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How Self-Inhibition Leads to Addiction

You may be unintentionally setting up your next addictive episode.

Nancy was a 28 year old teacher who addictively used the tranquilizer Xanax.  She didn’t take it randomly (addictive actions are never random); she used it almost entirely when her boyfriend Mitch withdrew from her to concentrate on his work, something he had been doing more and more.  At those times, she was tormented with an inner conflict.  She wanted nothing more than to angrily tell him how alone she felt when he pulled away from her.  But she was terrified that she would destroy their relationship if she spoke up.  Feeling utterly trapped, she had to do something to undo her sense of helplessness.  That's when she turned to Xanax.  Each time she decided to use it, she (momentarily) felt no longer helpless, since she could now do something within her own power to make her feel better.  As much as taking Xanax was seriously harming her life, at the time that she felt that tremendous drive to take it, she felt empowered.

This example is taken from my first book, The Heart of Addiction, where I wrote it as an illustration of how addiction works: addictive acts are substitutes (or displacements) for taking a direct action that is either frightening or forbidden, when people feel overwhelmingly helpless.  In Nancy's case, she didn't let herself confront Mitch because that touched on very old fears of being left alone.  But, since it is emotionally necessary for all of us to take some action to reverse feelings of being utterly trapped or helpless, her substitute action was driven by enormous intensity.

I am citing Nancy's story in this post as an example of one of the most common precipitants of new episodes of addictive behavior: self-inhibition.  Nancy's old fears about being abandoned make it understandable why she could not speak up more clearly to Mitch.  But by holding herself back, she was inadvertently setting up her next addictive episode, because she was actually trapping herself.

Here is another example:

Daniel suffered with alcoholism but was abstinent at the time of this vignette.  He had hired a contractor to rebuild his old wooden garage.  The contractor started the project but then left it half-done to go work somewhere else.  Daniel had paid for almost the entire job in advance, so he couldn't simply fire the workman.  He made several calls to him before the contractor finally called back saying he couldn’t return to Daniel’s garage until he completed another project; it would be at least 3 weeks.  Daniel protested mildly, which was his usual style, but the contractor said he would just have to wait.  Immediately following this conversation Daniel resumed drinking.

Daniel's story (which appears in my second book, Breaking Addiction), is another example of the same issue.  When he held himself back from responding more vigorously (which might have included not just a stronger verbal response, but threatening to contact the Better Business Bureau, his State's consumer services department, his lawyer, the local newspaper, and so forth), Daniel placed himself in a helpless position.  His way of dealing with that feeling was to drink, in exactly the pattern that defines addiction.  As usual with addictive behavior, his decision to get a drink made him feel better since it reversed his sense of helplessness, even though it did nothing to help his situation with the contractor or the garage.

Addictions are psychological symptoms that arise when people feel overwhelmingly trapped, and provide a solution to that feeling, driven by the fury that naturally comes with feeling trapped.  When people create their own helplessness by being overly inhibited -- not speaking up, acquiescing to being treated badly, etc. -- they are unintentionally precipitating their next addictive episode.  If you recognize yourself in these anecdotes, it pays to be alert to when they occur, and even to anticipate situations in which you are likely to cave in.

One of the points that I have tried to stress in my books is that, even if you cannot bring yourself to act directly when attacked, there is always some step you can take.  One man who suffered with alcoholism could not bring himself to speak up in a large meeting and was heading for a drink right afterwards when he realized it still wasn't too late.  He got out his laptop and wrote an email to everyone who had been in the meeting saying exactly what he wanted to say.  He never did have that drink.

Of course, in the long term, if being too meek is an issue for you, it would be sensible to find a good therapist to figure out why you hold yourself back.  But in the meantime, knowing how your addictive behavior works in you can save you from having to repeat it.

Posted on Monday, January 25, 2016 at 02:22AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References3 References

Is Addiction About Pleasure?

This is a very old mistake.

Pleasure has been confused with addiction for the last 5000 years.  The reason is that common forms of addiction, like drinking alcohol, taking other drugs, gambling, and seeking sex, are often pleasurable.  This surface connection has historically led people to conclude that anyone who is deeply driven to drink, take drugs, and so forth, must be seeking even more pleasure.  It's a short step from there to believing that addicts are immoral hedonists, people who pursue personal pleasure regardless of the cost to those around them or even their own future.  Of course that is all wrong.

Addiction is not about pleasure, even though some of the very people suffering with addiction believe it is.  I've known many folks suffering with alcoholism, for instance, who have told me their drinking was easy to understand: they just like the effect of alcohol.  But a moment's thought shows the problem with this reasoning.  Almost everyone likes the effect of alcohol.  In fact, many people love the effect of alcohol, yet are not alcoholics.  Indeed, if liking alcohol were the reason for alcoholism, most of us would be alcoholics.  Liking to drink cannot be the explanation for alcoholism.

Knowing this, there is a simple rule that is helpful to keep in mind if you are uncertain about whether you or someone else has alcoholism:

If you drink only because you like it, then you are not an alcoholic.

(I'm using alcoholism as an example, but this rule and everything I'm saying here applies to every addictive behavior.)

There is another reason that liking to do any behavior, or deriving pleasure from it, cannot possibly explain addiction.  Using alcohol as an example again, if pleasure were the reason alcoholics drank then they would stop or control their drinking once it started causing them trouble, just as they would stop or control their eating cake if their doctor told them they had diabetes.  After all, people with addictions are no more intrinsically self-destructive than anyone else.  Their lives may be ruined by their addiction, but in other ways they are as reasonable, careful, caring, and thoughtful as the rest of the world.  Yet, they don't stop or control their addictive behavior.  Clearly, there is something different and deeper than pleasure that is motivating them.

The drive to repeat addictive behavior is, in fact, completely different from a search for pleasure.  As I've described in earlier posts in this blog and my books, the drive behind addiction is linked to the evolutionarily normal need to get out of a trap, to reverse feelings of overwhelming helplessness.  Addictive acts temporarily relieve and reverse feelings of being utterly helpless.  This explains why people who have addictions keep doing them despite the harm they do to themselves and others.  From an emotional standpoint, they are responding to a far more important drive than concern for any long-range risk.

Addiction is actually nothing more or less than one very common way of trying to cope with feelings of intolerable powerlessness.  When coping mechanisms work poorly, as addiction does, we call them symptoms.  Addiction is neither more nor less than a psychological symptom, a way to deal with a difficult emotional state, like other symptoms we all have.  It has nothing to do with getting high, being gratified, or having any other kind of pleasure.

Understanding this should help to end the inappropriate scorn that has been directed at addicts for thousands of years, and help to end the inappropriate scorn that addicts too often heap on themselves.

Posted on Saturday, October 24, 2015 at 02:21AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References5 References

Is Evidence-Based Treatment All It's Cracked Up To Be?

Watch out for bad science masquerading as "evidence."

Evidence-based treatment is as accepted as motherhood and apple pie.  After all, evidence is the cornerstone of science itself.  Before the Age of Enlightenment, people could claim anything was true, but evidence tells us whether claims are justified.  There's just one problem: if the evidence is faulty or irrelevant, so is the claim based on it.  That is exactly what has happened for too much of what we are told in health care, and addictionin particular.  As a result, much of the country believes things about addiciton that are simply untrue.

We all know about the fallibility of "scientific evidence" from experience.  The media has repeatedly (and excitedly) told us of published proof of results later found to be completely false.  Think about all the times we've heard that one food or another is good, or bad, for us, only to hear later that the reverse is true. Or, a new treatment is a miracle cure, but then has to be stopped to prevent it from causing even more harm.  What happened to the "evidence"?  The answer is that it is often simply a correlation between two things.  Any time a research study consists of obtaining data from a lot of people, inevitably correlations will show up among separate factors.  If the correlation is statistically significant (unlikely to be caused by chance) then regardless of whether it is correct or meaningful, it becomes scientific evidence.  In one famous, and disastrous, case (we cited it in our book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry), women who took hormone replacement pills were found to live longer, a correlation that led doctors to advise women to take hormone replacement treatment.  Only later was it discovered that this was precisely the wrong advice.  The correlation (the "evidence") was caused by another factor entirely: the women who took hormone pills lived longer because they took better care of their health in general, not because of the pills.  In fact, taking hormone replacement therapy was dangerous and had to be stopped.  An even more dramatic example was a study which found that people who took a sugar pill (a placebo) were half as likely to die as those who did not!  This was a highly statistically significant finding, a clear piece of "evidence," but in the end just a meaningless correlation. As in the hormone replacement case, the people who complied with the requirement to take the placebo were simply different from the women who didn't comply: they were more actively engaged in their health and tended to follow directions.  They lived longer because of those factors, not the placebo.

This kind of problem with evidence is so well-known that it has its own name: "compliance bias".  It is just this bias that is common in addiction research, where people who become invested in (comply) with any given treatment regularly do better than can be expected from the general population.  It has become routine, for instance, for researchers to extrapolate from the 5 to 10%  percent of people who invest in AA and do well, using this finding as "evidence" to recommend that everyone should attend AA.  Of course, the reverse is true: only the 5-10% percent of people who can invest in (comply with) the AA approach should attend.  For everyone else it's a loss of time and effort that could be spent pursuing other approaches.  Indeed, the supposedly "evidence-based" recommendations for everyone to go to AA are a prime example of the compliance bias fallacy.

Another form of faulty evidence comes from studies that are conducted without randomly choosing the study population.  An example we found in addiction occurs when the only people studied to measure effectiveness of 12-step programs are those who have been exposed to AA-oriented treatment before the study even began, then assuming that the results of subsequent AA-oriented treatment applies to the general population.  This problem with gathering evidence is also well-known enough to have its own name: "selection bias".

A different problem with evidence is that it can be derived from studies that are simply looking at the wrong question.  Here is a classic example, originally described by renowned statistician Nate Silver of election-prediction fame (we discussed this in The Sober Truth):  The annual winner of the Super Bowl (either the AFC or the NFC champion) used to be thought to predict whether the stock market would rise or fall that year.  Why?  Because it had worked out exactly that way for 30 years in a row.  That was absolute, definite, hard evidence, because the statistical likelihood of this occurring by chance was practically zero.  There was only one chance in 5 million that this evidence was wrong.  But, of course it was wrong.  The Super Bowl result had nothing to do with how the market performed, as shown in the next 14 years.  What happened to that very definite evidence?  The answer is simple.  If researchers study something that is absurd, they still may find strong evidence -- statistical "proof" -- that it is true.  It was nonsensical to think that the Super Bowl winner had anything to do with the stock market, because of the enormous body of knowledge we already have about how stock markets work.  So, any result from testing that hypothesis, no matter how statistically significant, will also be nonsensical.   This kind of problem unfortunately happens quite a lot in research, and like other problems with "evidence," it has been carefully studied (a way to deal with this problem was devised centuries ago by a mathematician named Thomas Bayes ("Bayes' Theorem"), but his solution is routinely ignored).  Addiction research has been badly hurt by this error, because many researchers -- who, after all, are only human -- have studied and drawn conclusions about only the things that interest them, or that they wish to prove, without bothering to take into account evidence from outside their fields that suggests that their results might be scientifically absurd.

A prime example is the claims of evidence for the "chronic brain disease" hypothesis of addiction.  The proponents of this idea have taken evidence from rats and assumed that they apply to humans (because all mammals share the same type of "reward" pathway in the brain), and also assumed that changes produced in brains as a result of using drugscan turn people into addicts (because they confused the excited behavior of rats with human addiction).  These researchers are neurobiologists who are focused on neurobiology, and have ignored or not known all the evidence from outside their field which demonstrates that their conclusion is indefensible.  Not only is human addiction nothing like the behavior observed in rats, we've known for 40 years (since the famous Robins study of Vietnam veterans) that humans cannot be turned into addicts by this mechanism.  The veterans who took large amounts of heroin didn't become addicts, just as very few people given narcotics for pain leave the hospital looking for a drug pusher, and people commonly stop taking other drugs after using them for a long time and never return to them, even without any treatment.  The brain disease hypothesis is based on "evidence" that, like the Super Bowl example, is the result of ignoring the enormous body of truly relevant human evidence that proves the idea is false.

Many of the problems with bad evidence can be, and often are addressed by doing what researchers consider the gold standard: create experiments -- not passive data mining -- with randomized subjects and a control group to reduce factors such as selection and compliance biases.  But, when we reviewed studies on the effectiveness of 12-step programs for our book, we found that virtually none of them met these criteria.  In fact, almost every one suffered with not only selection and compliance biases, but numerous other issues of invalid evidence such as inadequate length of study (drawing conclusions about patients with a lifelong condition like alcoholism on the basis of a study lasting just 3-12 months, for example), and inadequate data collection (most "evidence" in addiction studies is based on self-report, in which people are telephoned and asked how they're doing!).

But the most serious problem with nearly all the evidence in studies of 12-step programs was that researchers ignored data that didn't fit their conclusions.  In virtually all of these studies, the majority of the subjects dropped out because they weren't doing well.  Yet, in the reported statistical results -- the "evidence" -- these people were ignored as if they had never been part of the study.  By taking into account only the people who were doing best, researchers falsely concluded that the 12-step approach was very successful.  As we showed in our book, once the dropouts were added back in, the results were reversed.

When people ignore the problems of "evidence-based" claims, false ideas become perpetuated as established scientific fact.  We've seen that recently in nutrition, where years of "evidence" supporting the idea that people should eat low-fat diets are now being overturned, replaced by advice to eat low-carbohydrate diets, as the old evidence is now understood to have been a bandwagon effect in which everyone hopped on board with the "low fat" idea, and ignored evidence to the contrary.  This "bandwagon" error is just what has allowed the "brain disease" idea to flourish, but we also discovered that not a single major addiction journal had published an article about the psychology behind the behavior we call "addiction" over the past 3 years!  It's not that such articles don't exist; there's a longstanding academic literature on the topic.  I've contributed to it myself in scientific journals and two earlier books about the psychology behind addiction (The Heart of Addiction, and Breaking Addiction).  But psychological understanding of addiction is simply not the interest, or expertise, of current addiction editors.  As a consequence, more and more highly questionable "evidence" is published, perpetuating its conclusions as if they are scientific fact, while alternative or conflicting ideas are pushed to the side.

The more you know about "evidence-based" science, especially in health care and particularly in addiction, the more skeptical you should be.  Investigative journalist Gary Taubes, citing the comments of  two  British epidemiologists, wrote that "those few times that a randomized trial had been financed to test a hypothesis supported by results from these large observational [correlation] studies, the hypothesis either failed the test or … failed to confirm the hypothesis."

The term "evidence-based" falls far short of what people imagine, or hope.  Motherhood and apple pie are fine, but we have to omit "evidence-based" treatment from the list of things we can trust.

[An earlier version of this post ran on the website The Fix.]

Posted on Wednesday, June 10, 2015 at 02:19AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References1 Reference

Spirituality and Addiction

Is addiction a problem of the spirit?

In the United States, addiction is often described as a "spiritual, physical, and emotional" problem.  The use of all these terms together has been a way to please people of every point of view, but unfortunately has done nothing to aid understanding or treatment (for more on this, see the post in this blog, "Is addiction a biopsychosocial phenomenon?").   One consequence of the popularity of this vague description is that people believe that treating addiction should address all of these elements.  Before focusing on spirituality, let's quickly consider the other two pieces of this 3-part view.

First, is addiction an emotional problem?  Obviously, it is.  Readers of this blog or any of the numerous psychological writings on addiction (including my academic papers and books), know that addiction can be shown to be a psychological symptom, just one version of the common emotional symptoms we call compulsive behaviors.  Importantly, once addiction is understood psychologically, it can be far more effectively treated.

Second, is addiction a physical problem?  Physical addiction is a common result of some drug addictions, but that has very little to do with the repeated urge to return to addictive behavior days or even years after the last dose of a drug, when there is no more physical addiction.  The other physical notion, the "chronic disease hypothesis" of addiction, was developed from study of rats and has been shown to be completely invalid for humans. (For a description of the numerous fallacies of this view, see earlier posts in this blog including the most recent post, "Answers to Addiction Questions".  A fuller discussion can also be found in my books, "The Heart of Addiction," and "Breaking Addiction," or academic papers, especially "Addiction as a Psychological Symptom" in the journalPsychodynamic Practice (2009) 15: 381)).

This brings us to spirituality.  Is addiction a spiritual problem?  To think about this we first have to define the word, "spirituality." This turns out to be surprisingly hard to do.   A search reveals that up to about 70 years ago, the terms spirituality and religion were almost synonymous.  But since then, "spirituality" has also been used to refer to a feeling or belief in the oneness between an individual and the universe, being in touch with one's soul or inner self, and even simply a sense of personal well-being.  None of these newer meanings has a specific reference to a deity or  to religion.

So, is addiction a spiritual problem?  If "spiritual" is used in the original sense as "religious" then the answer is certainly no.  Addiction is not a failure of religious devotion.  There is also no reason to think of addiction as a disconnection between an individual and the universe, or any other New Age ideas such as working for social change or channeling contact with spirits.  Since addiction is a psychological symptom, it probably could be loosely described as being out of touch with one's inner self, in the sense that there areunconscious elements in every emotional symptom. But calling addiction a spiritual problem on this basis would mean saying that every aspect of emotional distress was a "spiritual" problem.  That would add nothing to our understanding or treatment and would actually interfere with trying to figure out the specific emotional factors within people that produce this behavior.

Of course, sometimes people, including people with addictions, feel less distressed when they feel "spiritually" at peace—comfortable with themselves and their place in the universe.  But plainly that doesn't mean that addiction is a spiritual problem, or that treatment of addiction has anything to do with becoming more spiritual.

In fact, we know from numerous studies that when people rely on a treatment which claims that addiction is a spiritual problem, they are at high risk of relapse (for a review of these scientific studies see my book, "The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry").

Addiction is not a spiritual problem.  Indeed, saying that it is has caused a great deal of pain to many.  Addiction is hard enough for people, without having to think they have shallow or tormented souls.

Posted on Wednesday, March 18, 2015 at 02:18AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References1 Reference

Answers to Addiction Questions

Everything you wanted to know and weren't afraid to ask.

It's time for a year-end clearance of frequent questions about addiction. I've addressed these in the past but not everyone reads the questions and answers that appear after blog posts. So, here's a compact summary.

Question: If addiction is psychological in nature, as you say, doesn't that mean it's due to something wrong with the brain?

Answer: This question usually comes from folks who don't understand what psychology is, or how it works. Human psychology is a phenomenon that emerges when a few billion brain cells function together, creating s complex system. The individual cells have no psychology. When a brand new set of phenomena emerge from a complex system, they are called "emergent" properties, and the study of this is a whole field of modern physics called "Complexity Theory". The most important part of this is that the emergent properties can neither be predicted nor understood by studying the individual elements of the system. An example from outside psychology is what happens when atoms are combined in complex ways. They form new structures (molecules) that have properties that are not present in the atoms themselves, nor are they predictable from knowledge of atoms. The field that studies the properties and interactions of these molecules is so different from the physics of atomic structure that it has its own name: Chemistry. In the same way, we are all composed of chemicals, but the nature and properties of life cannot be predicted or understood from knowledge of the chemicals that compose us (no chemicals are alive, and you could never predict life from knowledge of chemicals). To understand life, you need a new science beyond chemistry: Biology. Human psychology is an emergent phenomenon that occurs when billions of cells create a complex system. It has new properties that can only be understood through a new science: Psychology. Trying to reduce human psychology to brain function results in simplistic thinking that can never explain the new system, any more than DNA molecules can be understood by knowledge of the carbon atoms that compose it. The good news is that psychological symptoms such as addiction certainly do not mean there is something being wrong with a person's brain.

Question: I have seen a juxtaposition of two brain scans, one on drugs, the other not. Isn't that proof of the "chronic brain disease" theory of addiction?

Answer: Some people who have been exposed to drugs have an excessive brain reaction (secretion of the neurotransmitter dopamine) when they are subsequently exposed to that drug. Dopamine secretion leads to an excited reaction in rats, causing them to scurry around looking for the drug which produced the excessive dopamine response. This is the basic finding that led to the "chronic brain disease" theory. But to have evidence of this theory in humans, you would have to show that people first develop brain changes, then, as a result, become addicts. Considering that most of the country currently believes this theory, it is remarkable that there are zero cases that show this. All the "evidence" is the reverse: that people who are already addicts have changes in dopamine release, just like the rats in the original experiments. To conclude that this explains addiction is equivalent to believing that coughing produces pneumonia.

But just as important, there is an enormous body of evidence showing that the "brain disease" theory must be wrong, because it is incompatible with the evidence of human addiction. There are literally millions of people who have taken high doses of drugs like heroin or alcohol, yet never become addicts -- exactly the opposite of what the brain disease theory predicts, and impossible if the brain disease idea were true. We also know from another huge number of examples that drug addiction can be replaced by non-drug addictions that are focused on gambling or shopping or playing games on the Internet. These common examples underscore that addiction is not about responding to exposure to the same drug one took before; it has nothing to do with the same drug you took before. Then there's the fact that in human beings addictive behavior is regularly triggered not by being exposed to a drug, but by emotionally-significant stresses and traumas. On top of that, when humans make the decision to take a drink, buy a drug, or drive to a casino, they are typically reasonably calm -- sometimes for hours -- while on the way. The brain disease idea is based on the immediate response of rats to drug cues -- their tiny brains are simple matters of see-and-react. That behavior does look like the sudden release of dopamine. Finally, we know that people can stop their addictive behavior as a result of human intervention, either through psychotherapy, or through self-help group support, or even on their own (there is a substantial spontaneous recovery rate for alcoholism, for example). None of this is consistent with a theory of addiction as a "chronic brain disease."

Question: I know that AA doesn't help everyone, but why criticize it?

Answer: Almost everyone phrases this question just that way: "AA doesn't help everyone …" But this wording contains a huge error. AA has a 5-8% success rate. Therefore, the question should be rephrased: "I know that AA hardly helps anyone who goes to it … ." Seen in this realistic light, the answer to the question is obvious. By referring almost 100% of people with addictions to 12-step programs, we are failing -- and harming -- the 90% who cannot make use of this approach. When people are sent to a program that cannot work for them, it's like prescribing the wrong antibiotic to a person with pneumonia. Sure, the drug works for a small percent of people with lung infections, but if you give it to everyone then you're going to have a lot of untreated, much sicker patients. AA should be criticized for its irresponsible attitude that people who don't benefit should attend more meetings ("90 in 90"), and that those doing poorly haven't "worked the program" hard enough.

AA also deserves criticism for its failure to live up to ordinary standards of caring for people. The people we rely upon for most serious problems in our lives have carefully studied, trained, and been credentialed in a field that has standards, then kept up with changes in knowledge over the years, modifying their approach according to the results of their practice, and according to what is new. AA does none of that. Even though AA is a non-professional organization, it still must acknowledge that it is appropriate for very few of the people sent to it, and must require that every one of their groups actively advise people to try something else when AA isn't helping them. Without these assurances, we cannot trust AA to deal with addiction.

Question: How can you criticize AA unless you have fully experienced it? By full experience, I mean making the decision to work through all 12 Steps.

Answer: The questioner believes that one must go through all 12 steps before deciding to opt out, or even criticize the program. It is a restatement of the myth that "AA works if you work it." This idea is not just an obvious example of self-serving circular reasoning (wouldn't every business like to claim that its product failures are because you didn't work at it hard enough), but leads people who are unhelped to blame themselves.

Question: I belong to a great AA group. It is open-minded and thoughtful. How does that fit with criticism of AA?

Answer: This question underscores the fact that AA is intentionally unsupervised and uncontrolled. While there are groups that are composed of thoughtful and open-minded people, we know from a huge number of accounts that there are many others that are driven by fundamentalist zeal, are rigid and judgmental, often ruled by old-timers who have a stern view that what was good for them must be right for everyone, and can be unsafe. To be trustworthy, AA must have guidelines to ensure that any group calling itself "AA" lives up to minimal standards of open-mindedness, protection of all members, and knowledge of the limitations of this approach.

Question: Isn't there a big difference between serious addictions and doing things like shopping or cleaning the house too much?

Answer: The effects of a behavior do not define its cause or mechanism. When a dangerous drug addiction can be replaced by other, much less dangerous compulsive behaviors (which often occurs), it underscores the essential fact that all addictive or compulsive behaviors are fundamentally the same, and that addiction has nothing inherently to do with any one behavior.

Question: The American Society of Addiction Medicine, the American Medical Association, the National Institute of Mental Health, the National Institute of Health, the DSM IV all define addiction as a fundamental and primary brain disease. How could they possibly all be wrong?

Answer: When people are quite young, it is useful and important for them to believe that authorities, starting with their parents, are always right. Later, we learn that authorities are simply human, and they make mistakes. Anyone familiar with the history of science knows that widely accepted (and taught) theories are regularly overturned a few years later. In the case of the "chronic brain disease" theory, it's especially important to understand that all of the agencies mentioned are relying on exactly the same small set of observations and hypotheses. If they had each conducted their own studies and independently arrived at the same conclusions, their shared view would be more meaningful. But, as I've described above, there is actually no good evidence for this theory, and even more important, it is absolutely incompatible with the realities of addiction in humans. Naturally, this begs the question why so many people have climbed on this bandwagon. Some of the answer is that we all have a tendency to follow a crowd; life is easier if you go along with the currently accepted wisdom. But it is also true that the people who invented the "chronic brain disease" theory of addiction are neither knowledgeable nor interested in human psychology. They are trained in neurobiology, and with that as their hammer, the world looks like a nail.

Question: Many authorities support AA. Shouldn't that that suffice to end discussion?

Answer: This comment came in response to the publication of my book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. It is a variant on the last question, and contains the same fallacy. The fact that authorities have endorsed 12-step programs is meaningless if they base their conclusions on the same poor science. It was the fact that the science behind AA is riddled with errors that made it essential to debunk it, not ignore it. The truly shocking thing about this question is not simply that it is foolish, but that it was written by a psychiatry professor, who we'd all hope would have known better. But, personal politics has a role in most human life, and this particular professor is a consultant to a large AA-oriented treatment program, something he didn't bother to mention in his critique.

Question: How can you say that addiction is a choice, like eating peanut butter?

Answer: This question confuses "choice" with compulsion. Compulsive/addictive behaviors are driven by deeper factors. That's why we call addictions "symptoms" rather than "foolish decisions". For a few thousand years, people have mistakenly thought alcoholics were weak-willed or pleasure-seeking hedonists, believing that they drank out of pure "choice". That was wrong then and it is still wrong.

Question: Isn't addiction a spiritual problem?

Answer: This is just a year-end summary! See my next blog post for a discussion of this question.  Happy New Year everyone.

Posted on Thursday, December 18, 2014 at 02:17AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References2 References
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