Although Stanton modified this piece to meet the sensibilities of the Hazelden editorial staff, and the then editor-in-chief told him that this article was tremendously valuable to her personally, Hazelden discontinued publication of the pamphlet in 1988, after eight years of consistently high sales. The new editor-in-chief, Linda Peterson, wrote Stanton that she took this step because, "Unfortunately, we have heard much criticism from our customers who are not in agreement with your stand on the disease concept."
Pamphlet published by Hazelden (Center City, MN), July 1980; modified from an article that appeared originally in Addictions (Ontario Addiction Research Foundation), Summer-Fall, 1977, pp. 21-41 and 36-57.
© 1977 Stanton Peele. All rights reserved.
The Addiction Experience
Morristown, New Jersey
It is understandable that people wish to explain their problems and pathologies in terms of forces which come from outside themselves, and over which they have no power. In this way we can reject accountability for our difficulties and eliminate the anxiety that comes from being responsible for both their causes and their remedies. The particular anxiety which we most welcome being freed from is that of painful self-reflection-the act of contemplating why we are the way we are and how short of perfect this is.
Alcohol and other drug addiction (and, as I shall show, non-drug addiction as well) is an area where the likelihood of such "escape from freedom" is especially great. Because these maladies engage nearly all of the body's system, physiological as well as psychological, we have tended to misconstrue the ways in which addiction grows from within ourselves in response to our environment. All data point to the fact that addiction is a lifestyle, a way of coping with the world and ourselves, a way of interpreting our experiences-including the experiences produced by psychoactive drugs. Heroin and alcohol do have a powerful impact on both a person's body and feelings, but these effects do not in and of themselves cause addiction. It is the way the person interprets and responds to the impact of a drug which is at the core of an addiction. This is determined by the individual's feelings about self and about life, as these are, in turn, determined by childhood experiences, personality, and current social setting.
Failing to recognize this means that we, as a society, will never be able to come to grips with addiction, and that it will continue, unchecked, to eat at our society from within. Nothing more need to be shown about the inadequacies and wrongheadedness of our conceptions than that. At the same time, as we spend more on cures and preventatives for addiction, our problems with addiction to narcotics, to alcohol, and to a whole host of other drugs grow inexorably.
The Experience of Addiction
Addiction is not caused by a drug or its chemical properties. Addiction has to do with the effect a drug produces for a given person in given circumstances-a welcomed effect which relieves anxiety and which (paradoxically) decreases capability so that those things in life which cause anxiety grow more severe. What we are addicted to is the experience the drug creates for us.
The most powerful addictive drugs in our society are, along with the narcotics, the barbiturates and alcohol. What these drugs have in common is not their chemical structures, which are widely diverse, but their common pharmacological property of depressing the action of the nervous system. In this way, they act to lessen a person's feeling of pain and sense of the difficulties in life at the same time they cause the person to be less able to deal with such difficulties. Thus begins the cycle of addiction. For as the person retreats to the drug to avoid coping, those things with which s/he must cope become less manageable and more frightening to contemplate. So potential addicts turn increasingly to the drug to gain the rewards which they are no longer capable of gaining from life, until, at some point, we may say that the main rewards are coming from the drug itself.
At this arbitrary point, people can be said to be addicted. They view those other aspects of their life with which they have ceased to deal seriously and from which they no longer gain satisfaction only in terms of how they relate to their addiction. People, jobs, other activities are all either impediments to or vehicles for obtaining the one thing they want to pursue-intoxication and loss of self-consciousness at the hands of the chosen addictive substance.
An important part of surrender to the drug is the feeling that they are not strong enough to resist it-not worthy to resist it. In some sense, they see addiction as the proper state of affairs. This negative self-image and the low self-esteem on which it is based are key points in the cyclical descent into an addiction. For the addict is someone who does not feel good about self, who dislikes the person s/he is. Addiction is predicated on a fear of the world, which is mainly an anxiety about one's own ability to cope with it. Whatever his or her actual ability, the addict believes s/he is incompetent in some significant way or area of life.
An addict welcomes the opportunity to resolve doubt and unease by being protected by some larger force, some greater power. A powerful drug, of course, fits this bill. But there are many other external structures and mechanisms to which a person can sacrifice control.
Patterns of Dependence
Researchers such as Charles Winick, Isidor Chein, Louis Lasagna, and Richard Blum who have studied addicts and people with extreme responses to narcotics have found tremendously strong patterns of dependence, not only on the narcotic, but on institutions and groups such as hospitals, prisons, and families. For example, one perhaps surprising finding by Blum is that narcotic and other illegal drug users are more likely than most people to have resorted heavily to legal medications in the past. Winick has discovered that many addicts are only able to give up their drug habits when they are relegated to some total institutional environment such as a prison or sanitarium.
Chein's research highlights an apparent contradiction: at the same time that addicts are greatly dependent both on people and institutions, their approach to groups and people is extremely manipulative. The addicts' early experience has been such as to teach them that they cannot hope to gain deep satisfaction from relationships, but that they can get what they want from them by relying on certain interpersonal ploys, such as playing the victim and acting helpless. As a result, although a major aspect of the addiction constellation is a lack of intimate relationships, addicts view the people they know as extensions of their habit. Thus they use people to gain sympathy, to extort money, to get help in securing their drug supply, even as they cannot gain from the people around them a feeling of security and sharing.
The Safety in Addiction
Just as an addict is, by definition, dependent (not from having taken the drug but from having the impulse to dependency in the first place), it is of the essence of addiction that an addict is passive. It is passive to take in something from outside of oneself to control one's life. This passivity also derives from the orientation of the addict towards life. Addicts doubt their ability to bring about the outcomes they want: i.e. they question their self-efficacy. Not believing it is possible for their efforts to be rewarded, they give up trying.
For the addict, the effects of the drug are the rewards s/he puts in the place of the real world rewards s/he is not confident or concerted enough to obtain. There are two ways in which the effects of a drug are welcomed by the addict. First, they are instantaneous, without the anxiety-provoking work and time that are required to achieve career goals or to sustain long-term interpersonal relationships. Second, they are sure, in the sense that, given a sufficient dose of the drug, you can get what you expect. Because the addict fears the uncertainty of involvements with work and with people, s/he is driven to the "safe" involvement of drug addiction.
In what way is addiction safe? An important dimension of the fear that motivates an addict is fear of failure. A person who fears failure is preoccupied with the potential negative consequences of any new or unfamiliar stimuli. Instead of accepting these novel stimuli as opportunities for pleasure or satisfaction or simply as things to be dealt with in the normal course of events, s/he prefers to avoid unfamiliar circumstances or challenges. When this is not possible (say, in the laboratory setting), such a person reacts to a challenge by taking either the easiest course or the riskiest one. In either case, the individual can escape the onus of the anticipated failure either by sticking to a task that can be accomplished or by attempting something so difficult that no blame can be levied. For example, in an experiment where children were given a ball to throw into a basket from any distance they chose, some of them made a personal game of the task by moving back a little farther from the target with each successful toss. Other children, high in fear of failure, either stayed right next to the target or moved too far away to be able to hit the target except through random luck.
Of course, it would be foolish to say that a child, or anyone else, who shows high fear of failure will become a drug addict. Too many other considerations enter into the equation. But the parallel between high fear of failure behavior and addiction is exact where, out of personal anxiety, a person takes the safest course for avoiding failure. The addict, in the fear of challenge or novelty, chooses either to make things as constant and predictable as possible, or to take such risks that s/he has no chance for consistent success or for completion. It may sound strange that it is the security of the predictable that causes an addict to return habitually to a drug. After all, taking drugs is a risky business often leading to disastrous results. Yet it is the predictability of sensation, the assurance that s/he will always get the same effect, that the addict seeks from heroin or alcohol. At the same time, being addicted offers an excuse for failures and for not even making the effort to come to terms with the rest of his or her life.
Explaining Tolerance and Withdrawal
How does this model of addiction explain tolerance and withdrawal? Addicts are uncomfortable with themselves and in their world. They lack the kind of complete life which normally provides people with enough interests and enough satisfaction from their environment to make addiction unappealing. The absence of these things allows an addiction to grow to larger and larger proportions in a person's life because there is nothing to counterbalance the need for the drug. This is the relationship of tolerance to the addicted lifestyle. As for withdrawal, when someone has artificially buoyed up sense of self and created a less threatening world to live in by means of a drug, then when s/he is deprived of this insulation and forced to reorient existence to a long evaded, harsher reality, that reorientation may well be agonizing. This is why some people, those who are vulnerable to addiction and its consequences, react to the absence of a drug with the kind of total withdrawal experience that other people, more whole in themselves, do not seem to feel.
Addiction is a logical extension of a way of life and its interaction with a drug experience, rather than of the chemistry of one drug or another. Addiction is not a physiological mystery, but rather an organic outgrowth of a person's relationship to the world. To understand any individual case of addiction, we must ask, "What does this person derive from the drug and from experiencing its effects?" In part our answers will be that it fills time, structures a life, provides a reassuring ritual, and offers an identity. Then we must go deeper, into the addict's own experience of the drug, and find out how and why it reassures, and from what it offers relief. Only by comprehending these problems and how the particular drug creates an escape from them, can we get to the true nature of the addiction for that person.
Power, Achievement, Guilt, and Addiction to Depressant Drugs
An issue crucial to the experience of depressant drugs like narcotics and alcohol is that of power and achievement. In our culture, there is a high premium placed on being able to control one's environment. A basic part of the North American ethos is that any individual can get what s/he aims for if s/he is sufficiently dedicated. When someone fails to do so, it is assumed it is because of personal weakness.
Interestingly, at the same time that an addict's behavior denies the validity of this idea, in that an addict is not capable of devotion to any goal aside from pursuing intoxication, s/he is very much caught within its grips. Addicts are people who are so discontented because of their inability to gain what they want that they use a drug to forget the failures which trouble them. The resulting further deterioration of their ability to accomplish their desires drives them back to the drug even more frequently. In addition, they have strong feelings of guilt because they are not getting done what they believe they should or what other people expect of them (while they are intoxicated), and these feelings, too, cause them to rely more heavily on the drug.
It is because of the strength of our culture's orientation towards individual accomplishment and responsibility that so many people in the culture are trapped by feelings of inadequacy. At the same time, in an increasingly institutionalized society where it is harder and harder for one to control one's life, these feelings are growing. It is for these reasons that addiction is such a widespread problem in our culture, and that it is a constantly expanding problem as more and more young people do not seem to be equipped to handle the complexity of the world which they face.
Narcotics fit into this pattern by giving users the soothing feeling that nothing more need be done to improve their life. Everything is fine, and so no additional effort or concern need be spent on the problems or tasks which confront them. All pain and anxiety are removed and, for a time, they can rest assured that their world is under their control.
Macho Dimension of Alcohol
Alcohol adds another dimension to this experience. In our culture, drinking and alcohol intoxication are associated with masculinity and power. When Ed McMahon and Dean Martin joke about how much they drink, they are participating in a culture-wide male humor which sees this as a symbol of their potency. It is for this reason that adolescent boys are so concerned to indicate how much they have drunk and can drink. The kinds of anti-social activities in our culture which are associated with drinking are nakedly connected to power. For example, fighting (with other men or with one's wife or girlfriend) and reckless driving are both expressions by the intoxicated person of his destructive control over others.
Consider the obnoxious behavior of someone who, when drunk, cannot listen to anybody else but insists on voicing his opinions loudly and repeatedly: the typical picture of the drunken bore. What the person is doing is removing the inhibitions and anxieties he normally feels about the value of what he has to say, his right to say it, or the willingness of others to listen. Now, protected by alcohol, he can give full vent to his ideas, attitudes, peeves, and rages. This is why the impact of a man's alcoholism is so often felt within his family by his wife and children. These are the only people he feels capable of dominating, of being able to force to submit to his will.
Personalized and Socialized Power
Hence, one of the key aspects of the experience of alcohol is the illusion of power it offers, the feeling that the person is potent and able to sway others. But it is a temporary control, and when the heavy drinker emerges from his intoxication, he is even more insecure about the regard that other people have for him and the value they put on what he says, so that the only outlet for him is more alcohol. The best study of the relationship between alcohol and feelings of power is David McClelland's The Drinking Man. McClelland found that having drunk alcohol, people are more likely to have power fantasies. He also found that alcoholics normally have higher needs for what McClelland calls 'personalized' power. In McClelland's scheme, 'socialized' power is the ability to influence people toward concerted or otherwise constructive activity. This is a successful way for a person to resolve a need for power in our culture. Personalized power, on the other hand, involves direct individual dominance of others, the most crude and least successful way to express the need for power.
McClelland uses his data to explain the preponderance of male alcoholics in our society. But the theory works as well for women. With alcohol, a woman can indulge the fantasy of greater control over her relationships with men or male-dominated institutions than she actually feels she has. In any case, it is not surprising that in our time-as more women aspire to positions of power and are less likely to accept the control of their own lives by others-that alcohol abuse by women is growing more rapidly than it is for men.
I have tried to describe elsewhere some steps society can take to combat what is, as this account indicates, a problem that only society can confront (see Addiction is a Social Disease). Put simply, society either has to create institutions which are more amenable to the influence of individuals so that there is not such a great residue of unmet needs for control and power, or it has to work to increase the competence of its individual members in exercising control over their lives. These are related issues and obviously both steps need to be taken. For example, if school allows children to develop and exercise responsibility within the institution, then they will learn better how to develop and exercise control in their own lives. Beyond this, the solutions to a social problem like addiction are as difficult and involved as are the sources of that problem in society.
Although approaching addiction as something which grows out of an experience enables us to understand better why people take drugs and how they come to abuse them, there is nothing in this definition which limits addiction to drugs alone. It is this fact which has caused so much confusion among theoreticians, for example, the many who now focus on 'psychic dependence' as the key element in drug abuse. What these drug investigators fail to realize is that there is nothing about the phenomenon of compulsive drug use for which there is not an exact parallel in other areas of human behavior.
This is not to say that psychoactive drugs do not have a definite impact on those who take them. Indeed, this is why narcotics and alcohol are so often connected to addictions: the effects they have on consciousness and feelings are so direct. But there are many other involvements and activities that hold for some people the kind of experience which leads to addiction. This is being widely recognized at a practical (if not a theoretical) level as a number of involvements-like gambling, overeating, television viewing, 'workaholism'- are coming to be regarded and dealt with as addictions.
Opportunity for Absorption
What is it about these activities that creates addictions for some people-in fact, a great number of people? All of them hold out the opportunity for a reassuring absorption in a consuming sensation which takes away the consciousness of life's problems. But what makes any activity an addiction is the person who undertakes it: personality, situation, motivations. If an individual turns to the involvement to escape from pain (physical or otherwise) and resorts to it increasingly as relief is experienced when engaged in it and anxiety and guilt felt when away from it, then that person will become addicted no matter what it is.
Envision compulsive gamblers transfixed in front of several slot machines. Their whole being is taken up with the motion of pulling the levers in order and the instantaneous gratification of seeing the results appear like clockwork before their eyes. They cannot think of anything else, like the things they are not doing while gambling or the money they are losing. When they stop, their minds come back to their real situation and they are burned with the disgust of realizing how much money they have thrown away. The answer for them: return to the always elusive solution of going for the big win.
Or consider the child glued to the television set, his or her mind dulled into complete passivity by the images on the screen. There have been a number of reports by scientists and television viewers themselves about the devastating reorientation brought about by losing a television set: the children are left with nothing to do and the parents are forced to deal with each other and their kids without the constant lulling presence of the set.
An addiction can also be formed in an interpersonal or institutional attachment. I wrote Love and Addiction with Archie Brodsky to expand the concept of addiction to the realm of dependent love relationships. In Part 1 of this article, I mentioned Charles Winick's research which showed that some heroin addicts 'grow out' of heroin addiction when they can become completely dependent on an institution like a prison or a hospital. Such a total involvement in an organization is the functional equivalent of what-in fact is-an addiction.
Recently a great deal of attention has been directed to cases of so-called brainwashing, where young adults or teenagers are taken by a group (usually religious) and converted into automatons: smiling, beatific servants of the order who will do whatever they are bidden. For the young people in these groups (many of whom, incidentally, have histories of unhealthy drug use), the religious order sets up a totally controlled social environment, where not only are all practical matters taken care of, but certitude of thought is also provided. Through worship of a leader and agreement with those around them, the young people lose their uncertainty and anxiety and will sacrifice any other commitments or interests to preserve this state. An interesting sidelight of this form of addiction is that if young people do leave the movement, they tend to become as negative toward the organization as they once were positive and may attack it just as fanatically as they once defended it.
Personal Meaning of Addiction
Eating is a kind of activity which clearly exemplifies the personal meaning of an addiction. Everyone has to eat, and yet some people eat to the point of severely limiting-and even shortening-their lives. The pain that comes from obesity, its deleterious effects on physical activity, social life, and professional appearance, and the relationship of excess weight to heart disease and strokes make it clear there are people who are well aware of how much they are hurting themselves through overeating and yet can do nothing to control it.
To understand the dynamics of this addiction, let us take as an example a child who has been taught by his parents to regard food as a reward. This can grow into a pattern of eating to gain self-gratification and to relieve anxiety. As the child grows older he sees increasingly that being overweight is a condition which makes him less attractive to others and about which he feels self-conscious. It becomes a part of his negative self-image, an ever-present and distressing indicator to himself that he is not a 'good' person. Yet whenever he is penalized for being overweight, as by not being able to participate in sports or by being rejected by peers, he has one refuge to turn to-eating.
When we see a fully developed eating addiction, we can realize just how difficult it is to break out of any addiction. An overeater who goes on an eating binge is the same as the alcoholic who, once s/he begins to drink excessively, is driven by accelerating feelings of self-disgust and guilt to go all the way, beyond satisfaction. Addicted eaters face problems and anxieties which cause them to rely more on food, which in turn exacerbates their problems and anxieties-an illustration of the cycle of addiction. Should overeaters, like alcoholics or drug addicts, behave in a controlled way for a day or for several days or weeks, they are still going to be fat and will still be tempted to fall back into the addiction. To leave the addiction behind, they will somehow have to break entirely with past patterns, often before new habits lead to rewards and have a chance to establish themselves. For these reasons, many of the methods developed for working with overeaters are helpful for designing a program to combat any addiction. I shall describe some of these methods in the last sections of this article.
Characteristics of Non-Addiction
If we recognize that addiction can appear in any type of involvement, we have to realize also that no activity - including drug-taking-is necessarily addictive. What makes an involvement not addictive is being able to control it and fit it into the rest of one's life. This means knowing when to stop doing something that is becoming harmful, which leads us in turn to what we might term the characteristics of non-addiction. People can resist addiction when they gain enough satisfaction from their lives to guarantee they don't have to seek one thing which alone must provide them with contentment. If people have involvements which mean something to them, there is less chance that a destructive involvement will dominate them, because there will be other activities and people they will not sacrifice. People need to have good feelings about themselves so they will not consciously hurt themselves; they need pride so they will not want to be out of control, both for their own sake and for others. They need to accept themselves in order to combat the guilt and anxiety which are at the center of the addiction cycle. Finally, they need to be able to acknowledge their problems to begin to deal with them before they grow to life-defeating proportions.
When Addiction Exists
If addiction can occur with any type of involvement, then we have to have ways of deciding when an addiction exists. The model of addiction which I have presented gives us some characteristics which can serve as criteria for this purpose.
1. Addiction is a continuum. Since there is no distinct physiological mechanism which 'sets off' an addiction, we cannot view addiction as an all-or-nothing phenomenon. The fact that addiction is a continuum underlies all the other criteria of addiction in that everything has a quality of relativity, of being more or less true of a given case as the case is more or less one of addiction. This indefiniteness in classification shouldn't upset us; after all, it is present in all behavior. Where we have gone wrong concerning addiction is in thinking there is something more-or less-to it than to everything else a human can do.
Thus far I have portrayed total addictions both with drug and non-drug involvements. These "ideal" cases are actually extremes at one end of a spectrum. In reality, it is only infrequently that a person's whole life is dedicated completely to an addiction in the way I have described. For example, the skid row alcoholic represents only a small part of the alcohol problem in the United States and Canada, just as there are many people in Weight Watchers groups who are not grossly obese. In this sense, a total addiction is a pathological version of a habit, and a person can be more or less addicted, depending on the extent to which his habit controls his life.
As I indicated, a person may only be predisposed to be addicted in one area of his life, in that area where he or she feels particularly weak or unable to cope. For example, we often find people who do not use a drug in certain situations but are driven to it in others. One man spoke to me about his drinking problem, which only surfaced when he came home to his wife and family at night. At his work, where he was a partner, he was completely engaged and never felt even a temptation to drink. To get this man to deal with addiction after a lifetime of avoiding it-to begin thinking about why he was uncomfortable at home with his family-would be a monumentally difficult task. This situation also calls to mind the workaholic who feels so at a loss to deal with intimate personal relationships that he devotes himself to his work, neglecting that which he is already having trouble coping with.
2. An addiction detracts from all other involvements a person has. In determining if an activity is addictive, it is necessary to decide whether it is harmful-harmful in the sense that it diminishes a person, makes one less able, undercuts one's life. This is obviously the case when something like overeating, smoking, drinking, drug-taking hurts the person's health or even kills. But the damage may not be so direct or evident. At the heart of the concept of addiction is the idea of a diminishing scope in life, until there is only one focus for the person-the object of the addiction.
This leads us to the primary criterion for an addiction: to the extent that an involvement detracts from the other parts of a person's life, so there is less ability and less interest in dealing with anything else, then to that extent the involvement is addictive for the person. When the individual can deal with nothing or can get gratification from nothing outside of the one involvement or without constant reference to that involvement, a full-blown addiction exists. Obviously, at some level only the individual can determine how much something is harming his or her world, and that is why ultimately addiction can only be evaluated and dealt with by the individual.
3. Addiction is not a pleasurable experience. An addiction eliminates pain. Addicts turn to it out of negative motivations-fear, anxiety, guilt, discomfort-which the substance or involvement serves to lessen for a time. While they may once have had a pleasurable response to the object of addiction, that has long since faded into the background by the time they are addicted. The euphoria that drugs like alcohol or heroin or barbiturates may cause in a person is the euphoria of a sudden releasing of cares. For this reason addicts are not concerned with the quality or type of the substance they can get (e.g. the flavor of liquor); they simply welcome its intoxicating effects. In the sense that an addict uses something to blunt awareness of pain, all addictions are indiscriminate. They are not sought out for their positive qualities. This suggests another major criterion for an addiction-whether a person derives pleasure from an involvement or whether it's turned to simply out of pain, fear, habit, and the avoidance of other things.
4. Addiction is the inability to choose not to do something. By the characteristics and criteria already listed for an addiction, we see that addicts are not able to make a decision to stop doing something when it begins to hurt or when it ceases to be pleasurable. Instead, they are driven by various motivations they cannot control to continue involvement until they are physically incapable of going further, or until some external force prevents it. Another criterion of addiction develops from this aspect of its definition-whether a person is capable of exercising choice in an involvement. Can s/he genuinely say that under some circumstances s/he will refuse to take the drug or to engage in the activity; are there other valued activities which will sometimes rule out the involvement; will the person sometimes not turn to the involvement in a situation which normally calls for it; can it be said, "This isn't good for me. I'm going to cut down"? The negative answer to all these questions is that, given a certain set of recurrent stimuli, a person will always act in the same way and make the same choice. That is to say, there is no choice. This is addiction.
Dependence on Treatment
An interesting sidelight to the theory of addiction as an experience, and to the fact that people can form addictive relationships to institutions, is the possibility that therapy for addiction can itself become an addiction. What might make a therapy or therapeutic group addictive? If the therapy were predicated on remolding individuals entirely in its own image, beginning by taking from them all the props of their previous identity, then it could simply be requiring that they now define themselves entirely in terms of a new external power-the therapy group. For a person addicted in this way, all experience would be filtered through the perspective of the therapy, all activities-including interactions with people-would center around the therapy, and personal identity would be completely tied up with being a participant in the therapy or therapy group. To break such a total dependence would be impossible, done only at the risk of returning the individual immediately to the drug addiction.
People addicted in this way might spend all their time talking about this previous addiction, thus limiting themselves to interactions with people who also had had such addictions, most likely simply other members of their group. They might find themselves drawn constantly to attend therapy sessions or group meetings, as these would now provide the structure and substance of their life. If addicted to the therapy or group, they would refuse to accept the possibility that any other approach had value for treating addiction. Essentially, individuals would not be confronting themselves and their habits in such a fashion as to change the basis of addiction in their life. Working still on fear, negativity, passivity, and dependence, a new force would have taken control of them.
Because therapy groups differ so much from one to another, and differ as well in terms of how each individual relates to them, it is impossible simply to say that some therapeutic approach is addictive, just as it is impossible to say that a given substance is necessarily addictive. Obviously, though, there are groups which fit my description. Many of these groups are extremely successful in the degree to which they keep members away from their previous addictions. In fact, because of the difficulty of coming to grips with any addiction, such groups may be among the few forces which succeed with any regularity in combating drug use. But in the long run, these organizations are not successful mechanisms for reducing addiction throughout society because in many cases they don't focus on addiction at all, but simply on the elimination of the use of one drug or another.
Personal Reorientation Necessary
Here the controversial issue arises again: can addicts return to the substance to which they were formerly addicted? The answer is no, if they are still addicted. But the fact of perpetual addiction is not a foregone conclusion. There are people cured of addiction, however few they are and however arduous the process. If there is not a real cure for the addiction, then overall, the addiction problem in our society does not decrease.
The issue is complicated by many other considerations. Pragmatically, it is better for people living in our society to be addicted to a group rather than to a drug, particularly an illegal drug. They are granted more social acceptance, are more likely able to hold a job, and do their body less harm. Also, complete dependence on the therapy group may be a stage through which people pass on their way to greater self-reliance, a kind of mechanism of detoxification which then allows them to work on the substance of their life-their problems with themselves, with people, with work, or whatever. In this case, addiction to therapy may be a necessary part of a complete personal re-emergence. As for determining whether a person should try to become involved again with the former addiction, the answer may simply be, "Why risk it?" Alcohol, cigarettes, and heroin are not necessary parts of a complete existence, and so if there is any danger of re-addiction, it may indeed make sense not to have any contact with the substance, particularly with all the unsavory consequences that surround an illegal drug like heroin. But this is not in itself a cure for addiction. It is obviously not a cure in the case of something like overeating, where it is impossible to practice complete abstinence. But I repeat, abstinence without personal reorientation is not really a cure for any addiction.
When Therapy is Crippling
When is a dependence on therapy actually harmful, meeting the primary criterion for an addiction? When therapy cuts back people's lives so they can only deal with fellow ex-addicts, just as many addicts deal only with addicts, they are being harmfully constrained. When, out of a fear of re-exposure to the addiction, they curtail activities not related directly to the therapy. When the therapy stalls in one stage, so that it is permanent or semi-permanent. The justification for a heavy dependence on therapy is that it prepares the way for a re-emergence into full life. When this is not the case, when after several years the group member is still filling his or her time with therapy sessions and meetings, the dependence on therapy is becoming a crippling addiction.
Perhaps the main problem with therapies designed to enclose all of a person's life, even if temporarily, is that they suit only certain people. In fact, by my description of people who become addicted, a totalitarian group will have the greatest appeal for them. They mind least and find most reassuring, the sacrifice of self required to be absorbed by the institution or group. And it is perhaps such vulnerable people who most need this drastic solution. Yet, as we have seen, the problem of addiction is not limited to overt addicts alone. There are all varieties of addictions, even to potent drugs. Hence there need to be groups for dealing with compulsive drug use which are open-ended, variegated, and flexible, in line with a clientele which is harder to specify and which has less need-and less willingness-to sacrifice everything for a therapy involvement.
Such therapies, which do exist for alcohol (although less frequently for other drugs) and are popular for overeating, smoking, gambling, and other addictions which society is more tolerant of, allow a person to keep up previous associations while working on the addiction. The goal of therapy is for clients to behave differently in these settings, with these people, and perhaps even with these same addictive involvements. They may, in fact, not only keep up with family, friends, and work while undergoing therapy, but, as a part of dealing with the addiction, may draw these other areas of existence into the therapy to improve relationships with them. They may, in the case of alcohol addiction, have as the goal a continuing, but moderated, involvement with alcohol. Again, this more open approach to therapy will not work in all cases, but is possibly an alternative for people less far along the scale of addiction or for those who react against complete immersion in a therapy environment. Most important, there is nothing about the nature of addiction which rules out such an approach.
There are, however, approaches to the addiction problem which the nature of addiction does rule out, or at least render useless. These, unfortunately, are the tacks governments seem most intent on following. Dr. Peter Bourne, President Carter's special assistant on drug abuse, announced that the U.S. government will not be concentrating on tobacco and alcohol use. Instead, it will attempt to block off the international sources of cocaine and heroin. What is wrong with this approach? To begin with, a series of government studies has shown that these policies have failed disastrously in the past. It is impossible to cut off even a small portion of the heroin flowing into North America from a number of Asian and Latin American sources. When the U.S. government was successful in doing so in a localized region (Detroit), the main result was a sharp increase in crime as drug prices shot up. But perhaps the most telling report is the most recent one from the National Institute of Drug Abuse. It shows that patterns of drug use are extremely elastic. Users go through varying periods of voluntary or involuntary abstinence depending upon availability of heroin, and they readily turn to alternative drugs when heroin is scarce.
There is nothing surprising in this from what we know to be true about drug addiction. Historically, whenever one drug popularly used for addiction was in short supply, the use of another grew. This was true when opiates were made harder for middle-class users to obtain in the early part of this century (many users became alcoholics), when heroin supplies from Europe were reduced during World War II (addicts turned to barbiturates), ad infinitum. That this has always been the case and will always continue to be so is due to the fact that addiction is a people problem, not a drug problem. And people addicted to one drug will always find some other substance to build their life around.
Society - The Major Addictogenic Mechanism
While we are pre-occupied with eliminating the sources of illicit narcotic supplies and with heralding the dangers of each era's new danger drug (glue-sniffing, Quaaludes, PCP), we lose sight of what we actually have to do to reduce addiction. Perhaps this is why we so readily get caught up in discussing the relative chemistry and symptomatology of one drug versus another. If government or any other remedial programs fail to note that addiction is a problem which stems from the individual and from society, that in order to cope with widespread addiction we need solutions which attack basic problems in the way children are prepared to cope with their environment, and that addiction does not disappear when one or another drug is made more difficult to come by, then we shall never make a dent in the addiction problem. All we need do to prove this to ourselves is to examine the rampant alcohol abuse among American teenagers in connection with their seeming lack of purpose and confidence in their futures.
In the nation which has always attacked heroin and heroin supplies more strenuously than any other nation, the U.S. persists in having one of the largest addiction problems. In fact, those countries who have either borrowed our approaches or in whose internal affairs we have involved ourselves (including Canada, France, and Italy) have uniformly seen their narcotic addiction rates jump. When we add to the narcotics the host of abused substances in the U.S., we note how alarmingly steady has been the growth of addiction in the country since the beginning of the century, to the point where it might now be considered our number one social and health problem as a nation.
By perpetuating our misunderstanding of what addiction is, we are managing to accelerate the already heavy trends toward increased addiction to all kinds of drugs. Consider the advertising of drinking, both in commercials and by the example of prominent personalities. Or reflect that, at a time when more and more people are having trouble controlling their impulse to gamble (there are six to nine million compulsive gamblers), more and more state governments are legalizing and promoting gambling. These are only some examples of how addiction comes from the very wellsprings of our society. In an article I wrote (Addictions, Winter '76) with Archie Brodsky, "Addiction is a Social Disease," we present the case that society is our major addictogenic mechanism.
The Myth about Methadone
Before turning to some remedial approaches that can have some meaning for the addicted individual, I would like to look at one last response to addiction which is in its way the reductio ad absurdum of our misapprehension of the meaning of addiction. It has become apparent that the U.S. government's greatest investment in drug treatment, the $50 million methadone program, is a failure. The medical team that pioneered methadone maintenance, Drs. Vincent Dole and Marie Nyswander, concede that its impact for good has been small "at best." Those cases where it has worked have been in settings with dedicated counselors, cooperative patients, and strong programs for personal exploration and skill training, under which circumstances any treatment, including heroin maintenance or its opposite, complete withdrawal, would have better chances of succeeding.
Methadone represents the latest in a long series of efforts to resolve the problem of addiction by the development of a new drug. As an effort to solve a complex problem with a simple external solution, it expresses an addictive bent in our society which is encouraged by those responsible for treating addiction. The search for a powerful analgesic which could substitute for morphine as a painkiller but would not have its addictive potential has been a constant theme in pharmacology in the 20th century. Heroin was originally marketed with this claim. So were the synthetic sedatives (barbiturates) and the synthetic narcotics (Demerol). From 1929 to 1941 the U S. National Research Council's Committee on Drug Addiction was engaged in this impossible task. And finally, we have methadone, to which we have addicted a large number of people, and which has become a popular black-market drug for the many addicts for whom it is now the drug of preference.
If we had been capable of learning from historical experience, we would never have imagined methadone could "cure" addiction, or even fail to be addictive. What that experience tells us is that any drug which has powerful painkilling effects, which dulls a person's sensibilities, will be used addictively. The reason: because this analgesia is the very experience around which addictions are built.
No Magic Cure
It is not possible here to do more than outline the directions a cure for addiction will take, and some techniques which can be employed. One thing is definite: curing addiction is hard. Seeking a shortcut, such as the 'magic' of a drug cure, is the kind of desire for a simplification of life which leads to addiction in the first place. For a person who is completely addicted, nothing short of changing that person's adaptive orientation will remove the sources of addiction. Addiction is a life problem, based on a fundamental feeling of deficiency, and no patchwork solution can hope to confront a problem of that magnitude.
It is for this reason that totally encompassing therapeutic communities have grown up as one of the few systematic treatment modes for severely addicted individuals. Such communities can work with a person on basic issues like self-concept, comfort and ability in relating to others, job skills, and accepting responsibility for one's life and one's actions. But the task of rebuilding a personality is fraught with danger. The primary issue is whether people will be made into new versions of themselves or into images of their groups. The issue around which this revolves, in turn, is whether the client is being prepared to deal with the world outside, or to remain in the world created by the therapeutic community. Different groups and organizations vary in their awareness of these issues and their success in reintegrating the client into the world beyond the therapy group.
Heroin addiction and alcoholism are only a small part of the addiction phenomenon, however. Focusing on those who have these life-dominating addictions is unfair to them at the same time that it takes our attention away from other important individual and social problems. Dealing with addictions which are less noticeable-either because they are less severe, or simply because they are less disapproved of-creates its own difficulties. In many cases, because these addictions draw less attention to individuals, they can excuse compulsive and destructive behavior more readily. It's been said that alcoholics and drug addicts are lucky in some ways. They have been forced to deal with things in themselves and in those around them that others are allowed to miss all their lives, often with debilitating consequences.
When Kenneth Cooper began his research on the physiological benefits of so-called 'aerobic' exercises, mainly running, he found that the servicemen he used as subjects showed unanticipated gains as a result of the program. Most of these men had developed sedentary lifestyles in the military, and many suffered from overweight, excessive drinking, and habitual cigarette smoking. By becoming active runners, they also usually started to regulate other areas of their physical conduct, for example, modulating their diets and cutting down and eliminating their use of drugs. What happened from a psychological standpoint was that they began to feel good about themselves, and to see that they were contradicting their own health efforts by their addictive behaviors.
A child is able to resist addictions when s/he has a sense of self which rules out self-destructive habits. A person who has not developed this attitude in childhood must institute more concerted policies to engender it as an adult. A program of running is one method for accomplishing this. It is an example of a kind of activity whose immediate, short-range impact expands readily into larger areas of self-regard and self-regulation.
Leap of Faith
The person embarking on a planned strategy of change must continue to shift between these large and small issues of change. Addicts who begin to replace an addiction with a new relation to the world take a few small steps which are not enough, initially, to guarantee that the new identity can support itself. They are making a leap of faith, starting on a journey whose end-point they can only envision at some dim future time. To keep on the path they have laid out they must continually return to the image of the person they ultimately want to be. At the same time they must anticipate the rewards the new self will gather by seeking recognition for the gradual progress they are currently making. Perhaps a therapist or other addicts engaged in similar struggles can provide this support and acknowledgment. But the individual must be the first to note how well s/he is doing.
The effort to change always involves moments of weakness and distress at not making the headway one hopes for. These are the crucial moments in fighting addiction. One has to be prepared to confront backsliding with a degree of equanimity which will prevent despair and giving up. Therapies for overeaters emphasize that, should people slip from a diet, they should not give themselves over to guilt of the kind that leads to an uncontrolled binge. One mistake is one mistake, no more and no less, and the person must be the first to make allowances if this will enable sticking to the overall course of action.
As the person's lifestyle shifts, s/he grows slowly into his or her new image. New, more constructive behaviors emerge as old compulsive behaviors fall away; real rewards flow to the individual for the new person s/he continues to become. As a former addict, care has to be taken that old patterns don't return. There are certain settings which former addicts may never feel strong enough to be in without risking a relapse. Often these involve being with people, like a mate or parent, whose behavior either in general or around the specific addiction sets off the addictive cycle. For this part of therapy, serious decisions about relationships-whether to de-emphasize some or even leave some behind entirely-have to be made. Ex-addicts may also have to stay away from activities or substances to which they have extreme responses for whatever reason. For obese people these may be rich foods which are high in sugar content and which produce for them an uncontrollable double dose of guilt and a "sugar rush."
Curing addiction is straightforward and incredibly difficult at the same time. It takes no secret potions or mechanisms aside from rearranging whole areas of one's life and parts of all aspects of that life. Addiction is at the very heart of life, at the same time that it is antagonistic to life. It is a turning away from life, a limiting of oneself which is not only unnecessary but is ultimately destructive. Therefore anything which enhances life combats addiction, and an existence which is rich and fruitful offers the best assurance that addiction will not appear or reappear. And, finally, combating addiction is a never-ending process. Nobody is ever completely there, just as nobody is absolutely free of addiction in all areas of his or her life.
A Habit Gone Awry
Any person who faces addiction in some facets of his or her existence may require drastic reorientations in those areas. This is just as true for the individual who has repeated drinking bouts or who abuses diet pills or tranquilizers or who goes on compulsive eating binges as it is for a person who is hospitalized for alcoholism or who is arrested for heroin use. Yet in these cases there may be less reason for- or possibility of-submitting to a comprehensive therapy program. Also, as I have pointed out, such programs are not necessarily acceptable or workable for all people. What remains is to take the key elements present in any successful treatment for addiction and to de-mystify them, to make them available to everybody in whatever form may be applicable.
To free ourselves of addictions, we have to learn to like and respect ourselves, and to cope with and gain respect from our environment. In speaking about self-concept and the confidence that we can come to terms with the world and simultaneously gain the appreciation and love of others, we are approaching addiction in a global way. We need also to look at it through the opposite end of the telescope, from the standpoint of the habit that has gone awry and has grown bigger than the habitué. Working from this angle, we can design a self-tailored 'behavior therapy' regimen, based on our awareness of why we turn to our addictions and what triggers this response. This analysis demands that we examine our lives to ferret out those points where we experience difficulty in acting appropriately. It means being unrelentingly honest in uncovering those situations which frighten us.
Armed with such a self-analysis, one can begin to modify the patterns which make up one's life and which result in addicted behavior. For example, Henry Jordan of the University of Pennsylvania discovered that obese people tend to eat in all rooms of the house, rather than limiting eating to a dining area (and mealtimes). Thus a first step is for obese people strictly to limit themselves to eating at set times, when they actually sit down and prepare and consume a real meal. These early steps towards breaking addictive patterns necessarily have an artificial quality which people just beginning to control their behavior must rely on. To get beyond this, besides making healthier eating habits second nature, they will also have to reflect on more basic issues, such as why they resort to the addictive behavior as a way of dealing with problems, and where the sources of their anxieties lie.
Space to Choose
Being free from addiction means being able to choose how to respond to a set of stimuli. Somehow people have to be able to escape the direct link between being presented with a certain situation and automatically turning to their addiction. One method for giving someone the space to choose has been employed by some anti-smoking groups. They ask the addict to fill out a small rating sheet each time s/he contemplates smoking a cigarette. If the anticipated enjoyment is not above an arbitrary point-say, a three on a 10-point scale-then the smoker is to put away the cigarette until the rating goes up. Gradually, the smoker is asked to raise the threshold rating at which s/he allows a cigarette until a point is reached where s/ he can quit altogether. This method makes use of several of the characteristics of addiction, particularly the fact that an addiction is not used for pleasure. It allows the addict to realize this and to hold back at that moment of choice where the addict most often goes wrong.
More Than Stop-Gap Measures
Addictions fill essential gaps in a person's life, not the least of which is empty time. Obviously, if a major way to pass time is to eat, smoke, drink, or consume other drugs and to be in places where one of these activities is carried out, then other activities must be found with which to replace the focus on the addiction. Hobbies can be utilized or other interests or job-related skills to submerge the desire for addictive involvement. But for this substitution to become permanent- and here again we return to the global level of self-concept and a satisfying relationship to the world-the activity will have to be more than a stop-gap measure which leaves the person continually looking at the clock to see whether a sufficient amount of time has been put in at the chore.
Addiction is a potent, albeit illusory, source of gratification, and anything which would replace it must likewise provide important gratifications. The characteristics of involvements which fill this bill are that they give us good feelings about ourselves and that they bring out our abilities in such a way that other people can respond to them. Thus we develop feelings of our own worth which are reinforced by the respect and admiration of others. Activities which have this combined weight become mainstays of our existence, generating a resistance to the appeal of addiction which is not easily overcome even in moments of weakness.