake them when they don't use their addiction for self-medication.
Please keep in mind that I am talking now about very advanced addictions in clients entering a hospital treatment program. Using the list of triggers mentioned in a previous column, we correlated each person's scores on two sub-sets of items, the substance related addictions and the activity related addictions. Among patients coming to the hospital for treatment, the correlation between the two was extreme. If the client was high in substance use or abuse, he or she tended to be high in non-substance use. Few clients reported having problems with just a single addiction. Multiple addictions were the rule. I learned from interviews that these additional patterns of use often didn't seem to amount to full-blown dependencies, but they were there. I suspect they were just waiting to grow worse if they were given a vacuum to fill. Although some patterns were not as severe as others, the concern is that what is presently controlled may become a full-blown addiction when the primary addiction is put on hold.
Addictions, however, are not like light switchers, either on or off. Addictions are very fluid affairs growing stronger and weaker throughout life and with changing circumstances. That's a problem in calling addiction a disease. Although the severity of a physical illness can vary somewhat between individuals, you either do or don't have a physical illness such as chicken pox. In physical illness, a specific cause can usually be identified and often eliminated. But people can slide up and down the scale of severity with any addiction depending, I think, on the emotional background of life. It is tempting to believe that the addictive agent or activity is the cause of the dependency. Our thinking stops at that point. If that's all we took as truth, we would become prohibitionists trying to eliminate some very useful things that average or normal people can use and enjoy in moderation, Besides, prohibition always seems to fail and cause even worse social problems.
A large sample of high school students took the same quiz listing their triggers, and had much, much lower total scores. Members of the staff had lower scores than their patients, thank goodness. Among the students with slightly higher scores, the activity addictions predominated. The kids tended to overdo it sometimes in shopping, exercise, collecting and talking. Would these be the children who would progress to substance abuse? We don't know that, but it is a fascinating question.
These particular high school kids in Reno, Nevada lived surrounded by gambling, and many of their parents worked in the gaming industry. Not only were there many large casinos, but also the gas stations and food markets offered slot machines. Nevertheless, few of the kids reported gambling as a problem. The common attitude was that gambling is for the tourists and there were much more interesting things to do. I wonder if hanging out at the mall could be an addiction?
Denial is said to be a hallmark of addiction. This means that the addicted person has trouble seeing a dependency for what it is: loss of control. He or she minimizes, ignores and avoids the problems caused by addiction and usually claims an ability to stop at any time. This denial is well known among recovering people and therapists. Interestingly, denial may have something to do with the spread of Twelve Step recovery programs from alcohol to all manner of addictions. Rather than look at all possible destructive behaviors at one time, most people prefer to pick just one. In the telephone directory of most large cities, and on the Internet, you can find listings for: Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Emotions Anonymous, Sex and Love Anonymous, Cocaine Anonymous, Marijuana Anonymous, Credit Abuse Anonymous, Tobacco Anonymous, and more. There are those who even see violent behavior, robbery and child sexual abuse as addictions for some. As I write this I've not found anywhere a self-help group that welcomes all addictions of all sorts.
Is this host of different self-help groups good news? At first glance, it would seem wonderful that people are banding together to use the Twelve Steps for recovery for all these different addictions. But I've seen what goes on in many of the different groups. In some groups of alcoholics, smoking, sugar use and caffeine consumption rage out of control. Some members of Gamblers Anonymous would benefit from membership in Overeaters Anonymous. Some members of O.A. turn to alcohol after their meetings. Some members of Cocaine Anonymous argue that marijuana is an acceptable recreational drug. Almost all addicts think they are entitled to some rewarding substitute for what they must give up in their primary addiction. We call these feelings entitlement feelings.
A.A. groups sometimes forbid members to mention any problems they may be having with other addictions and insist that members stick to the announced topic. "We can only deal with one problem at a time," seems to be the slogan. And that, to my mind, suggests massive denial. It also raises the question: what is the real problem after all? What underlies multiple dependencies and what is common to all?
From all these different self help groups arise many wonderful recovery stories; that's the happy news. Substitute addictions, however, may emerge to make life hell once more. Nothing more than the name of the addiction has changed, and then the whole process of ruin, denial and the need for a new recovery begins again.
I remember one fellow who stayed away from his addiction for years attending meetings of his Twelve Step group where he was a leader, but he never gave up his constant womanizing. He never stopped taking graft money in his construction business. He got drunk a lot, too, because he did not see alcohol as primary problem.
Until and unless we begin to see all these separate addictions as mere symptoms of some deeper, more profound and underlying disorder, the chaos will continue. People will become different, not better. As long as we ignore the serious and likely occurrence of substitute and multiple addictions, relapse will be the rule rather than the exception. New, substitute addictions undermine the resolve to abstain from the primary problem, relapse occurs and life is worse than before.
Mental health professionals take part in the denial conspiracy, but their motivations may have a different origin. In the United States and in some other countries, profit drives the professional's interest in treating addictive behavior. Under certain health insurance plans we can treat sequential addictions that crop up in the individual over time, but we may be prevented from offering treatment for the same addiction a second or third time.
For a select and well-to-do few, going to expensive treatment programs again and again seems like hospital dependence. In other areas of medicine, some hypochondriacs visit one hospital after the other seeking the soothing attention ill health brings. I knew one fellow who was such a hospital pest that he ended up in neurology getting a pre-frontal lobotomy. That cooled him off permanently and he didn't seem to want much after that.
The names of our treatment programs reflect a narrowness of focus: they are usually separately named and often have separate staffs for alcohol, gambling, and drug abuse. People today go for specialized treatment such as alcohol or gambling. Some of these specialized programs are hospital based and some are located in halfway houses or in day treatment centers. These programs often employ recovering peer counselors who may or may not know anything about other addictions or about more general health issues.
Recovering peer counselors, some say, are essential to help in the recovery process. They certainly can serve a good examples. Another view is that they are cheap labor, have little training in health care and serve mainly as Judas Goats leading the innocent addict to financial slaughter by the medical establishment.
Some professionals have built reputations and even financial empires treating specific addictions; they may have invested a great deal emotionally and financially in specialized treatment. The government offers research grants for all the different addictions so that the separation of treatment facilities continues because of money interests. Funding sources often demand a narrow focus. Why, for example, would the casino industry be interested in anyone but the problem gambler? The gaming industry contributes money for research on gambling problems at the same time it uses free alcohol us get clients to gambler more impulsively. They know that many heavy gamblers are also heavy smokers; to that end they spend huge amounts of money for air circulation systems in order to avoid a ban on tobacco. Lavish food buffets also flourish in casinos, and food is used as a complementary thank you for having gambled away a lot of money, so don't expect the gaming industry to support research on obesity.
Various government agencies have specific legislative mandates to help in very limited areas of addiction and either cannot or will not venture into other fields no matter how pertinent they may be.
We can break through the denial that all addictions share a common psychology and physical bonds only with compelling evidence. So, it starts with a theory of addictive susceptibility or vulnerability, it starts in recognizing what I have called The Addictive Response. If we can build a good general theory of addictive behavior and then show that it works to produce effective treatment, things might begin to change.
Speaking of research, it is very difficult to prove that professional mental health treatment for addictive behavior works at all. If you want to put a new prescription drug on the market, you have to prove that it works and that it doesn't kill people. The claims made by the producers of over-the-counter medicine are also carefully monitored for truth. But, there are very few long term studies of how well treatment for addictions works, or if it works at all. When we put together a program we pile on whatever seems like it has a chance of helping. As a result we never know which part, if any, had an effect. Was it the lectures, the films, the evening Twelve Step groups or perhaps merely the respite and attention of being cared for? Good follow-up is difficult to do in any case because it's so hard to track down program graduates even a few months after they leave a program.
In spite of the lack of evidence of real benefit, however, programs for addiction grow in number every year and honest efforts to show the effectiveness of treatment are under weigh.
I will always believe, again with little evidence to lean on, that simply admitting a problem and walking through the doors of a treatment program or a self-help group is the single most important cure one can begin for oneself. Recognizing a problem is the first necessary step in solving it.
There are some recovering people and many mental health professionals who claim that changing more than one addiction at a time is impossible. But, that claim is based on the assumption that there is really a multitude of different disorders rather than a single disorder to be treated. A common, underlying disorder would probably require very different treatment methods, different staff training and different funding schemes. Treatment for the Addictive Response would, I'm sure, be rather different from that offered in specialized addiction programs.
I used to call the basic disorder the Addictive Response Pattern (ARP), but The Addictive Response (AR) will do. The general theory of AR also offers a Model of Addiction and Recovery Stages (MARS) that I will present in the next few installments. If we decided there is actually only a single disorder to be treated, the content of what we teach people would be different and would reflect different values, priorities and lifestyle changes, different from those commonly held today. We might see that the task is much greater than we had thought, but we might also find easy, efficient and effective ways to approach change, to formulate methods and goals that we have not yet imagined in our specialized work.
I suspect that denial explains the resistance to seeing different addictions as only signs of a single underlying disorder, but there always reasons for denial and they need to be understood, changed and let go of if we expect progress.
We can sympathize with someone in severe physical pain, but when someone is suffering from intense and constant unpleasant emotions we may not even notice it. Even if someone we know complains of feeling wretched, we are at a loss to make helpful suggests, so we simply tell them to cheer up, get over it or go see a shrink.
It is easy to make up different classes or types of addiction, types such as substance abuse verses activity addictions. Or, we could divide up the addictions in terms of mood elevators(uppers) and tranquilizers (downers). Still other classifications could be made on the basis of what particular emotions seem to drive the individual addict. What is difficult is to see are the underlying characteristics of all real addictions. At the most general level, unpleasant emotions are evident in every case. Setting up different classes is easy, but I do not think very helpful. Seeing the underlying unity in various addictions is more difficult, and will take willingness to think at a very broad level.
Most likely, there is little point in making a substance versus activity distinction when we have at hand other reliable ways of deciding when any addiction exists in an individual.
Most of the addicted clients in the hospitals where I worked wanted to think that they were just like normal people except for their particular, self-identified dependency. They thought that if they could just learn to stop using their favorite addictive, life would be back to normal. That, of course, is one of the most popular delusions among addicts. They think, If I could just stop doing X, life would be wonderful again.
I don't want to destroy the hope some addicts have, but there are two problems with this thinking. First, there is some likelihood that, without special care, a new addiction will be substituted for the old one. Call it cross-addiction, but this is very common in someone starting to abstain from a primary addiction. They almost always want something to fill the void left by the old addiction. Second, life has probably never been normal for most fully developed addicts, especially if they started early. They often have little desire or skill for normal living, and when they practice being normal it seems dull or frightening at first. Worst of all, they don't know how to deal with their darkest feelings, emotions that overtake them when they don't use their addiction for self-medication.
Please keep in mind that I am talking now about very advanced addictions in clients entering a hospital treatment program. Using the list of triggers mentioned in a previous column, we correlated each person's scores on two sub-sets of items, the substance related addictions and the activity related addictions. Among patients coming to the hospital for treatment, the correlation between the two was extreme. If the client was high in substance use or abuse, he or she tended to be high in non-substance use. Few clients reported having problems with just a single addiction. Multiple addictions were the rule. I learned from interviews that these additional patterns of use often didn't seem to amount to full-blown dependencies, but they were there. I suspect they were just waiting to grow worse if they were given a vacuum to fill. Although some patterns were not as severe as others, the concern is that what is presently controlled may become a full-blown addiction when the primary addiction is put on hold.
Addictions, however, are not like light switchers, either on or off. Addictions are very fluid affairs growing stronger and weaker throughout life and with changing circumstances. That's a problem in calling addiction a disease. Although the severity of a physical illness can vary somewhat between individuals, you either do or don't have a physical illness such as chicken pox. In physical illness, a specific cause can usually be identified and often eliminated. But people can slide up and down the scale of severity with any addiction depending, I think, on the emotional background of life. It is tempting to believe that the addictive agent or activity is the cause of the dependency. Our thinking stops at that point. If that's all we took as truth, we would become prohibitionists trying to eliminate some very useful things that average or normal people can use and enjoy in moderation, Besides, prohibition always seems to fail and cause even worse social problems.
A large sample of high school students took the same quiz listing their triggers, and had much, much lower total scores. Members of the staff had lower scores than their patients, thank goodness. Among the students with slightly higher scores, the activity addictions predominated. The kids tended to overdo it sometimes in shopping, exercise, collecting and talking. Would these be the children who would progress to substance abuse? We don't know that, but it is a fascinating question.
These particular high school kids in Reno, Nevada lived surrounded by gambling, and many of their parents worked in the gaming industry. Not only were there many large casinos, but also the gas stations and food markets offered slot machines. Nevertheless, few of the kids reported gambling as a problem. The common attitude was that gambling is for the tourists and there were much more interesting things to do. I wonder if hanging out at the mall could be an addiction?
Denial is said to be a hallmark of addiction. This means that the addicted person has trouble seeing a dependency for what it is: loss of control. He or she minimizes, ignores and avoids the problems caused by addiction and usually claims an ability to stop at any time. This denial is well known among recovering people and therapists. Interestingly, denial may have something to do with the spread of Twelve Step recovery programs from alcohol to all manner of addictions. Rather than look at all possible destructive behaviors at one time, most people prefer to pick just one. In the telephone directory of most large cities, and on the Internet, you can find listings for: Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Emotions Anonymous, Sex and Love Anonymous, Cocaine Anonymous, Marijuana Anonymous, Credit Abuse Anonymous, Tobacco Anonymous, and more. There are those who even see violent behavior, robbery and child sexual abuse as addictions for some. As I write this I've not found anywhere a self-help group that welcomes all addictions of all sorts.
Is this host of different self-help groups good news? At first glance, it would seem wonderful that people are banding together to use the Twelve Steps for recovery for all these different addictions. But I've seen what goes on in many of the different groups. In some groups of alcoholics, smoking, sugar use and caffeine consumption rage out of control. Some members of Gamblers Anonymous would benefit from membership in Overeaters Anonymous. Some members of O.A. turn to alcohol after their meetings. Some members of Cocaine Anonymous argue that marijuana is an acceptable recreational drug. Almost all addicts think they are entitled to some rewarding substitute for what they must give up in their primary addiction. We call these feelings entitlement feelings.
A.A. groups sometimes forbid members to mention any problems they may be having with other addictions and insist that members stick to the announced topic. "We can only deal with one problem at a time," seems to be the slogan. And that, to my mind, suggests massive denial. It also raises the question: what is the real problem after all? What underlies multiple dependencies and what is common to all?
From all these different self help groups arise many wonderful recovery stories; that's the happy news. Substitute addictions, however, may emerge to make life hell once more. Nothing more than the name of the addiction has changed, and then the whole process of ruin, denial and the need for a new recovery begins again.
I remember one fellow who stayed away from his addiction for years attending meetings of his Twelve Step group where he was a leader, but he never gave up his constant womanizing. He never stopped taking graft money in his construction business. He got drunk a lot, too, because he did not see alcohol as primary problem.
Until and unless we begin to see all these separate addictions as mere symptoms of some deeper, more profound and underlying disorder, the chaos will continue. People will become different, not better. As long as we ignore the serious and likely occurrence of substitute and multiple addictions, relapse will be the rule rather than the exception. New, substitute addictions undermine the resolve to abstain from the primary problem, relapse occurs and life is worse than before.
Mental health professionals take part in the denial conspiracy, but their motivations may have a different origin. In the United States and in some other countries, profit drives the professional's interest in treating addictive behavior. Under certain health insurance plans we can treat sequential addictions that crop up in the individual over time, but we may be prevented from offering treatment for the same addiction a second or third time.
For a select and well-to-do few, going to expensive treatment programs again and again seems like hospital dependence. In other areas of medicine, some hypochondriacs visit one hospital after the other seeking the soothing attention ill health brings. I knew one fellow who was such a hospital pest that he ended up in neurology getting a pre-frontal lobotomy. That cooled him off permanently and he didn't seem to want much after that.
The names of our treatment programs reflect a narrowness of focus: they are usually separately named and often have separate staffs for alcohol, gambling, and drug abuse. People today go for specialized treatment such as alcohol or gambling. Some of these specialized programs are hospital based and some are located in halfway houses or in day treatment centers. These programs often employ recovering peer counselors who may or may not know anything about other addictions or about more general health issues.
Recovering peer counselors, some say, are essential to help in the recovery process. They certainly can serve a good examples. Another view is that they are cheap labor, have little training in health care and serve mainly as Judas Goats leading the innocent addict to financial slaughter by the medical establishment.
Some professionals have built reputations and even financial empires treating specific addictions; they may have invested a great deal emotionally and financially in specialized treatment. The government offers research grants for all the different addictions so that the separation of treatment facilities continues because of money interests. Funding sources often demand a narrow focus. Why, for example, would the casino industry be interested in anyone but the problem gambler? The gaming industry contributes money for research on gambling problems at the same time it uses free alcohol us get clients to gambler more impulsively. They know that many heavy gamblers are also heavy smokers; to that end they spend huge amounts of money for air circulation systems in order to avoid a ban on tobacco. Lavish food buffets also flourish in casinos, and food is used as a complementary thank you for having gambled away a lot of money, so don't expect the gaming industry to support research on obesity.
Various government agencies have specific legislative mandates to help in very limited areas of addiction and either cannot or will not venture into other fields no matter how pertinent they may be.
We can break through the denial that all addictions share a common psychology and physical bonds only with compelling evidence. So, it starts with a theory of addictive susceptibility or vulnerability, it starts in recognizing what I have called The Addictive Response. If we can build a good general theory of addictive behavior and then show that it works to produce effective treatment, things might begin to change.
Speaking of research, it is very difficult to prove that professional mental health treatment for addictive behavior works at all. If you want to put a new prescription drug on the market, you have to prove that it works and that it doesn't kill people. The claims made by the producers of over-the-counter medicine are also carefully monitored for truth. But, there are very few long term studies of how well treatment for addictions works, or if it works at all. When we put together a program we pile on whatever seems like it has a chance of helping. As a result we never know which part, if any, had an effect. Was it the lectures, the films, the evening Twelve Step groups or perhaps merely the respite and attention of being cared for? Good follow-up is difficult to do in any case because it's so hard to track down program graduates even a few months after they leave a program.
In spite of the lack of evidence of real benefit, however, programs for addiction grow in number every year and honest efforts to show the effectiveness of treatment are under weigh.
I will always believe, again with little evidence to lean on, that simply admitting a problem and walking through the doors of a treatment program or a self-help group is the single most important cure one can begin for oneself. Recognizing a problem is the first necessary step in solving it.
There are some recovering people and many mental health professionals who claim that changing more than one addiction at a time is impossible. But, that claim is based on the assumption that there is really a multitude of different disorders rather than a single disorder to be treated. A common, underlying disorder would probably require very different treatment methods, different staff training and different funding schemes. Treatment for the Addictive Response would, I'm sure, be rather different from that offered in specialized addiction programs.
I used to call the basic disorder the Addictive Response Pattern (ARP), but The Addictive Response (AR) will do. The general theory of AR also offers a Model of Addiction and Recovery Stages (MARS) that I will present in the next few installments. If we decided there is actually only a single disorder to be treated, the content of what we teach people would be different and would reflect different values, priorities and lifestyle changes, different from those commonly held today. We might see that the task is much greater than we had thought, but we might also find easy, efficient and effective ways to approach change, to formulate methods and goals that we have not yet imagined in our specialized work.
I suspect that denial explains the resistance to seeing different addictions as only signs of a single underlying disorder, but there always reasons for denial and they need to be understood, changed and let go of if we expect progress.
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