This article belongs to Addictions Anonymous column.
While interviewing hundreds of addicted clients over the years it became obvious to me that addictions are what mental health experts call developmental disorders. That is, they develop over time as the result experience, genetics and growth. Sometimes they appear quickly and sometimes it takes years, but the stages of their development always seemed similar between individuals and between addictions. I evolved a description of the stages of addiction and recovery as a kind of theoretical structure, as a teaching device when I worked at the Veterans Administration Hospital in Ren, Nevada. Later, the stages were included in several published papers and eventually in a treatment manual developed for use in treating problem gamblers in Las Vegas by a company called Trimeridian.
It also became clear to me that, although the separate addictions have been treated as very different problems, they are manifestations of a single underlying disorder that I�ve called the Addictive Response Pattern or simply, the Addictive Response.
My desire was not so much to build a formal theory as to describe as simply as possible a general process many addicted individuals go through. The description includes common intellectual and behavioral features that appear as people grow and change from an initial addictive experience through the final stage of recovery and abstinence.
The Stages of Addiction and Recovery Model (SARM) suggests a continuous development and change process best viewed as an unfolding series of characteristics with no abrupt change points such as hitting some sort of bottom or particular point of desperation. Older theories viewed the growth of addiction and recovery as opposite patterns while SARM attempts to describe a continuous process of development.
The developmental flow suggested by SARM is divided into six stages each of which is a description of the thinking of an individual with respect to a particular addictive at any given moment. The term addictive is used here as a noun to indicate the substance or activity that holds addictive potential for vulnerable individuals. It is the trigger needed for the addiction.
SARM does not assume that the individual is in the same stage with different addictives. That is, one could be in the advanced stages of alcoholism but a beginning gambler. Knowing what stage of progression or development an individual is in with respect to different addictives might be useful in predicting the need for treatment, the level or intensity of treatment, and the possible outcome in terms of quality of life and abstinence.
Developed in the context of a program for different addictions - a program we called the Addictive Disorders Treatment Program - we dealt with a broad range of addictions including gambling, alcohol and substance abuse. SARM should be valid for all addictive developments and could be applied to any addiction, even those not seen as a primary addiction for any given client. Research shows that clients with any specific addiction very often have other addictions that are usually not addressed in specialized programs for alcoholism, problem gambling, overeating or substance abuse.
The tendency to substitute some other addiction for one that has become inactive is nearly universal. Clients are, in fact, sometimes encouraged by advisors to find substitutes to fill some supposed void once they have undertaken abstinence from a primary addiction. Thus, without intending to develop any new addiction, an alcoholic may find increasing problems with gambling or overeating during periods of alcohol abstinence. Smoking and abuse of prescription drugs are frequent in addictive disorder clients as are non-substance dependencies such as compulsive spending and over-working on a job.
There is a risk of harming people with a single-minded, narrowly focused treatment of one addiction at a time. Let�s suppose we have someone coming for help with a gambling problem. She is a long time smoker, but smoking was not permitted during treatment sessions, was not seen as relevant in treating the gambling and was ignored. Other minor or sub-clinical potential addictions were ignored while the gambling was suppressed by treatment. We learned, during the initial interview, that there was some overeating, occasional misuse of prescription drugs and unfaithfulness to the spouse. Again, these were not the focus of treatment and were basically ignored. They did not fit the diagnostic standards applied in treatment at the time.
This individual, to summarize, was a moderate drinker who occasionally over-used cold remedies, engaged in casual sex from time to time and was somewhat overweight. None of these were treated as problems as staff focused attention on the gambling, and yet her other behaviors, although at the time moderate, may have been more dangerous to health than the gambling. Had her treatment focused on learning what are called coping skills�skills necessary for self-managing emotions and behavior�it may have been of some general benefit. Unfortunately, in most specialized treatment programs, other addictions are seldom mentioned and discussions focus on the primary or identified addiction.
Was the specialized gambling program successful? If we look only at the gambling, yes. She went home, attended Gamblers Anonymous and all seemed well. Unfortunately, compensatory addictions soon developed. She almost never gambled following treatment, but drinking, promiscuous behavior and the use of barbiturates escalated. She continued to expose herself to the health risks of tobacco use. The woman was still looking for a solution to her lifelong dark feelings that were not addressed by the program for gambling.
When a primary addiction is suddenly stopped there is a very strong tendency to develop a compensatory addiction that is usually one the client already had at some milder level and which now grows stronger and serves as a substitute preventing real emotional and intellectual growth. Compensatory addictions soon undermine abstinence from the primary addiction and are a major cause of relapse. This is why it is so important to assess a person�s progression in all likely addictions at the beginning of an intervention or treatment for a specific addiction. Of what value is successful alcoholism treatment if the client leaves with a stronger likelihood of gambling or prescription drug abuse? Again, it is very likely that the different addictive progressions within the same client sometimes move independently and mask the single underlying disorder that I have called the generalized Addictive Response Pattern
The division of life into stages is arbitrary and artificial; it�s like calling different parts of a river or a road by different names, and we do this sometimes just to be able to talk about different parts of the same process. The test of the usefulness is whether or not the addict can see how these parts played out in life.
I recognize six stages of development in the addict:
1. Delight and Discovery
2. Protection and Promotion
3. Defense and Denial
4. Resentment and Relapse
5. Acceptance and Abstinence
6. Growth and Gratitude
1. Delight and Discovery: In this first stage, a person samples a trigger, probably for the first time, and may experience a rather immediate and strong emotional contrast effect. Sometimes, of course, a first use causes fear or nausea, but with some encouragement for continued use the user of the new trigger finds it will produce a high or altered state that contrasts vividly to the customary background of dark feelings, emotions that have never been confronted and dealt with. Hyperphoria and sometimes great relaxation replace the normally painful collection of depressing emotions and thoughts. Having had this delightful experience, the new user of the addictive suddenly becomes a champion of its use not only for self, but for others as well. The trigger is suddenly seen as a kind of miracle drug or extremely important activity. The user is self-medicating rather than solving emotional problems.
With some triggers such as smoking tobacco or marijuana there is only an increase in general comfort level and ability to relax, not an excited high. The user may not even notice this change in feelings, but will easily become dependent upon it.
The social isolation of the addict-to-be may begin when others not subject to the same tensions, dark feelings and thoughts see little point in heavy use of the addictive. Attempts to convert the wrong (invulnerable) people to use eventually drive people away, and the individual is left to the company of like-minded users
First use is described by addicts in many ways:
It was like coming home to a warm fire.
I felt like a huge stone had been lifted from my shoulders.
I finally felt normal and relaxed.
It gave me such self-confidence like I�ve never known before.
Life took a new, wonderful meaning for me.
I never relaxed, even when I slept, until I found this.
I knew then that I could do anything. It made me feel invincible.
It�s a wonderful way to relax and take a break.
It�s my one big treat, my one expensive luxury.
Some beginning addicts do actually stay at this mild level without further obvious progression, and they may stay there for long periods until some life reversal or major transition increases vulnerability. Some are willing to give up use because the loss of friends is too high a price to pay for fun. What is called natural recovery is possible at any point depending on the individual�s level of vulnerability. Dark feelings come and go; they can exist at all levels of intensity. Some others may find an alternative addiction that fits better in their social circle.
2. Protecting and Promoting. The new addict continues to try to promote use among others convinced he or she has discovered some great truth. Enthusiastic evangelical crusading, of course, doesn�t pay off. The user may find employment in a related industry, anything from street drug sales to a return to college to study pharmacy. One fellow took a job selling wholesale to taverns and spent his days visiting many bars giving out free bottles to bar tenders and sample drinks to patrons. One new gambler recruited a group of friends to help in a betting scheme he thought would beat the casino. (He�s still in jail.)
The addict may oppose any social or legal restrictions on use of their particular addictive; all restrictions seem unduly harsh, the addict tends to view him or herself as a rebel or enlightened reformer. The circle of real friends grows smaller while the devotion of fellow users is mistaken as real friendship. At this point the addict is protecting the trigger from blame, protecting use of the trigger and still attempting to promote its use by others.
3. Defense and Denial. At this mid point in the development of an addiction the social and financial costs become gradually more obnoxious interfering constantly with the enjoyment of the trigger. The addictive trigger, in fact, may now require increased use in amount and frequency. Tolerance for the addictive increases, but the original refreshing high gets harder to reach.
The addict may hit physical or financial limits of consumption at this point without reaching the old, desired level of euphoria or satisfaction. At the same time, physical tolerance is gradually lowered as the years pass.
Family arguments become increasingly bitter, problems on the job may develop and possibly there are legal problems such as drunken driving charges, loan sharks and even crime to support the addiction. Increasing pressure to stop or hide the use of the addictive leads to resentment and an increase in background dark feelings when not using. There may be ineffective and half-hearted efforts to stop or moderate use. Rebound depression now demands a more immediate return to elaborate anticipation and use. The addict may gradually become more secretive attempting to hide use from family and co-workers.
4. Resentment and Relapse. Growing resentment at social sanctions against use and at the damage being done by constant use lead to outbursts of anger, impulsive acts and frequent periods of angry abstinence followed by devastating periods of return to use. Attempts to abstain are undermined by a refusal to change values and priorities. The addict has many criticisms of any program or therapist that tries to help often blaming others for a relapse. Abstinence at this stage is often similar to what has been called a dry drunk. Dark feelings that have been suppressed by the addictive may come to the surface during periods of abstinence. The addict is particularly vulnerable at this point to compensatory or substitute addictions. For some, resentment and constant relapse become a way of life. By now, the addict may have lost everything worth having and may become uncaring, isolated and even suicidal. It is extremely difficult to talk about help with such an addict since, by now, he or she has experienced a variety interventions none of which have worked. A sense of hopeless surrender to the addiction may develop and we hear them saying, �I know I was doing the wrong, stupid thing, but I just didn�t care anymore.�
5. Growth and Gratitude. A relatively few addicts reach this final state that is the doorway or beginning of normal living. There may come about a radical change in values and attitudes about life and about addiction. Some, of course, have reported having a spiritual experience, an epiphany or sudden insight. Most, however, discover a different way of thinking and living more gradually through a self-help group, individual counseling, study on their own or simply increasing age and life experience. They gradually, in a hundred different ways, learn to manage dark feelings. People can and do continue their psychological growth and can outgrow addictions without substituting new ones. As they once blamed their addiction on other people, places or events, they may now credit their newly found ability to abstain to something going on in their lives at the time of this breakthrough. It might be a twelve step group, a psychotherapy experience, religion, college, etc. Any one of these experiences and many others can produce the new ideas and the new ways of dealing with destructive feelings and impulses.
Hopefully, the reader at this point may have some greater understanding of the bug that bites the addict, and about yet other bugs still waiting to bite. But, understanding and insight alone do not amount to a cure. Psychological growth takes work, study, time and energy. In the next few articles, I take a more detailed look at the attitudes, lifestyle changes and problems offered by most so-called Twelve Step groups. So, at this point, we move away from describing the development of addiction in order to look at the problems of what has been called the recovery from addiction.
It also became clear to me that, although the separate addictions have been treated as very different problems, they are manifestations of a single underlying disorder that I�ve called the Addictive Response Pattern or simply, the Addictive Response.
The Stages of Addiction and Recovery Model (SARM) suggests a continuous development and change process best viewed as an unfolding series of characteristics with no abrupt change points such as hitting some sort of bottom or particular point of desperation. Older theories viewed the growth of addiction and recovery as opposite patterns while SARM attempts to describe a continuous process of development.
The developmental flow suggested by SARM is divided into six stages each of which is a description of the thinking of an individual with respect to a particular addictive at any given moment. The term addictive is used here as a noun to indicate the substance or activity that holds addictive potential for vulnerable individuals. It is the trigger needed for the addiction.
SARM does not assume that the individual is in the same stage with different addictives. That is, one could be in the advanced stages of alcoholism but a beginning gambler. Knowing what stage of progression or development an individual is in with respect to different addictives might be useful in predicting the need for treatment, the level or intensity of treatment, and the possible outcome in terms of quality of life and abstinence.
Developed in the context of a program for different addictions - a program we called the Addictive Disorders Treatment Program - we dealt with a broad range of addictions including gambling, alcohol and substance abuse. SARM should be valid for all addictive developments and could be applied to any addiction, even those not seen as a primary addiction for any given client. Research shows that clients with any specific addiction very often have other addictions that are usually not addressed in specialized programs for alcoholism, problem gambling, overeating or substance abuse.
The tendency to substitute some other addiction for one that has become inactive is nearly universal. Clients are, in fact, sometimes encouraged by advisors to find substitutes to fill some supposed void once they have undertaken abstinence from a primary addiction. Thus, without intending to develop any new addiction, an alcoholic may find increasing problems with gambling or overeating during periods of alcohol abstinence. Smoking and abuse of prescription drugs are frequent in addictive disorder clients as are non-substance dependencies such as compulsive spending and over-working on a job.
There is a risk of harming people with a single-minded, narrowly focused treatment of one addiction at a time. Let�s suppose we have someone coming for help with a gambling problem. She is a long time smoker, but smoking was not permitted during treatment sessions, was not seen as relevant in treating the gambling and was ignored. Other minor or sub-clinical potential addictions were ignored while the gambling was suppressed by treatment. We learned, during the initial interview, that there was some overeating, occasional misuse of prescription drugs and unfaithfulness to the spouse. Again, these were not the focus of treatment and were basically ignored. They did not fit the diagnostic standards applied in treatment at the time.
This individual, to summarize, was a moderate drinker who occasionally over-used cold remedies, engaged in casual sex from time to time and was somewhat overweight. None of these were treated as problems as staff focused attention on the gambling, and yet her other behaviors, although at the time moderate, may have been more dangerous to health than the gambling. Had her treatment focused on learning what are called coping skills�skills necessary for self-managing emotions and behavior�it may have been of some general benefit. Unfortunately, in most specialized treatment programs, other addictions are seldom mentioned and discussions focus on the primary or identified addiction.
Was the specialized gambling program successful? If we look only at the gambling, yes. She went home, attended Gamblers Anonymous and all seemed well. Unfortunately, compensatory addictions soon developed. She almost never gambled following treatment, but drinking, promiscuous behavior and the use of barbiturates escalated. She continued to expose herself to the health risks of tobacco use. The woman was still looking for a solution to her lifelong dark feelings that were not addressed by the program for gambling.
When a primary addiction is suddenly stopped there is a very strong tendency to develop a compensatory addiction that is usually one the client already had at some milder level and which now grows stronger and serves as a substitute preventing real emotional and intellectual growth. Compensatory addictions soon undermine abstinence from the primary addiction and are a major cause of relapse. This is why it is so important to assess a person�s progression in all likely addictions at the beginning of an intervention or treatment for a specific addiction. Of what value is successful alcoholism treatment if the client leaves with a stronger likelihood of gambling or prescription drug abuse? Again, it is very likely that the different addictive progressions within the same client sometimes move independently and mask the single underlying disorder that I have called the generalized Addictive Response Pattern
The division of life into stages is arbitrary and artificial; it�s like calling different parts of a river or a road by different names, and we do this sometimes just to be able to talk about different parts of the same process. The test of the usefulness is whether or not the addict can see how these parts played out in life.
I recognize six stages of development in the addict:
1. Delight and Discovery
2. Protection and Promotion
3. Defense and Denial
4. Resentment and Relapse
5. Acceptance and Abstinence
6. Growth and Gratitude
1. Delight and Discovery: In this first stage, a person samples a trigger, probably for the first time, and may experience a rather immediate and strong emotional contrast effect. Sometimes, of course, a first use causes fear or nausea, but with some encouragement for continued use the user of the new trigger finds it will produce a high or altered state that contrasts vividly to the customary background of dark feelings, emotions that have never been confronted and dealt with. Hyperphoria and sometimes great relaxation replace the normally painful collection of depressing emotions and thoughts. Having had this delightful experience, the new user of the addictive suddenly becomes a champion of its use not only for self, but for others as well. The trigger is suddenly seen as a kind of miracle drug or extremely important activity. The user is self-medicating rather than solving emotional problems.
With some triggers such as smoking tobacco or marijuana there is only an increase in general comfort level and ability to relax, not an excited high. The user may not even notice this change in feelings, but will easily become dependent upon it.
The social isolation of the addict-to-be may begin when others not subject to the same tensions, dark feelings and thoughts see little point in heavy use of the addictive. Attempts to convert the wrong (invulnerable) people to use eventually drive people away, and the individual is left to the company of like-minded users
First use is described by addicts in many ways:
It was like coming home to a warm fire.
I felt like a huge stone had been lifted from my shoulders.
I finally felt normal and relaxed.
It gave me such self-confidence like I�ve never known before.
Life took a new, wonderful meaning for me.
I never relaxed, even when I slept, until I found this.
I knew then that I could do anything. It made me feel invincible.
It�s a wonderful way to relax and take a break.
It�s my one big treat, my one expensive luxury.
Some beginning addicts do actually stay at this mild level without further obvious progression, and they may stay there for long periods until some life reversal or major transition increases vulnerability. Some are willing to give up use because the loss of friends is too high a price to pay for fun. What is called natural recovery is possible at any point depending on the individual�s level of vulnerability. Dark feelings come and go; they can exist at all levels of intensity. Some others may find an alternative addiction that fits better in their social circle.
2. Protecting and Promoting. The new addict continues to try to promote use among others convinced he or she has discovered some great truth. Enthusiastic evangelical crusading, of course, doesn�t pay off. The user may find employment in a related industry, anything from street drug sales to a return to college to study pharmacy. One fellow took a job selling wholesale to taverns and spent his days visiting many bars giving out free bottles to bar tenders and sample drinks to patrons. One new gambler recruited a group of friends to help in a betting scheme he thought would beat the casino. (He�s still in jail.)
The addict may oppose any social or legal restrictions on use of their particular addictive; all restrictions seem unduly harsh, the addict tends to view him or herself as a rebel or enlightened reformer. The circle of real friends grows smaller while the devotion of fellow users is mistaken as real friendship. At this point the addict is protecting the trigger from blame, protecting use of the trigger and still attempting to promote its use by others.
3. Defense and Denial. At this mid point in the development of an addiction the social and financial costs become gradually more obnoxious interfering constantly with the enjoyment of the trigger. The addictive trigger, in fact, may now require increased use in amount and frequency. Tolerance for the addictive increases, but the original refreshing high gets harder to reach.
The addict may hit physical or financial limits of consumption at this point without reaching the old, desired level of euphoria or satisfaction. At the same time, physical tolerance is gradually lowered as the years pass.
Family arguments become increasingly bitter, problems on the job may develop and possibly there are legal problems such as drunken driving charges, loan sharks and even crime to support the addiction. Increasing pressure to stop or hide the use of the addictive leads to resentment and an increase in background dark feelings when not using. There may be ineffective and half-hearted efforts to stop or moderate use. Rebound depression now demands a more immediate return to elaborate anticipation and use. The addict may gradually become more secretive attempting to hide use from family and co-workers.
4. Resentment and Relapse. Growing resentment at social sanctions against use and at the damage being done by constant use lead to outbursts of anger, impulsive acts and frequent periods of angry abstinence followed by devastating periods of return to use. Attempts to abstain are undermined by a refusal to change values and priorities. The addict has many criticisms of any program or therapist that tries to help often blaming others for a relapse. Abstinence at this stage is often similar to what has been called a dry drunk. Dark feelings that have been suppressed by the addictive may come to the surface during periods of abstinence. The addict is particularly vulnerable at this point to compensatory or substitute addictions. For some, resentment and constant relapse become a way of life. By now, the addict may have lost everything worth having and may become uncaring, isolated and even suicidal. It is extremely difficult to talk about help with such an addict since, by now, he or she has experienced a variety interventions none of which have worked. A sense of hopeless surrender to the addiction may develop and we hear them saying, �I know I was doing the wrong, stupid thing, but I just didn�t care anymore.�
5. Growth and Gratitude. A relatively few addicts reach this final state that is the doorway or beginning of normal living. There may come about a radical change in values and attitudes about life and about addiction. Some, of course, have reported having a spiritual experience, an epiphany or sudden insight. Most, however, discover a different way of thinking and living more gradually through a self-help group, individual counseling, study on their own or simply increasing age and life experience. They gradually, in a hundred different ways, learn to manage dark feelings. People can and do continue their psychological growth and can outgrow addictions without substituting new ones. As they once blamed their addiction on other people, places or events, they may now credit their newly found ability to abstain to something going on in their lives at the time of this breakthrough. It might be a twelve step group, a psychotherapy experience, religion, college, etc. Any one of these experiences and many others can produce the new ideas and the new ways of dealing with destructive feelings and impulses.
Hopefully, the reader at this point may have some greater understanding of the bug that bites the addict, and about yet other bugs still waiting to bite. But, understanding and insight alone do not amount to a cure. Psychological growth takes work, study, time and energy. In the next few articles, I take a more detailed look at the attitudes, lifestyle changes and problems offered by most so-called Twelve Step groups. So, at this point, we move away from describing the development of addiction in order to look at the problems of what has been called the recovery from addiction.
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