Ask the Experts: Addictions
A neuroscientist, a peer navigator and a psychoanalyst offer their insights and advice.
Interviews by RonniLyn Pustil and Debbie Koenig
Neuroscientist and professor of developmental psychology
Radboud University, Holland
There’s no doubt that addiction causes changes in the brain and that there’s a physiological substrate to falling in love with substances. But addiction is not a disease. My main argument is that the brain is changing whenever we learn anything. And the more intensely we learn something, the more our neurocircuitry changes. That happens when you fall in love or join a religious order or become a sports fan. With addiction, it’s the repeated pursuit of a particular goal (heroin, alcohol, crystal meth ...) that causes recurrent changes and gradually grows a network of brain connections that support that behaviour and make it seem like the only game in town.
There’s no doubt that the brain changes. But the medical model, the dominant model which views addiction as a disease, has a fatalistic quality to it. The implications of the medical model—that addicts need medical treatment and that going into treatment will lead to a cure, which is generally handed down from a professional authority—remove the sense of autonomy, self-motivation and empowerment that are key to recovery.
When I say that addiction is not a disease, I’m not saying that there aren’t a lot of brain processes that are deeply involved in addiction. I am saying that we can think about brain processes and talk about them in a clearer and more potent way—without the baggage of the disease model, which doesn’t do addicts much good.
People who say that addiction is a disease often argue that if we call addiction a disease rather than a choice, it removes the stigma. I think that is absolute nonsense. People with HIV know better than anybody else that being viewed as having a “disease” does not get rid of stigma. It just doesn’t work that way.
If you recognize that addiction is partly a neurobiological process, then you also realize that you can’t just decide one day to stop. It’s not that easy. Yes, choice is involved but it’s not something you suddenly do with a snap of the fingers. It’s important for people to understand that. That can reduce stigma without calling it a disease and saying you need treatment.
So what can help people? There’s no one-size-fits-all solution. It depends on the person, their situation, their support network. Statistics show that most addicts recover and most of those who recover do so without any formal treatment. Those are the facts.
When people who have a more extreme form of addiction need help, there are many paths to take: standard forms of psychotherapy, CBT (cognitive behavioural therapy), mindfulness-based approaches, Acceptance and Commitment Therapy, motivational interviewing… Many psychological approaches help people to get to know themselves better, put their goals in order and connect with their future, as opposed to just their present. That is the main challenge. Addiction is very focused on the now (“I’m feeling crappy and I just want to get high right now, I don’t care about tomorrow”).
There are good neurobiological reasons for that: dopamine, dopamine, dopamine.
Dopamine is a neurochemical that is sucked up into the reward centre of the brain. When people have very powerful goals that are attractive to them, one of the things that dopamine does is focus all your attention on the present tense and what’s right in front of your face. That makes it very hard to get a perspective that will lead you to be able to think in future terms and think of where you want to be, not only in an hour (smoking meth or drinking) but also tomorrow and next week. Forms of psychotherapy treatment that help people expand their perspective and move in that direction can be very valuable.
When people become addicted, neuroplasticity works in a particular way: Your brain starts to rewire in terms of that particular goal. The good news is that when you go through recovery, neuroplasticity is ongoing. You continue to rewire, resculpt, reshape neural pathways throughout your life, as long as you continue to learn. Neuroplasticity plays an important role in all kinds of healing, including addictions, which is very hopeful.
Addicts find it very helpful to recognize that there is a biological substrate. So it’s not that you’re such an awful person, but rather, you got stuck in a biological feedback loop that is difficult to break out of. But the brain is plastic and the feedback loop can be altered.
Interrupting the cravings can be a dramatic moment or a process. I’m in touch with thousands of addicts around the world and sometimes people relapse again and again and again and finally they say, “F*** this, I’m just not going to do this anymore. It’s just too awful.” Others just stop suddenly and never use again, and there’s every gradation in between.
St. Paul’s Hospital, Vancouver
In high school I turned to alcohol to relieve the emotional pain of losing my father, who passed away after two years of battling cancer. My mother had struggled with alcoholism her whole life and died in her early 30s while living on the streets of downtown Vancouver. I grew up not knowing my mother and only remember seeing her a few times. I was 14 years old and just starting junior high when I was told of her passing.
I had no concept of what I wanted to be or who to trust. I thought my destiny was to drink myself to death. Then I turned to drugs, initially smoking marijuana in high school. After graduating, my drinking continued but I managed to keep it under control.
At a cabaret one night I met the man who was to become the father of my two daughters and we were together for seven years. After giving birth I continued to drink, eventually finding myself in a treatment centre after a family intervention. It was there that I was introduced to Alcoholics Anonymous and managed to maintain my life, some sanity and my sobriety for almost four years.
Then I found myself missing the chaos in my life. I left my relationship, took my daughters and went to live with my brother, who was drinking heavily at that time. I eventually picked up a drink again when I was 27 and I was off to the races. I gave my daughters back to their father and went to a party that lasted for six years. I got into unhealthy relationships and did things that I never ever thought I’d do.
I was introduced to intravenous drug use by one boyfriend, which began a downward spiral that saw me committing petty crimes to support my cocaine and heroin addictions. After six years living day by day on the streets or on other people’s couches, I ended up in the same place my mother had been before she died—desperate, hungry, lonely and tired. One day I called a women’s recovery house in Surrey and was told to get there as soon as possible if I wanted a bed to sleep in.
Once there, I stayed clean for 30 days. After some blood work, the house doctor explained that I was HIV positive. It was January 1997. I was in shock. In the recovery house there was no privacy, so my condition became common knowledge. There were other girls who were HIV positive so they were somewhat of a support; one even took me to a support group for HIV-positive people.
Once out of the recovery house, I focused on staying clean and sober, went to AA meetings and tried to be the best mother I could be. My main inspiration for staying away from drugs was my desire to be a mother again.
I have managed to stay sober since October 10, 1997, with the help of many healthcare providers, AA and some very close loving friends. My health has been relatively without scare. I continue attending AA meetings to help with my mental and emotional well-being.
AA allows me to walk into a room without feeling judged for my addictions; however, I don’t talk about my HIV at meetings. I keep that for the select few I trust. I have seen AA members who were open about their HIV diagnosis and then felt like outsiders, some eventually falling back into addiction. A handful of my friends gave up on their health due to being HIV positive. I definitely don’t want to go out and kill myself due to my addiction or my HIV. Right now my sobriety is the most important thing in my life—without it I have nothing.
After establishing relationships with nurses and doctors at St. Paul’s Hospital, I was offered a position as a peer navigator. In my work I support others who are HIV positive, many of whom also live with drug and alcohol addictions. I always share my story with clients and tell them I am sober. If they need help with drinking or drug issues, I direct them to the proper services. Doctors, nurses and social workers ask for my support when we have a newly diagnosed client who needs someone to hold their hand. I love my job helping others and hope that one day people will understand that they can be anything they want.
To anyone who doesn’t believe they have a life because they are HIV positive and struggling with an addiction, I want them to know that I went back to school and completed my Associate Degree and have almost completed a bachelor of social work. Life is good and I am very grateful I am alive and was given another chance.
Clinical social worker and psychoanalyst
I prefer to stay away from using the label “addict,” as it helps in my psychotherapy work with gay, bi and other men who have sex with men, many of whom are struggling with trauma and some of whom are HIV positive and use substances as a way of coping. The idea of an “addict” has so many negative connotations. People with these histories may already be marginalized due to their different identities (race, class, sexual identity, gender performance, ability, etc.), and already experience a lot of prejudice. I don’t want someone to worry that I’m going to think of them as an addict, and I find it easier to address the problematic aspects of substance use when we open a space to explore what this means for them.
Many people who are struggling with substance use have histories of emotional and mental health needs. I also stay away from the term “mental illness” and frame it in terms of mental health promotion. Substances are more often than not used to deal with intrapersonal, interpersonal and other types of social stressors. Oftentimes clients come in seeking treatment with the idea that the substance is the problem, but as the therapeutic relationship develops, we see that it is something that actually helps them cope. When substance use becomes the only way that they have of coping, then it can become problematic.
For example, if someone needs to use a substance because otherwise he doesn’t know how to handle himself at a party in the first three years after an HIV diagnosis, then the issue may not be the alcohol itself but the problems that the person is having coping with his diagnosis. In our North American society, we tend to push for quick solutions, and sometimes alcohol and substances offer that “quick fix.” When we talk about how the substance helps the person cope, we are able to talk about underlying issues they are struggling with and find strategies that can help them cope in more effective ways.
I find it’s easier for people to start working through their difficulties when the substance doesn’t get demonized. When the substance gets stigmatized, the substance user gets demonized, too, which usually leads them to become more isolated and sometimes ramp up their drug use. If I feel embarrassed about the way that I cope and I don’t have a way to articulate that concern, I may be pushed to use more as a way to regulate my nervous system (anxiety). The substance may make me feel less alone. If I am dealing with constant rejection on Grindr because of my HIV status, for example, the substance may hold a special place as I know it will always be there for me and never turn away from me
What I find most useful for people who self-identify as having a problem with the way they use substances is a combination of group work and individual psychotherapy. That way they can process in their individual psychotherapy some of the stuff that comes up for them when they are in the group. The experience of being in a group really helps a person normalize the experience of using substances as a way of coping and decreases the shame of using that usually leads to relapsing. Dealing with the shame in a group context is very powerful. A group also offers a supportive network that can have some of the functions that the substance had for them.
In a nutshell, what helps people “kick their addiction” is an understanding of how they’re using the substance to cope and substituting that way of coping for something that makes them feel more empowered. For example, a person might identify that they get the same sense of relief from a close, warm and kind connection with a friend that they get from using substances. Understanding the patterns of use, the triggers and the consequences usually helps people to make different choices.