Some people have addictive tendencies. They use mood-altering substances and processes primarily in order to change the way they feel. They do so because they feel down, different, excluded, depressed for no discernable reason. They may be surrounded by friends and family or have privilege and opportunity and yet still feel that they don’t really belong.
They discover that the effect of a mood-altering substance or process is magical: their mood is lifted and they feel normal. They will never again want to give up the opportunity to recapture that good feeling. If they want to have a party to lift their spirits even further, they know what to use – but they discover that they come crashing down afterwards. Then the withdrawal effects are covered by further use of the mood-altering substance or process.
In time, they find that they need more of the mood-altering substance or process in order to achieve the same effect as previously. Tolerance develops. They also discover that other substances and processes also have a mood-altering effect. So they use them when they are either unable to get their chosen substance or process or when it’s beginning to cause damage or when other people express concern.
The end result is the pattern that we see commonly: addicts become dependent upon particular mood-altering substances and processes, the dose that they use tends to increase in time (other than in addiction to prescription drugs such as antidepressants, tranquillisers, and sleeping tablets where the dose tends to remain constant because they stay in the body for so long that their effect becomes cumulative) and they use a range of mood-altering substances and processes to get similar effects when one or another becomes damaging. Even so, they continue to use these addictive substance and processes despite damage and despite the repeated serious concern of other people.
Addicts are exasperating. They are demanding and yet intolerant, talented and yet stupid, friendly and yet inconsiderate, and they have a host of other dualities.
What we are observing in this Jekyll and Hyde existence is the difference between the individual and his or her disease: the individual shares all the good characteristics but, under the influence of addictive disease, the bad characteristics come to the fore. Even so, addicts are totally responsible for their behaviour as it affects other people. Saying that they have a disease can never be used as a justifiable excuse for unpleasantness or worse.
Epidemiological studies, such as the Scandinavian adoption studies, show that alcoholism goes more commonly in association with a genetic background than with the family of upbringing. The Vietnam War Veterans studies show that 90% of the returning GIs could get off drugs and could subsequently go back to drinking alcohol sensibly and even having the occasional illicit drug without significant damaging effects. But 10% could not.
Some people interpreted the study as illustrating that the 10% were weak-willed. Analysis of that 10%, or of any group of addicts, would have shown that they were far from that: they were very often exceedingly strong-willed, being determined to prove something that couldn’t be proved: that they could use mood-altering substances responsibly. Many other aspects of their lives may illustrate responsible behaviour. They may be highly creative and they may be highly proficient in their professional lives – but they cannot handle mood-altering substances or processes appropriately. They do not have that gift.
In my treatment centre in 23 years I treated over 5000 inpatients suffering from depressive illness or one or another form of addictive or compulsive behaviour.
Our research department, headed by Professor Geoffrey Stephenson, Emeritus Professor of Psychology at the University of Kent at Canterbury, administered my addiction questionnaires, looking at each of 16 different addictive outlets for the following 12 specific characteristics:
- Pre-occupation with use or with non-use.
- Preference for, or contentment with, use alone.
- Use as a ‘medicine’, to help relax or sedate or to stimulate.
- Use primarily for mood-altering effect.
- Protection of ‘supply’, preferring to spend time, energy or money in this way.
- Repeatedly using more than planned: the first use tends to trigger the urge for the next.
- Having a higher capacity than other people for using the substance or process without obvious initial damaging effects, although in time this ‘tolerance’ is lost.
- Continuing to use despite progressively damaging consequences.
- ‘Drug’-seeking behaviour, looking for opportunities to use, and progressively rejecting activities that preclude use.
- ‘Drug’-dependent behaviour, ‘needing’ the addictive substance or behaviour in order to function effectively.
- The tendency to ‘cross-addict’ into other addictive substances or processes when attempting to control use.
- Continuing to use despite the repeated serious concern of other people.
The crucial distinguishing factor of these 12 characteristics is that they clearly divide the addictive population from those who may be silly at times. The first 8 were taught to me by Dr Richard Heilman of Hazelden in Minnesota. I added in the other 4.
Giving 4 positive answers within any of the 16 sets of 10 statements indicates an addictive nature and the need for further assessment. I demonstrated this, with clinical examples, in 1986 in a presentation to 1400 delegates at the South Eastern Conference on Alcoholism and Drug Addiction (SECAD) in Atlanta, Georgia. I demonstrated the broad nature of cross-addiction and the consequent important risks of relapse.
When people make the gratuitous remark, ‘We’re all addicted to something’, it simply isn’t true on our evidence. There is an addictive population that is clearly separate from the non-addictive population. Some people (probably 10%-15% of the entire population) are addicts and the rest simply are not.
This doesn’t mean to say that the non-addictive population cannot be damaged by the use of mood-altering substances and processes. Of course they can. Any fool can get drunk and drive a car and crash – but someone who is addicted to alcohol is more likely to do so. Consequently, my questionnaires are only part of my clinical assessment. I look also at the damage that people have accumulated in their lives. This can be a very accurate predictor of whether someone has – or does not have – an addictive nature. Addicts continue to use mood-altering substances and processes despite all sorts of damage that they cause to themselves and to other people around them.
Ultimately they reach the state where they feel that they cannot continue to use a particular mood-altering substance or process because it is causing too much damage. But then they have to face the prospect of living without it and they cannot bear that either. In that situation of being between a rock and a hard place, they may commit suicide. The Samaritans estimate that 20% of all suicides occur in alcoholics alone. Adding in the drug addicts, the sufferers from eating disorders, the gamblers and the other addicts, we can see that suicide is a very common consequence of an addictive nature. Our patients are suicidally depressed.
Doctors generally treat suicidal depression with drugs. In my rehab I don’t. I use the Twelve Step programme of Alcoholics Anonymous (also applied to narcotics, eating disorders, gamblers and other forms of addictive behaviour). But when an addict (A) takes his or her mind off himself or herself and puts it onto helping another addict (B) anonymously, then it is A who gets better because the altruistic effort has a mood-altering effect. As with alcohol or drugs or sugar or any other mood-altering substance or process, this effect wears off and therefore it has to be repeated if the effect is to be maintained. Hence the recommendation that our patients should attend regular meetings of the Anonymous Fellowships, such as Alcoholics Anonymous, Narcotics Anonymous, Overeaters Anonymous, or Gamblers Anonymous and work the Twelve Step programme on a daily basis for life.
Unlike work and exercise and other commonly recommended therapeutic processes, there is no downside to a Twelve Step programme. I treat exercise addiction and I treat workaholism (exercise and work can be used addictively by addicts of any kind but commonly by those with eating disorders). It has to be said, however, that sometimes the greater challenge with many addicts is to get them to work or exercise at all.
The answers to my questionnaires show that addictive behaviour comes in clusters:
Hedonistic: alcohol, recreational drugs, prescription drugs, nicotine, caffeine, gambling and risk-taking, sex and love addiction.
Nurturant of self: food (bingeing, vomiting, starving or purging – mediated through the mood-altering effects of sugar and white flour and other refined carbohydrates), work, exercise, shopping and spending.
Addictive relationships: using other people as if they were drugs or using oneself as a drug for other people.
Some of my patients have all their addictive tendencies channelled into just one of these clusters. Others have them spread over two and some – like me – have all three. This observation is important because it will predict the intensity and length of treatment needed. It will also provide a guideline for specific abstinence. Anyone with an addictive tendency in one of these outlets should be recommended to be abstinent from everything else in that cluster.
Physical substances have to be avoided altogether (because the first use in any day tends to trigger the impulse to use again and again) but addictive behaviours have to be used in the same way as anyone else would use them. Thus, someone with a shopping or spending addiction has to learn to shop for goods that are needed rather than shop for England as a mood-altering process.
Someone with a relatively small total amount of addictive tendency, primarily channelled into one or two outlets such as alcohol or nicotine, may not require treatment but can be recommended to go directly to Alcoholics Anonymous or Nicotine Anonymous and work the same Twelve Step programme for the nicotine addiction as for alcoholism.
Other people have widespread addictive tendencies and require either outpatient or in-patient treatment in order to become abstinent and recognise – through other members of the group – what they are really up against (addictive disease rather than simply social, professional or financial problems in their personal lives) and they become familiar with working the Twelve Step programme on a day-to-day basis.
Essentially, I treat two things: the depression itself is treated through the Twelve Step programme, and the denial (the basic psychopathology of addictive disease that tells the sufferer that he or she doesn’t have it) is treated through group therapy, so that patients become aware of the commonality that is shared by other members of the group and hence they see themselves reflected in the mirror of the group.
Thus the recommendation for long-term relapse prevention is that people should attend regular meetings of the Anonymous Fellowships and work the Twelve Step programme on a daily basis for life. With that treatment, addicts can get into full remission and live normal, happy and productive lives, free from the use of any mood-altering substance or process.