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Addiction

This discussion is not so much intended to describe dealing with addiction as an addicted person--there are many good sources for that--but rather the intention is to describe elements of addiction relevant to relating to an addicted person. This is an area in which confusion and doubt often dominate.

Addiction is a largely self-sustaining process. That is, once it starts, the effects of use are what drive further use. Still, there is a tendency to try to understand the 'what' of addiction by understanding the 'why,' or the proposed 'pre-exposure' cause of addiction. There is always robust debate about whether there is a predisposition to addiction, and just what constitutes this pre-disposition--physical or psychological elements.

In recovery from addiction, it is clear that both physical and psychological changes must occur. For instance abstinence (a physical intervention) is overwhelmingly accepted as necessary, but the psychological changes must be present also, to maintain the abstinence. This discussion will not emphasize the debate around cause, but rather emphasize the 'how' of addiction, and concepts in recognition and recovery.

Addiction is a dedication to changing one's mood quickly and decisively by willful choice, independently of what is happening in the environment, and with disregard for the consequences. To do this, a compulsive relationship with a substance or experience develops. Willful mood change, however, is almost a mainstream value in our culture. Society generally only frowns on the 'out-of-control' aspects and this is partly why addiction can become so advanced before it is recognized.

Addiction involves, in the immediate-term, a detrimental obsession with an altered state (intoxication), but in the long-term, it also involves the emergence of an altered state of mind that functions somewhat like a second or altered personality, and which is self-sustaining. Usually this altered state of mind is accompanied by a changed look in the eyes and mid-face. The combined dysregulation of an altered state of mind in an altered state becomes very difficult for others to deal with, and of course is often intrinsically self-destructive.

This altered personality is perhaps not the core self of the person, but it is a deeply instilled brain state, one that is harder to change the longer it has been operative. In individuals in which addictive use starts early, the altered personality seems to form more quickly and hold more tenaciously, perhaps because of the vulnerability of the developing brain. There is a concept in the field of 'addictive personality.' This is more the result of addiction than the original cause, and perhaps should be called 'addicted personality,' but it does strongly reinforce addictive actions.

Abstaining from the altered state is a necessary step and a necessarily first step in the recovery from active addiction. However, addressing the altered personality has proven generally necessary to achieve a sustained remission. Abstaining from the altered state but remaining with the altered personality is called being a "dry drunk." This phrase describes more than poor native coping, although that is an element. A dry drunk involves having the distorted thinking and feeling of the active addiction brain state, at least episodically.

Addiction often involves putting powerful mood altering chemicals into the body, but can involve any manipulation of intense experience to unnaturally alter brain chemistry through reward (dopamine) and relief (endorphin) systems. Classic examples of this are sex, gambling, danger, and 'new love' (as in pursuing exciting elusive new relationships in an unreal manner) Increasingly screen-time (computer, smart phone, etc...) is itself being used to alter mood.

Addiction is a complex phenomenon that has many definitions, each centering on an important aspect, and each definition is therefore useful. The sheer recognition of of a specific case of addiction is hampered not so much by difficulty defining it, but rather, is hampered more by denial and concealment.

Recognition of Addiction

There are well tested criteria to diagnose addiction, and these are incorporated into the criteria for 'diagnosis' in a book called the DSM-IV. I have listed them below. These criteria are not controversial. They may be misunderstood or attributed to other things if the full truth of use is concealed.

  1. Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance. Tolerance arises from a combination of liver and brain adaptation and may reverse very late in the disease as there is extensive damage to those organs.
  2. Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance or (b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
  3. The substance is often taken in larger amounts or over a longer period than intended.
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  5. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
  7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

The first two criteria speak to physical dependence, which has been the classic medical way to approach addiction. The latter five criteria speak to unmanageability, which is the usual interpersonal or sociological way to approach addiction.

Unmanageability is discussed more below. Some behavioral addictions, such as gambling may seem to fail the physical dependence aspect but meet the unmanageability aspect, while some substances such as tobacco, sugar, or caffeine seem to meet the physical dependence aspect but not the aspect of unmanageability. Where unmanageability is absent (or really just low) it can be controversial to use the term addiction, which implies the need for treatment. However, when looked at closely, all addictions alter brain functioning beyond the normal limits of response. Manipulating the brain like this, whether with chemicals or with intense experience, produces both up-regulation, the basis of dependence and withdrawal, and an distorted approach to problems, the basis of unmanageability.

It is also generally of use to be aware of clues to addiction where the full truth is concealed and/or unknown. Some of these clues are below:

The question sometimes arises whether addiction can be considered where the substances are medically prescribed. The belief that prescription rules out addiction where the features otherwise exist is moral thinking not chemical thinking. Addiction is a chemical not a moral phenomenon. None of the seven main criteria for addiction above have any mention of prescription. Addiction is defined by what happens when the person takes the substance, not by what happens to bring the substance to them. Indeed a person in recovery usually has to reject prescribed addictive drugs against the advice of prescribers (physicians, dentists, advanced nurse practitioners, or physician assistants) only a tiny minority of whom understand addiction.

'Underlying Problems'

As mentioned above, there is a tendency to try to solve addiction by looking for 'underlying problems' and trying to solve those. It is an attempt to find an 'original cause' and undue it. This works with many health issues but not with addiction. As stated above, addiction is a self-sustaining process that requires no other problems to underlie it. Everyone has problems (not meant to be a flippant statement), whether there is addiction or not. It is an element of addictive thinking to believe that one should be without problems. Often addictive activity is employed to make evidence of problems go away from consciousness. Sane living consists not in 'not having problems' but rather addressing problems responsibly and adaptively.

Where addiction is active, trying to solve other problems becomes a farce, because the machinery of addressing is one of the aspects of functioning that is the most undermined by addiction. Other problems may be relevant once recovery is well underway, but in active addiction or early recovery they are at most, a red-herring. Traditional psychotherapy or counseling is not effective, and may even be counter-productive, where addiction is active. Largely I believe this is because while all the 'right things' can be said, there is not a connection between what is said and what is felt. A therapist can neither work with what is being said nor with what is not being said. As for body-based therapies, which side-step many problems of conversational approaches, in addiction they will not be successful because the nervous system is being artificially tampered with.

Self-proclaimed other problems from the point of view of the addict/alcoholic may also be misdirection to divert attention from the addiction, or plain excuses. There is also of course, among addicts trying to get better, a wish for the craving to go away first so that cessation will be easier. But the craving is a result of using, and only cessation will begin a change in craving.

Many if not most of these other problems often disappear if stable recovery is achieved, or are amply addressed by the elements of recovery. In fact, because addiction tends to be recognized only after it it well underway for several years, there is a great tendency to mistake the serious effects of addiction that start to show up at that point for the causes of the substance use that is just starting to get really noticed. For instance a man or woman separates from his or her spouse and substance use becomes more noticeable. It is far likelier that using was the source of relationship troubles than the other way round. The loss of help or structure from the partner explains the more public showing of addiction's effects. A similar confusion occurs when there is a loss of a job.

Occasionally it is possible to discern that the addicted person has indeed some problems not related to addictive use. These however, can only be meaningfully addressed once there is a solid element of recovery in place.

Shame is well-understood to predate and be involved with addiction but no work on shame (or low self-esteem) will be effective until addiction is adequately addressed as a problem in itself. As discussed in the section below on the 'high/low split,' compensatory grandiose elements usually have to be confronted first.

Physical Dependence

All addiction produces physical dependence in the body, inasmuch as the brain's own chemical balances are altered. With regular (not necessarily even daily) use, the nervous system re-regulates to adapt to the altered state and this is responsible for tolerance and withdrawal. It is also responsible for the sustained lack of pleasure in early recovery--it simply takes a long time for the brain to return to a state in which pleasure can be experienced by natural, non-addictive activities. This is in addition to any problems experiencing pleasure that existed pre-exposure.

The popular and even medical concept of physical dependence however is dominated by the pattern seen in alcohol and opiate dependence where abrupt cessation precipitates an autonomic nervous system storm that wracks the body and can, in the case of alcohol. be fatal. Because other addictions do not have this autonomic storm, the misconception of psychological addiction has arisen.

All addictions produce changes in the brain (physical) and changes in the mind (psychological). The psychological changes include maladaptive belief systems, a distorted way of evaluating situations, and associations that certainly complicate or defeat recovery. However, all addiction has its base in the physical, and this distinction is important. To change something that is only in the mind, should require only changing the mind, which is a mysterious process which seems like it should be instantaneous and based on will. But bias toward the instantaneous and willed is actually a feature of addictive thinking. Healing a physical condition, however, requires removing the toxin, time, rest, and gentle practices that are rebalancing to the nervous system. (Here we are talking about healing physical dependence, not healing the entirety of addiction as detailed below) All of these measures must be chosen or assented to by the mind, but they cannot be willed and they work outside consciousness.

It is well understood that for the body, where there is physical dependence, a very slow progressive decrease in dose (a wean) is optimal. However, for the mind, when an addictive substance is weaned cravings are powerful and constant and last for the entire weaning period, making it into a torture. Compliance with a slow wean is humanely impossible. Therefore the only practical weans are very quick ones.

Physical dependence itself becomes the 'topmost' driver for the addiction. While this is recognized where the physical dependence is severe as in middle and late addiction, tolerance and withdrawal are present in early addiction but are hidden, denied, and attributed to other causes. This is why all treatment begins with abstinence.

Complete withdrawal is the process of the nervous and metabolic processes returning to 'normal' during a long period of abstinence. It is often the first week of cessation where life-threatening withdrawal may occur that gets all the attention. But with alcohol for instance, the withdrawal continues for 1-2 years where it may never be quite complete but just plateaus. 'Behavioral' addictions disrupt the reward and dopamine systems of the brain and also have lengthy withdrawal periods.

A simplistic attitude toward addiction is "complete the withdrawal, then abstain from there on" If use is restarted after a complete withdrawal or remission longer than a year, it is attributed to 'lack of goodwill.' However, relapse is the bane of addiction treatment. This has given rise to the term 'psychological dependence.' Splitting addiction up this way may not be very useful in practice, but it is clear that addiction needs a unique disease model that includes every aspect of the person

Even in active addiction, the person is withdrawing a greater percentage of the time than he or she is 'high' or 'good' The psychology of addiction is more centered around withdrawal than it is euphoria. Addicted people are obviously quite dissatisfied and unhappy in demeanor rather than euphoric! For chemical addictions particularly, and all addictions to some extent, the top most driver of continued use is the continuous combating of withdrawal symptoms, whether this is realized by the user or not.

The Disguise of High Functionality

Often addiction will come to light in a case where most onlookers had not, or still do not recognize it. The adjective "high-functioning" is then applied. Functionality is no marker of non-addiction, almost the opposite. Below are some reasons why:

False Emotional Sophistication

All addictions block feeling. However, it is possible while high (even not obviously high) to intellectually and conversationally go to topics that seem to be deeply self-searching, emotional and insightful. This is only possible' however, because the anesthetic effect of using cuts off the feeling. It is feeling that provides implications for action. Later when not high, the addicted person won't even allow the topic to be mentioned. This pattern tends to disarm others who are fooled into believing the addicted person has a better handle on the situation than that person really does. Real honesty requires feeling, and of course this has direct implications for recovery.

Unmanageability

I define unmanageability as the process whereby negative consequences of using do not have any moderating effect but in fact produce escalation in use. The effects of use are 'combated' with more use, often unconsciously but sometimes consciously. This can occur alongside elements of high functionality as described in the section above. In the above section on recognizing addiction, the unmanageability of use is described, but below are listed aspects of the unmanageability of living.

There is a small group of addicted persons, especially with alcohol or marijuana, that is able to eventually put a strained ceiling on quantity while using daily. This ceiling will be high compared to non-addicted users. It will, however provide somewhat greater predictability day to day, and less scandal ensues. This is not evidence of non-addiction. There is a steady erosion of character and potential, denial is in full bloom, and the material and emotional dependence on others tends to grow whether the addicted person recognizes it or not. Any disturbance has a potential to restart escalation in use and unmanageability in behavior.

Peace of mind is the absence of anxiety, depression, or excitement. Addiction, among other things, is the attempt to fight depression and anxiety with excitement, with no ability to achieve peace of mind. The life spirals out of control.

Highs

There are four different types of 'highs' that figure in addiction: arousal, satiation, trance state, and seeking.

The arousal high consists of a sense of intense, unchecked power and gives feelings of being untouchable and all-powerful. Arousal makes addicts believe they can achieve happiness, safety, and fulfillment. It also usually increases sex drive and makes use of that for mood alteration. Arousal comes from amphetamines, cocaine, ecstasy, and from the behaviors of gambling, sexual acting out, spending, stealing, and so on.

A satiation high gives the addict a feeling of being full, complete, and beyond pain--in a word, enough. (Arousal gives the addict that satiation can be achieved easily as a byproduct of powerful actions) Heroin, alcohol, marijuana, benzodiazepines, and various behaviors such as overeating, and watching TV all produce satiation highs.

Trance is a dissociative state where numbing is prominent. Trance is more commonly associated with behavioral addictions. Strong 'escapist' activities, risk-taking, or fantasy may be placed in the trance category.

Seeking is the experience of anticipating one of the three other highs. It is conditioned by overuse of the dopamine-based reward system in the brain. The brain is wired to drop everything else when a cue to pleasure like sex or food appears. Seeking requires some other pleasure in the first place but becomes compelling in itself. Seeking gets incorporated into 'using rituals.' Seeking is largely behind internet pornography addiction.

All types of high block awareness of pain and distress. Addicted people usually have a preference for one of the three types of high. A preference for satiation is sometimes called 'liking downers" but it is not the sedation that is wanted but the feeling of enough. Not uncommonly, the addict will attempt to mix the arousal and satiation highs somewhat, as in the practice of mixing heroin with cocaine in a 'speedball.'

A closely related state is the excitement of chasing the high. Once the decision is made to use again, the brain anticipates by releasing dopamine. This is both a conditioned response and an innate response of the brain to anticipation of pleasure. In mid and late addiction, anticipation may actually be the strongest re-inforcer because of habituation to the effect of the drug or process.

Almost certainly, in early recovery, the high is still the best possible experience the addicted person can remember or imagine, but the high is being avoided (with great effort) because of the consequences. This recovery will not be really stable until the addicted person grows in the capacity for pleasure and relationship so that he or she can incur better experiences than these highs or altered states. Stated another way, it is alternatives to and not consequences of the high that make recovery more stable (but of course not certain)

Emotion and Mood

Emotions are involuntary body responses to events or people in the environment, or memories of the same. As reflections of what is (or was) happening, they are individually neither good or bad, but just are. Examples of emotions are fear, anger, joy, sadness, terror, disgust, and mirth, among others. The subjective experience of emotion is based upon the mind's perception of the bodily response. However, the perception is not necessary for the emotion (body response) to be present.

Moods, on the other hand, are a mental product of the difference between perceived challenges and perceived capacities and resources to meet these challenges. If there is perceived to be a surplus, the mood is good; if a deficit, the mood is bad. That is why folk wisdom knows that people tend to be generous when the mood is good and stingy when the mood is bad. Moods are forward looking. Because they reflect perception of prospects they can, unlike emotion, be said to be positive or negative along a spectrum. Unlike emotions, moods can be quite distorted, both about capacities and challenges. Resulting cognitions may at times be unrealistic. Examples of moods (from most positive toward negative) are mania, elation, encouraged, hopeful, neutral, dour, discouraged, desperate.

Addiction is about mood not emotion. The goal of intoxication is to lessen emotion (and its sister anxiety) while at the same time enhancing mood. Using is not just a matter of pleasure in the moment, it is meant to be pre-emptive, that is produce a mood so over-arching that whatever happens next will not faze the addict.

Nicotine is an example of an addiction which has been socially acceptable because the 'highs' are not socially disruptive and the unmanageability is considerably less than other drugs of abuse. However, the mood management function is prominent.

Over time artificial mood management has a progressive durable effect. In early addiction, disinhibition may release more distorted displays of emotion, but over time emotion is dampened., while mood swings increase. Addiction decreases emotion but increases moodiness. This is a recipe for poor reality testing.

Self Will

Self-will is trying to define the self by picking an image and willing oneself to live up to it. Self will as a way of life is wide spread and does not always lead to addiction, however, where addiction exists, self-will is sure to be there also. Whatever the role of self-will in the origin of addiction, it usually is the pivotal element in the maintenance of addiction.

In practice, self-will leads to a stance that a life is made by deciding exactly what should happen and then making it happen, by doing what one thinks should get that result. Self-will always results in a shaky sense-of-self. It may seem to produce good results in limited domains where one has control, but it fails in complex social or interpersonal conflicts. Self-will leads to controllingness (to achieve one's will) denial (denial of reality to support the illusion that one's will is being implemented), and collapse (a refusal to participate in life when one cannot have one's way.)

With addiction, will power is not the solution, it is the problem, or at least the problem within the solution. However addiction develops, recovery is complicated by an exaggerated tendency to try to control what happens, and of course control mood.

No one has endless willpower because living continuously by will exhausts the person and prevents sound renewal and refreshment. Also the direction of will-power is easily distorted by rationalization. It is easy to go from willing abstinence to willing oneself to use secretly, or willing oneself to use "in a controlled way" (but of course an aspect of addiction is that control is lost immediately upon first re-use) The continuation of self-will after abstinence has begun is known as 'white-knuckling it'

Denial

While lying and cover-up certainly are common with addiction, denial is the inability to see the truth. It is the opposite of realization. Behaviorally, denial is proceeding as if something is not happening, hasn't happened, or is unimportant, or is harmless, when in fact what has happened and is happening and is serious and injurious. Denial may have 'willful' elements at first but with any duration it actually solidifies into a state of not knowing or not feeling, and this is a dissociative state.

Another aspect of denial is insincerity. Everything the addicted person says is said based on the purpose of the moment. Nothing is tied to honest assessment of the situation or honest self-assessment. Some things that are said may be true but that is not why they are said. Self-contradiction is routine. It is not possible to have a productive conversation.

People around the addict are often infected by denial because to have any peace with the addict, they must proceed as if something isn't happening or as if they are not feeling something. Eventually this is converted into 'firmware' in the brain. Denial is contagious and progresses through a group if not strongly challenged. Being desensitized or habituated to an ongoing serious problem is part of denial as well. Because of the burden of having splits and compartments, where there is much denial mental efficiency and mental energy will be low.

Denial is the hand-maiden of self-will because when self-will fails in the world, denial can block the evidence of this failure. Addictive use supports denial and denial supports addictive use--this is why some involuntary aspects of treatment as well as strong confrontation can be helpful in the early picture of recovery--it breaks this tight loop. Denial is more than dishonesty, it is truly a brain dysfunction that keeps the denier from the full appreciation of the consequences of the addiction.

Confrontation: Professionals working with emotional functioning learn quickly that confrontations are generally only effective if used sparingly and well-timed. This is because a confrontation brings up defenses and may in fact just strengthen them. With problems other than addiction, avoiding confrontation may create a secure relationship in which defenses lower by themselves. With denial however, as in addiction generally, strong and frequent confrontation is necessary (but not sufficient) until recovery is well-established because denial grows when not confronted, and in fact it starts to infect the whole system. Yes it is true that lecturing, pleading, scolding, moralizing, etc.. are counter-productive. But it is necessary to acknowledge what has happened, and its effects on people, feelings, and events. Confrontation in this arena is an art, which is why professionals are often involved.

Resentment

Resentment is a form of denial in which the sheer occurrence of something is not denied but the legitimacy of it having happened is denied. This leads to festering hostility, moral righteousness, and non-cooperation. Because what is resented is not accepted, it is not addressed realistically, and unreal living results. Resentment often becomes both the driver and the rationalization for using.

Isolation

Eventually in the addictive process, obnoxious, secretive and dishonest behavior alienates others. Denial prevents any real conversation or communication--when it is not possible to talk 'about the elephant in the room' it is difficult to talk about anything. The unreality is harmful to others, and unless they are using addictively, they must remove themselves.

For the addicted person, attachment shifts toward the addictive substance or event, and away from from people. Even if interaction still happens with others, the others become objectified.

Also to protect the continued option of using, addicted persons using large amounts have to use in private because even other heavy users would insist there is a problem.

'Terminal Uniqueness'

This is the belief that one has unique problems. unique circumstances, and unique suffering that requires unique solutions. Grandiosity may or may not be overt. Addiction removes all vestiges of connection with others and produces terminal uniqueness. This becomes an immense barrier to getting help because of course, all help is based in the common principles of addiction.

High-Low Split

With addiction, there is almost always the co-existence of a very low self-esteem with a grandiose and infantile ego. Grandiosity sometimes shown in an inflated opinion of oneself, but more commonly it is shown by a compulsive reliance on and reference to achievement, pride and rigidity, an attitude of entitlement, manipulation (because whatever one wants is though to be right) and objectification of others (seeing not whole people but just the presence or absence of opportunity.) Self-deprecation is grandiosity because it is an apology (usually insincere anyway) for not being perfect, and using perfection for a reference point is grandiose! However remorseful an addicted person may seem to be acting, it will still be impossible to concretely address a practical grievance because his or her pride will be wounded instantly and there will be a lashing out.

Actual humility is a heartfelt understanding of one's place in the natural order and in the human community. Self-hate is not humility, just the opposite. Remorse need not be born of humility.

In middle or late addiction especially, grandiosity is often shown by a collapsed state. That is, the addicted person refuses to participate in anything in which he or she is not (seemingly) performing excellently or superiorly or feeling great or superior. After a destructive episode or period, efforts to 'straighten out' may be started but are hard to maintain because they are mundane and humbling. Grandiose unrealistic plans for 'straightening out' are common. Using again is always a maladaptive way to quickly start feeling again the way the addicted person feels he or she should feel.

This split leads to a style of life in which the person is often self-deprecating, pleasing, and deferential in interactions with others, but maintains a secret contempt for others. This is not true humility. Sooner or later, especially if challenged, the contemptuous grandiose state takes over and the pseudo-humble state vanishes. This is sometimes known as "Dr Jekyll-Mr Hyde" behavior. Relapses sometimes seem to resemble an episode of dissociation, but that is a topic beyond the scope of this article.

This is a situation not unique to addiction, but addiction exaggerates it greatly. During times of abstaining the 'Dr Jekyll' side is shown, during times of using, the 'Mr Hyde' side is shown. This complicates addressing the addictive behavior because the 'low' state brings sympathy from others and the 'high' abusive state sends others fleeing but is always disavowed later by the 'Dr Jekyll' self as an aberration.

Usually the low state is thought of as 'being good' and the high state is thought of as 'being bad.' But this is the very type of conceptualization that perpetuates the split. Both states are highly unbalanced and depend on the existence of the other. Trying to suppress 'Mr Hyde' completely, which is the usually way of attempting recovery, just leads to more explosive outbursts at perhaps longer intervals. What is need is a unification of the two distorted halves, to achieve self-respect, humility, and good boundaries. Guilt will be natural with addiction, but guilt is a bad engine for recovery because it strengthens this split. The recovery practice of making amends is not meant to anchor behavior to guilt feelings but rather get guilt out of the picture.

With recovery from addiction, sustained (but not permanent) ego-deflation is needed. In time, humility can take hold. Most relapses happen when the addicted person starts to feels better. Hitting bottom is a term describing a point in time when a combination of factors have finally deflated the ego of the addicted person beyond the point where denial can re-inflate it. Abstinence is natural in this state. Abstinence for a time usually brings about an improvement in feeling and life-manageability, causing self-will to surge and a relapse often follows. The 'periodic' addict is in fact making this pattern into mini-cycles. This of course is a tricky point since recovery is after all intended to allow addicted people to feel much better. But better feeling has be built on a better foundation than 'elation'. Twelve step programs emphasized this aspect of recovery and for that are mistakenly believed to insist on self-loathing. Self-loathing, however, is part of the high/low split--humility is something different.

'Hitting Bottom'

In any story of addiction and recovery, there will be a narrative element called 'hitting bottom' This is a point in time in which a successful effort for recovery was begun, and life and emotional circumstances started improving. Hitting bottom as a retrospective organizing concept of recovery is unassailable. It seems to describe a state of being that includes desperation and willingness, which enables the addicted person to accept previously rejected options and steps

Bottoms are generally described by the damaging consequences that are going on at the time of the turnaround. However comparison of 'bottom stories' will show that many addicted persons do not stop at what stopped another addicted person. More tellingly, the point at which many addicted persons stop using is actually not at the point of worse consequence but at the point of some 'lesser' consequence. There is no consequence of addiction (besides death) that is intrinsically a bottom.

Consequences don't really guide addiction, and alone they will never end it. One very good operational definition of addiction is continuing to use despite severe negative consequences. Addiction's power over consequences is very understandable in the short run: the 'high' makes the addict oblivious to pain, squalor, rejection, guilt, lonliness, loss etc... However, relapses are common even among addicts that have both sustained sobriety and addictive history. Since these individuals know the consequences of using, and of not using, at least intellectually, before they get high, the process of addiction itself seems to build in or trigger a disregard for consequences. This understanding should inform public safety and public health approaches to addiction whenever a 'hard-line' is contemplated

Recovery from addiction is based on alternatives and the addict's acceptance of alternatives. A bottom is more an opening wherein the addict or alcoholic can view the alternative of recovery differently and accept it. A sustained recovery requires developing the capacity for truly satisfying alternatives to getting high.

Of course, consequences are necessary for the basic sanity of a situation--enabling (as discussed below) leads to disorientation of all parties and even greater difficulty grasping healthy alternatives. Interventions if done well are really just the natural consequence of family and friends seeking clarity and boundaries. Those family and friends that are not naive may understandably wait for a bottom to avoid wasting effort and hope, But there is little evidence that 'bottoms' are fore-ordained or immutable. There is a 12-step saying: "You hit your bottom when you stop digging." It is difficult to 'call a bottom' until it is well past. True, willingness needs to be present in the addicted person in some form for recovery to be effective. But a complete 'hands off' attitude may not be optimal.

However, this is a very tricky area where 'home remedies' often get sucked into the addictive process. Most loved ones want to both 'hasten' the 'bottom and also soften it. But softening a bottom is often at odds with hastening it. This is the dilemma behind 'tough love' approaches.

'Fixes' versus Solutions

A strong element in addictive thinking is the belief that one thing will fix everything, and that the task is to think of or find that thing and rely on it. Drugs to get high are often referred to as a fix during active addiction. But in trying to overcome with addiction, many other fixes are tried: geographical moves, job changes, relationship changes, belief system changes (abstractedly and not involving beliefs about oneself), substitute ways to change mood, etc.. None of these will work because the very attitude toward the fix (self-will, instantness, control, deliberate mood manipulation) is the actual problem. It is sometimes said that alcoholics and addicts don't want solutions, they want problems to go away.

There are solutions, but these solutions are neither quick or easy or subject to complete control. Rather than making changes happen, one puts oneself into experiences that are conducive to positive changes. Solutions are more a direction requiring many steps, with previously unseen steps revealing themselves the farther one moves in a healing direction. Solutions for very difficult problems in living require patience and some type of faith in life and growth. The solution to addiction is not comprised of any one step or any collection of steps, but is rather comprised of the changes in body and mind one experiences by taking these steps. The search for a fix is a wider problem than even the field of addiction, it is a cultural tendency.

Recovery and Treatment

Recovery is the process of 1) stopping the artificial mood alteration, 2) avoiding conditioned cues of using (persons, places, things) in the short run and changing conditioning slowly over the long run for those cues that would be life-limiting to forgo forever, 3) combating denial with new habits of rigorous honesty and robust open communication, 4) combating self-will with practices of humility, 5) taking care of one's body, 6) participating in a sober community, being with people who recognize and challenge addictive thinking. Being with merely non-using people may not be enough because some mainstream values in our culture are addiction-friendly 7) finding real fulfillment, 8) once past early recovery, addressing other problems honestly. In recovery, there is no finish line, only a direction.

Experience has shown that it is not possible to address the altered personality of addiction without addressing underlying basic character issues that may have predated the active addiction. This is not to say these are causative or 'underlying problems' (as discussed above) It is to say that the addiction brain state gets too intertwined with human emotional limitation by the time of recovery, and so the way of life must be addressed from the ground up. An addicted person wishing to recover can not afford the complacency toward personal limitations that a none-addicted person can.

For recovery to ultimately work, the addicted person must want it and want it badly. However, the treatment phase of recovery can be successful even if the addicted person doesn't want it. This is because treatment gives the addicted person a chance to deal with the realities of his or her situation Inpatient treatment forces a period of non-intoxication and interrupts contact entirely with those people. places and thing that have become conditioned cues for using. Intensive outpatient treatment is also intended to enforce non-intoxication and disrupt associative patterns. Treatment is an optional element within recovery that has for its more limited purposes, some opposite principles from long-term recovery, such as limited coercion and limitations on autonomy. It is important not to confuse the strategies of treatment with the overarching principles of recovery as a whole

The subject of treatment often leads to the subject of intervention. Intervention is first and foremost a process of discernment by all parties seriously affected by the addict/alcoholic. Each person must think in terms of responding to the addictive behavior continuing forever. Indulgence based on mere hope of imminent change is ruinous to boundaries and sanity, and usually leads to enabling in some form. Out of realistic discernment, boundaries and limits flow naturally. Second, intervention is a process of communication among these people that identifies common boundaries that are arising out of the discernment. This communication automatically leads to more support among everyone involved and is a benefit by itself. Third, these consistent boundaries are communicated to the addicted person all together in one group to avoid splitting and triangling. Treatment is almost always offered at this time, and it is often accepted because it will be the only plausible alternative to restore or maintain full relationship between the addicted person and everyone else. Intervention is not a way to 'trick' or 'force' someone into treatment-that type of strategic thinking is part of addictive thinking.

Because addiction will have grown roots into everyone around the addicted person, intervention is a type of surgery for the group where elements of addiction and co-dependency are confronted. Co-dependency is a huge barrier to intervention, and co-dependency is often strongest in the most vocal critics of the addiction. That is why the services of a professional are generally used to great benefit. The intervention professional is not so much to 'manage' the addicted person (in active addiction, psychological services are usually futile) but rather for the guidance and psycho-education of the group. This will of course benefit the addicted person in some way because it removes at least the shared interpersonal elements of denial.

Accountability

Accountability is a strict responsibility to address, in a robust and creative way, and on an ongoing basis, all the consequences of one's actions, intended and unintended. Accountability makes one part of a community. By contrast, punishment is an aversive experience imposed after a behavior intended to decrease its recurrence. Punishment does not build accountability or community. It is difficult for accountability and punishment to overlap because the aversive requirement of punishment is at odds with the satisfaction of accountability. The alcoholic/addicted person quickly comes to experience all the natural, logical, legal, and social consequences of the disease as punishment. That is why recovery programs of all types stress accountability. It is important to understand that accountability will be undermined by any attempts to enforce it with punishment.

Twelve Step

Where there has been an inability to stop addiction on a rational, willed basis (which is the norm rather than the exception), twelve step solutions are usually offered. Twelve steps programs address the problem of self-will with surrender and humility and the problem of denial with rigorous honesty and thorough disclosure. For many people surrender, humility and honesty are summed up in the concept of a relationship with a higher power.

It is easy to quit on a rational basis. It is extremely difficult to 'stay quitting' on a rational basis. A person's rational faculty is always at risk of capture by unconscious and half-conscious drives--this is the origin of rationalizations.

The aspect of a higher power is very controversial. A higher power can be anything except oneself. There are other ways to recovery than twelve step, but to be durable, they must address the problems of self-will and denial. For most, recovery cannot succeed on a rational basis because the reasoning functioning is always subject to rationalizations.

Twelve step groups are not just informational meetings, but easy-to-enter hard-to-flunk communities. Learning to function in a community provides a community for accountability, a healthy means of self-definition to replace self will, and honest feedback that combats denial. The community also offers a different means to contain painful feelings.

Co-Dependency

In a love and attachment context, codependency is unconditionally loving those who love you conditionally. Leaving aside the word love, it can be restated that codependency is accepting the conditions of the other unconditionally. This basic situation usually underlies codependency as relating to addiction.

In the context of addiction, co-dependency is when one person attempts to manage his or her mood by managing the addicted person's choices. As stated above, the dependent (addict) is usually trying to manage his or her own mood directly and willfully. Both are will based strategies. In any dependent/co-dependent relationship, there is a tremendous battle of wills. While the relationship may have superficially the aspects of a being a cooperative one, fundamentally it is adversarial, with the dependent exaggerating elements of self-determination, and the codependent becoming entirely focused on the other.

The dependent take too little responsibility for what he or she does and its consequences, and the co-dependent takes too much responsibility for what the dependent does. Superficially, the solution is somewhat different for each, the dependent needs to start taking more responsibility and the co-dependent less responsibility. More deeply, however, the need is for the same things--self-respect, honesty, and humility. Many codependent 'types' do become addicted and manage to become dysfunctionally more selfish that way. If they then find sobriety, the codependency may re-emerge.

It is a myth that co-dependents approve of the addictive or self-destructive behavior of the addicted person. Almost always there is great disapproval (but at the same time no effective action or boundaries.) If there were approval, you simply have a second dependent and the tie between the dependants will be weak ('fair-weather friends'.) One dependent rarely cares much about the choices of another dependent (unless there is a romantic/sexual relationship). Despite expressing disapproval, the codependent often in fact actually enables addictive behavior, but it is usually done with the conscious idea of harm reduction, and the covert idea of gaining favor and influence with the dependent.

Co-dependents don't trust their own judgment, and more often than one would imagine, they defer to the judgment of the addicted person, who evinces the opposite of doubt. The attraction for the co-dependent really is that the the addicted person is a pseudo-leader in the relationship, with the codependent 'following' by cleaning up the mess and seeing to the practical details.

Denial is also an essential component.of both dependency and co-dependency. Denial is necessary to avoid the conclusion that something much more drastic and truly adaptive must be done to address the problems. Codependent's find it almost impossible to let go of a relationship however bad it is. In fact the more chaotic the relationship, often the stronger the holding power. It is the codependent's strategy to make him- or herself indispensable to the other, and so problems become essential.

Enabling

Enabling is interfering with the natural consequences of addictive behavior. It includes supporting the addict/alcoholic financially, going along with denial, hiring lawyers, paying damages, spreading doubt of the addiction among others, cleaning up, suppressing one's annoyance, etc. Helping is when what is provided allows the recipient to do more. Enabling is when what is provided allows the recipient to do less. Therefore the distinction between helping and enabling depends less on the exact action and more on what the recipient is really doing. It is very easy for a family to slide from helping to enabling as an addiction takes hold, especially in adolescence or young adulthood.

Much enabling comes from codependency, but it may also arise out misinformation and misdirection from the addicted person. It may also be done out of sheer self-interest as when a prominent family protects its reputation.

A great deal of enabling is undertaken as harm reduction, with the idea that once recovery happens, the healing required will be less. Harm reduction, however, is usually only harm delay. From a public health perspective, in which it is understood that most cases of late addiction do not recover, harm reduction strategies make sense especially from an infectious disease or public services utilization point of view. From a family or an individual point of view, with any struggling addicted person, reducing harm (apart from life or limb threatening events) furthers denial and unreal illusion.

Tough love is a strong measure to combat not addiction but codependency and enabling. The stance of not rescuing the addicted person is self-evident, but the stance of no contact (unless there is treatment or recovery) is harder to grasp. But a no contact policy is usually necessary to keep everyone from being sucked into denial. The actively addicted person usually conditions their cooperation, even in conversation, upon only talking about the good things. But if what is in the forefront of one's mind is the unaddressed addiction, than not talking about it is participating in denial.

The Alcoholic\Addicted\Failed Family System

The following section combines labels and concepts from from both the work of Sharon Wegscheider and Claudia Black, since to this author, both of them describe the same essential construct. First there are two 'adult roles'

Then there are four 'child' roles. While these roles allow for the development of certain positive qualities, no real leadership or assertion qualities are allowed in the system. Moreover, there is focus on near-term adaptation--stretching or striving or exploring is not supported.

From this model can emerge an understanding of the 'adult child' but that is beyond the scope of this page. The narcissistic family system (described on my page about narcissism) can co-exist and merge with the alcoholic family system.

Engaging With an Addicted Person

Maintaining a relationship with an addicted person is notoriously difficult. Where addiction is active, it is not possible to have a normal relationship. There are basically three ways to go: 1) keep the person at arm's length or have no contact (detachment), 2) have a pseudo-normal relationship, talking only about non-addiction, non-problem areas (denial) or 3) try to address the addiction (confrontation). Loved ones usually are not able keep the person at arms length and usually end up alternating between the last two courses of action. As explained elsewhere on this page, however, those approaches do not mix well. It is in fact the first and third courses that are compatible with each other and with sanity! There are three unique elements that emerge strongly in a relationship with an addicted person that lead easily to a feeling of betrayal if not understood

False Fragility It is instinctive to understand that on a sensitive subject, it is counterproductive to push a person too far. Better to back off when the other person gets too distressed and let them "come around' However, with addiction, this will just support denial. Addiction causes a rapid and sudden escalation in demeanor and tactics when the subject of addiction or its effects comes up. The same escalation arises when any healthy or effective boundary is enforced. The addicted person acts like he or she is being 'killed' when the situation is more like something they dislike is happening.

It is therefore not possible to determine at all the correctness of an action by the response of the addicted person. At times, very strong confrontation is necessary. The confrontation may meet with stonewalling, leaving, or lies, but it will still support sanity and prevent denial from overtaking the family or group. If the issue is one that can be truly 'let go', then never bringing it up may be an option. Confrontation in this area is a skill.

Vortex of Pity When another person reports something bad or unfair has happened, good people tend to offer sympathy, which is recognition of another's loss. The reported injustice or mistreatment is not investigated, that usually would be unfeeling since the recipient is indeed upset at the moment. With addiction, however, the consequences of using are experienced by the addicted person as unjust and evidence something is wrong with the world. The call for commiseration never ends and the addicted person is hypersensitive to any potential lapse in sympathy. This becomes pity and self-pity which feeds the 'victim role' that develops in addiction, because the compassion is used wrongly to subvert the evidence that bad things happening in the addicted person's life are not bad luck in their specific instances but rather natural consequences. Inadvertently, goodwilled people are drawn into validating the addicted point of view.

Double Struggle The addicted person struggles against the disease but also struggles against those who want to help him or her struggle against the disease. When dishonesty and manipulation comes to light, two extremes are possible: the offense is put down to the disease effects entirely, or is taken personally entirely. The former supports denial, and the latter leads to rupture of the relationship. Addiction intertwines its compulsions around the self-determination part of the personality. It is neither true that the addicted person has no free will or that he or she has complete free will. Accountability is necessary for recovery, but this is best 'built into' tools and systems that are transparent, rather then left to the 'honor system.'