Addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships.
Now I am very much opposed to the anthropomorphisms that are so common in the addiction field where we often hear about “the disease talking”, but being a child of the 70’s and 80’s I was exposed to Frank Zappa’s rock opera Joe’s Garage where Joe forms an intimate relationship with a household appliance, so maybe my mind has been open to the idea of forming a relationship with inanimate objects – such as drugs, gambling or money!
Introduction
We all have basic relational needs. Bowlby, who is known for his attachment theory, says that children need four relational needs to be met in order to grow up with secure attachment: Validation, companionship, the need to have someone “stronger and wiser” to lean on and the need to influence what is happening in the relationship.
I would say that these needs can translate into 3 basic relational needs that we all have:
Spiritual connection
By Spiritual Connection I do not mean in the typical religious sense necessarily, although many people have found this connection in religion, but this could also be a relationship with anything bigger than self that helps inform morals, beliefs, behaviours, ethics and the like. It could be an inner “higher self”: something stronger or wiser to lean on.
Social security
By social security I mean that we want to fit in. We want companionship and validation. We want to belong – even the solitary person identifies themselves with a sub-culture.
Individual significance
Individual significance is the search for our place in the universe as an individual – that we are worthy of love, and at the same time we can control our surroundings and environment.
There is a biological imperative to form relationships – after all, no man is an island, or “to be human is to be in relationship with others”(Erskine, Moursund, & Trautmann, 1999).
Often it is the breakdown or lack of meaningful relationships that either move the individual towards chaotic substance use or reinforce substance use. Similarly, good relationships can move the individual out of substance use. In 1958 epidemiologist William Farr concluded that “Marriage is a healthy estate…The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony.” Marriage is one of the protective factors when it comes to addictive disorders.
If we look at the large epidemiological studies and the remission rates we find that the majority of people who meet the criteria for substance use disorders “mature out” of these disorders, often as they begin to find social security and individual significance in their interpersonal relationships, jobs, economic status and acceptance of self. For example, if we look at the data from the Epidemiological Catchment Area Survey of 1991 we see that most substance abusers and dependent individuals are not married. The data would seem to indicate that those who are chaotic substance users struggle to form enduring relationships with potential life-partners.
Figure 1: Married/Single in Psychiatric Disorders
So, can we conceive addictive disorders as a pathological relationship? Let’s start by looking at what happens when we fall in love and how that corresponds with our current understanding of addiction.
What happens when we fall in love?
Romantic love is mental illness. But it's a pleasurable one. It's a drug. It distorts reality, and that's the point of it. It would be impossible to fall in love with someone that you really saw.
- Frank Liebowitz
Most of us would define love as an emotion. In fact, it is more a type of motivated behaviour. The feelings of love are to be found, neurologically, to be rooted in the limbic reward and motivation systems. When we fall in love, we note a number of profound changes in behaviour. In the paper “Defining the Brain Systems of Lust, Romantic Attraction and Attachment”, Fisher, Aron and others describe 13 psychophysiological characteristics commonly associated with romantic love, and it is clear to see how these are mirrored in addictive disorders.
To summarise, when we fall in love, the object of affection takes on an undue importance. There is increased salience attribution and a corresponding decline of interest in the things that were once important to us; we focus only on the positive aspects, ignoring the negative.
We know the profile of a person in love: They forget to eat, they focus all their attention on their new-found lover, ignore their friends, miss appointments; they spend undue amounts of time and money on the object of their desire. They do things they would never consider doing in their “sane” state. Sounds like they’re addicted but they are simply in love, a very human condition that makes us seem to take leave of our senses.
Helen Fisher, who has conducted a number of studies, including the one quoted above, is one of the foremost authorities on romantic love and has turned this into fame and fortune through the dating websites match.com and chemistry.com. She says: “Romantic love is an addiction. It’s a very powerfully wonderful addiction when things are going well and perfectly horrible when things are going poorly”
Neurobiologically there is impaired decision making ability in the pre-frontal cortex. There are brain changes taking place. There is the age-old battle between the limbic system and the executive branch! Serotonin levels drop which leads to intrusive thinking around the object of love. Dopamine increases and focuses attention.
Fisher and Aaron also studied relationship breakups using fMRI scans to see exactly where there was brain activity. Part of this study was to examine the obsessive thinking that is so often part of romantic break-ups. The researchers concluded: “The specific findings are significant because they tell us that the basic patterns seen in previous studies of happy love share key elements with love under these circumstances; they also tell us that what is unique to romantic rejection includes elements that are very much like the craving for cocaine.”
Nietsche wrote “There is always some madness in love. But there is always some reason in madness.”
And that reason, it has been proposed by Fisher and others, is because of the evolutionary need to find a mating partner and stay connected with that partner until the off-spring can develop some level of self-sufficiency.
Interestingly not many mammals form monogamous relationships. However, prairie voles do, and so their pairing and mating habits have been studied fairly extensively. In a paper by Burkett and Young they state:
“There is an exceptionally strong parallel between these plastic changes from pair bonding and the plastic changes seen in drug addiction. As D1 Receptors are upregulated during pair bonding and D2 Receptor are stable, this plastic change represents an alteration in the balance of D1R/D2R signalling in the striatum in favour of D1R, similar to what is seen in human PET studies of drug addiction”
The paper goes on to explain the similarities between pair bonding and addictive disorders in terms of the endogenous opioid system and the complex interaction with dopamine, Corticotropin Releasing Hormone, oxytocin and arginine vasopressin. They also have a really interesting table in the paper that shows the parallels between Social Attachment, Maternal Attachment and Drug Addiction, which is worth a look if you are interested, but is outside the scope of this talk.
Burkett and Young conclude:
“These data also provide evidence for the theory that social attachment systems governing maternal bonding and pair bonding to a mating partner are subverted by drugs of abuse to create addictions that are just as powerful as natural attachments. In a very real sense, we may be addicted to the ones we love.”
So relationships can be a form of addiction, or even a barrier to developing other kinds of addictions. As we know by curing one addictive behaviour, we may precipitate another. Indeed, the breakdown of romantic relationships can lead to the development of addictive disorders. As Lance Dodes, author of “Heart of Addiction” says “addictive acts occur when precipitated by emotionally significant events.”
Addiction as Love/Relationship/Attachment
Never fall in love with a person with a substance abuse problem because that drug will always be the other woman.
– Unknown
The title of the 14th Chapter of Dr Gabor Mate’s book “In the Realm of Hungry Ghosts” is “Through the Needle a Soft Warm Hug”. He is obviously talking about IV heroin use.
Lance Dodes writes: “For others, taking a drug or eating or gambling substitutes for a loved person whom they have lost. They make, in effect, a new relationship with the bottle or the racing track, a relationship that they never have to lose. “
Typically one may be inclined to think of drug use as correlating with lust or sexual desire. While there is certainly overlap, addiction is more closely related to romantic love and desire. If you are familiar with the term salience attribution, or motivational wanting, you will most likely be familiar with the work of Kent Berridge and his lab. Berridge has done ground-breaking work in demonstrating that liking and wanting are two distinct states of mind. He also points out that the areas of the brain linked to pleasure are rather small while the areas linked to desire take of a lot more real estate. As humans we are driven by desire.
One of the major questions in the addiction field is “why do people keep using after it stops being pleasurable?”
Marc Lewis, the developmental neuroscientist and author of the book “Memoirs of an Addicted Brain” and I have discussed this issue at some length. We both believe that this apparent paradox can be resolved when we move beyond the reductionist disease paradigm and acknowledge that addiction can be viewed as human attachment.
Early drug use can be compared to that initial period of romance in relationships, and the problems are easily overlooked. Some users are able to end the relationship before it becomes too destructive. But others come to depend on the relationship and find the possible pain of separation greater than the consequences of continued substance use.
The substances become a form of intimacy regulator, and feed into the avoidance of other forms of communication and create a pathological homeostasis of unresolved loss. There is an aspect of continuity in the addictive relationship that gives identity, a certainty of temporary escape from the tragic feelings of loss of true relational connection.
As an interesting aside, the work of Harvard Sociologist Lee Rainwater has shown that in economically disadvantaged areas people are more likely to try and meet their relational needs through a relationship with a substance or behaviour, while the middle-class look towards emotional attachment with other people for self-gratification.
The Role of sub-culture and Religion
Beyond the search for individual significance through direct relationships, many people also derive their sense of social security from the sub-culture that they enter when using drugs. Even the solitary heroin user derives some sort of collective identity from his choice of heroin.
William White has examined the complex and diverse roles that individuals play within this drug culture in his book “Pathways: From the Culture of Addiction to the Culture of Recovery: A travel Guide for Addiction Professionals”. Indeed the drug culture provides a place of refuge and social significance for many.
If we look at the need for spiritual connection we can also find that these needs can be met by the addiction. Dr Richard Wilmott, author of “American Euphoria: Saying “Know” to drugs” recently posted this provocative statement:
“Today one of the main criteria for a diagnosis of drug addiction/alcoholism is: continuing to consume alcohol or another drug “despite unpleasant or adverse consequences” (DSM). For the Christian martyrs the same criteria would apply. People of that time and place—Rome, 2nd century A.D.—could also say that this new Christianity was like a drug that endangered lives and that being a Christian had all the adverse financial, social, psychological and physical consequences that we now see in the lives of drug addicts and alcoholics. And yet Christians, of all ages, in spite of the consequences, continued to profess their faith… and continued to be eaten by lions…………Likewise, given contemporary social policy, adverse consequences befall those who abuse drugs. They lose the respect of their peers; they violate the expectations of family, friends, and colleagues; they miss out on educational opportunities; they have poor work performance and lose their job. They make harmful decisions. They "burn their bridges". Their health suffers; they have overdoses, and they die.
None of these predictions are of consequence to most “addicts”. Like the Christians who suffered and died for their faith, the addict has also made a choice… to lose everything for the “faith” in the euphoria of the drug experience. In this light it is not difficult to understand that the main treatment for alcoholics and addicts in America is religion as promulgated through the faith based AA Twelve Step programs.”
Marx’s statement that “religion is the opiate of the masses” comes to mind. It forces us to ask the question: “Is the desire for spiritual connection somehow met by the drug use and drug culture”?
The controversial field of neurotheology seeks to examine the changes in neurobiology caused by the religious commitment that could result in the choice of death over renunciation, or, similarly, the pre-existence of structural brain differences that may pre-dispose the individual towards such commitment. The reductionist or materialist point of view is that religious experience is nothing more than the results of predetermined neural activity that arises as a result of genetic, ecological and/or evolutionary pre-disposition. Similar views are held regarding the field of addiction by Volkow, Leshner and many others.
In his book The God Gene: How Faith is Hardwired into our Genes, Hamer proposes that a variation in a gene known as VMAT2 is the "God Gene", and through the effect of this gene on dopamine, serotonin and norepinephrine we are hard-wired for transcendence. Anyone with even a basic knowledge of addiction neuroscience will recognise the same monoamines mentioned as being amongst the usual suspects in addictive disorders. Indeed they are closely linked to the motivational and reward system.
William White in an essay entitled The Role of Spirituality in Substance Abuse Prevention, describes spirituality: "A heightened state of perception, awareness, performance or being that personally informs, heals, empowers, connects, centers or liberates". Once again, this sounds like drug use to me, although for those suffering from addictive disorders the drug often reveals itself to be an imposter, in much the same way as the abusive marriage partner reveals their true nature.
In his book The God Gene: How Faith is Hardwired into our Genes, Hamer proposes that a variation in a gene known as VMAT2 is the "God Gene", and through the effect of this gene on dopamine, serotonin and norepinephrine we are hard-wired for transcendence. Anyone with even a basic knowledge of addiction neuroscience will recognise the same monoamines mentioned as being amongst the usual suspects in addictive disorders. Indeed they are closely linked to the motivational and reward system.
William White in an essay entitled The Role of Spirituality in Substance Abuse Prevention, describes spirituality: "A heightened state of perception, awareness, performance or being that personally informs, heals, empowers, connects, centers or liberates". Once again, this sounds like drug use to me, although for those suffering from addictive disorders the drug often reveals itself to be an imposter, in much the same way as the abusive marriage partner reveals their true nature.
So we can see that love can be conceived as addiction, addiction can be conceived as attachment or relationship and that addictive behaviours can conceivably satisfy the three relational needs.
Informing Treatment
All this conjecture, in my mind, is only of importance if it can inform treatment.
One of the most important predictors of success in addiction treatment is indeed the therapeutic bond. Research tells us that the mode or model of therapeutic intervention is less important than the relationship the patient develops with the therapist and facility. The SAMHASA registry of Evidence-Based Practices states:
• The development of a good alliance is essential for the success of psychotherapy, regardless of the type of treatment.
• The ability of the therapist to bridge the client’s needs, expectations, and abilities into a therapeutic plan is important in building the alliance.
• Because the therapist and client often judge the quality of the alliance differently, active monitoring of the alliance throughout therapy is recommended.
• Responding nondefensively to a client’s hostility or negativity is critical to establishing and maintaining a strong alliance.
• Clients’ evaluation of the quality of the alliance is the best predictor of outcome; however, the therapist’s input has a strong influence on the client and is therefore critical.
It has been said that in the case of those recovering from addictive disorders the therapist becomes the subject of primary attachment. For this reason ethical/boundary issues are extremely difficult to manage in the treatment of addictive disorders. Certainly in our outpatient program we have found that people form a relationship with the centre, the therapist and the community. It is, in my opinion, vital that this is recognised and be maximised as part of the transient process where the individual patient is encouraged to shift their primary relationship from the drug/culture to the treatment providers and peers, and then on to meaningful external relationships. Unfortunately we often find that the relationship does not grow beyond the therapeutic setting, and therefor as soon as this new supportive relationship is not available, a fall-back to the old relationship, or relapse, is inevitable.
I would say that the “success” of programs such as the 12-step programs does not lie primarily in the process, but rather in the relationships that the addicted person is able to form. To find Individual significance even with the “addict” identity by saying “my names Shaun and I’m an addict”, to find social security in the group, and to find spiritual connection in the "higher power" are for me far more compelling factors in the recovery process than dubious concepts such as “powerlessness”, “denial” and “the disease”.
Similarly we see that “spiritual awakening” can precipitate an almost instant miracle cure for addictive disorders – as Jung has stated “Spritus contra spiritum”, or in the view of William James "The only cure for dipsomania is religiomania." Obviously, in the majority of cases, these awakenings are not Damascus road experiences like Paul’s where it’s only God and the individual, but rather there is a church structure that becomes the new system – satisfying the relational needs on many levels, with the addict experiencing the new identity as the prodigal son, the social security of a non-judgemental community who provide encouragement and the new found spiritual connection with God. By finding a new identity in religion the three basic relational needs are met and separation from the drug is less painful, or at least manageable.
Now I’m not suggesting that we send everyone to Church! What I am suggesting is that we need to be cognisant of the importance of the sense of relational loss that occurs when someone decides to leave their drug of choice. In the words of Alison Wilson Shaeff: “something that required the best of you has ended. You will miss it.”
We need to be acutely aware of how we as treatment professionals, both individually and as a collective in the treatment setting, become the focus of attachment and the meters of relational need as the patient divorces their addiction.
In the words of Gabor Mate:
"When my patient addicts look at me, they are seeking the real me. Like children, they are unimpressed with titles achievements, worldly credentials. Their concerns are too immediate, too urgent.........What they care about is my presence or absence as a human being. They gauge with unerring eyes whether I am grounded enough on any given day to coexist with them, to listen to them as persons with feelings, hopes and aspirations that are as valid as mine. They can tell instantly whether I am genuinely committed to their well-being or just trying to get them out of my way. Chronically unable to offer such caring to themselves, they are more sensitive to its presence or absence in those charged with caring for them."
Conclusion
So I would like to conclude by suggesting that maybe our patients need less addiction counselling and more counselling relationship; and, perhaps, some relationship counselling.
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