Addiction is a Disease, but this doesn’t Reduce Treatment to a Medical Model
Alastair Mordey explains how successful recovery from addiction engages self-directed neuro-plasticity through psycho-social treatments such as CBT, 12 Steps & Mindfulness, and that these approaches are particularly effective when combined into an integrative model.
As practitioners we often seem to debate two issues over and over again. Firstly whether addiction is a disease or not, and secondly, how should it be treated? I would like to combine these two areas of debate into one, and explain that for me, seeing addiction as a disease doesn’t reduce its treatment options down to a medical model. Quite the opposite. The way that addiction develops gives us vital clues as to which methods we need to employ, and these interventions are predominantly psycho/social and spiritual in nature. We now have an understanding of the human brain as a highly plastic (changeable) organ, and due to this principle of plasticity our psychology can significantly affect our biology. Three of the most effective treatments which achieve this in my view are; 12 Steps, CBT and Mindfulness, and when combined, they complement each other enormously, especially if we understand why they do what they do.
Addiction professionals often talk informally about the similarities between Cognitive Behavioural approaches and 12 Steps in treating addiction, in particular REBT’s focus on disputing irrational thought and gaining unconditional acceptance of self, others and the world. Analogous 12 step practices would be checking your thinking with others and handing over pathological controllingness (self-will) to a higher power, support group or sponsor. These similarities first presented themselves to me quite naturally (as I’m sure they did too many other people) whilst learning the ABCs used in Beck and Ellis’ therapeutic models. I remember thinking “wow”, this is a lot like a Step 4 resentment inventory.
Quite simply put, a Step 4 resentment inventory requires us to know who we are resentful with? What they did? How this threatened us? What was our part in it, and what are we going to do about it? This is exactly analogous to a CBT approach where we might ask, A – What activated us? B – What do we believe about it? C – What are the consequences – how are we behaving? D – Dispute our thinking – or see our part, and E – do something ‘effective’ to resolve it like making an amend.
This revelation (which is actually fairly obvious) started me on a journey of hybridizing the two approaches for work with addicted clients. Along the way I realized many practitioners were already doing the same thing, but at that point an unexpected event occurred. I moved to Thailand, started running a treatment centre (The Cabin Chiang Mai) and crucially, I was introduced to Mindfulness.
Mindfulness is a meditation practice which can be completely secular, but which evolved from the Theravada Buddhist tradition. You’ve probably heard of it before. Its local name in South East Asia where I practice is Vipassana (which literally means ‘insight’). Rather like 12 steps, and Ellis style REBT, it focuses on gaining acceptance over things as opposed to trying to get on top of them, or conquer them.
The more I looked the more I realized that the connection between 12 steps and Mindfulness is well documented, as are the similarities between CBT and Mindfulness. But the combination of all three is so much more powerful than the sum of its parts and to understand this we need to go back to the basis of what addiction actually is.
According to The American Society of Addiction Medicine, addiction is a “primary, chronic and progressive brain illness” (ASAM, 2011). As a disease, the ‘broken’ bit is the brain’s reward system, and specifically the way dopamine, the brain’s pleasure – reward chemical, is functioning. In essence addiction is reward deficit, triggered by stress or what we would now refer to as trauma. Reward deficit leaves sufferers with a broken ‘sense’ of pleasure and a broken sense of pleasure is pretty serious in the same way a broken sense of sight is pretty serious, and it throws up recognizable symptoms namely; lack of reward, meaning and purpose, restlessness, irritability and discontentedness. These symptoms often present in adolescence before an individual even begins using or drinking and the symptoms will certainly persist after cessation of using if treatment is not consistent because the illness is chronic (incurable). We have a name for the return of symptoms during sobriety – ‘dry drunk’ – and dry drunk is a collection of the un-medicated symptoms of poor dopamine function.
Whilst The National Institute on Drug Abuse (US) estimate that 40-60% of the vulnerability to addiction is genetically inherited this does not mean that addiction can only be seen through the lens of the medical/biological model. Environment plays a big part too, because our brains are highly plastic and changeable, especially when we are young. Stressful or traumatic environments can down-regulate (lower) dopamine function over time, creating a reward deficient brain. So environment often ‘triggers’ the illness as ASAM have also noted. It is apparent that dopamine’s role in addiction is central and that this neurotransmitter is a common denominator behind all addictive drugs and processes, but how does it do this, and what does that then tell us about how we need to treat the illness in our clients?
Dopamine’s much vaunted role as a ‘pleasure’ chemical is slightly misleading. The actual role it plays in providing pleasure feelings is via the meaning or purpose it confers on that pleasure or reward (in this case the drug). This is a subtle difference. It is wanting more than liking. Due to genetically inherited or environmentally created reward deficiency (poorly functioning dopamine receptor sites and other related phenomena) addicts brains’ can’t interpret the dopamine signal that’s being produced, and can’t experience the meaning or pleasure in ordinary rewards which ‘normal’ people take for granted. Dopamine helps us understand the purpose of rewards… “oh this is good….this is useful….I want it.” Drugs, alcohol and highly rewarding processes like novel sex or gambling provide a ‘louder’ signal which reward deficient addicts can ‘hear’, and recruit the meaning they need.
For this reason, meaning and purpose is central to addiction, but it is also central to recovery from addiction. In my view this is precisely why addiction is instinctively felt to be a ‘spiritual’ illness. What is more spiritual than meaning and purpose? If you think about it, we are not so focused on providing reward and pleasure for clients in their early recovery (to replace their reward deficit) but rather we are trying to instill in them a sense of meaning and purpose. Addiction is a social illness, as well as a biological/psychological illness, and meaning for human beings comes down to being social. Gaining interconnectedness with others (fellowship) has meaning. Service work with others (Step 12) has meaning. The altruism involved in service gives recovering addicts a sense of purpose and cuts right to the heart of our intrinsic nature as social animals. We are apes…not cats!!
The meaning and purpose that 12 Steps provide is much more central to the sustainable, manageable feelings which clients need than mere thrills or substitute rewards would be, otherwise we could just send our clients skydiving, or teach them how to win more, and then they would recover via the pleasure and reward feelings they were recruiting. No, holistic dopamine reinforcement is provided through purpose and meaning. Recovery through the Steps is in effect, a slow release and long acting method of dopamine reinforcement, rather than a nasty, spiky dopamine boost which is procured through drugs, alcohol, novel sex, money and anything which has strong addiction potential.
Whilst the 12 Steps play a very central role in correctly medicating the illness by implementing meaningful and purposeful feeling states, Mindfulness and CBT’s role comes more into play in treating the part of the illness that affects the front of the brain. Denial, or hypo-frontality (low functioning of the forebrain) impairs sensible decision making in addiction sufferers. As ASAM noted in their 2011 definition; addiction is an illness of “reward, memory, motivation…and related (brain) circuitry”. Many a loving, but addicted parent has neglected to attend that crucial case conference to regain custody of their child in favour of sitting at home in their bedsit injecting heroin. The addict has no choice; it’s not complicated, it’s a brain thing! Addicts’ brains are also more sensitized to cravings than non-addicted peoples brains are. They seem to have a genetic talent for it.
But if we can stop clients from acting on their addiction by slowing down their stress – craving – drug-seeking neural pathway, then we have time to challenge (dispute) their reasoning, both in one to one work and even more effectively in group. The relationship of CBT and Mindfulness here is circular. The microscopically slow movements of a Vipassana prostration practice, or the acknowledgement of uncomfortable sensations such as itches during a sitting meditation, are ideal behavioural practices for dealing with cravings and urges. The Buddhist perspective of impermanence teaches the client that unpleasant things like cravings are just as impermanent as anything else. Pleasure is impermanent – cravings are impermanent.
Active addiction itself is a short term way of medicating reward deficient symptoms but it is really just a ‘quick fix’. Eventually it becomes counter-productive by lowering dopamine functioning overall and exacerbating the addiction. Engaging recovery activities such 12 Steps, CBT exercises and Mindfulness, works across the reward system by raising dopamine tone in a slow release, long acting manner, and ‘coaching’ the frontal lobe through delaying gratification and challenging impaired thinking. This starts to fix the problem long term. The more our clients implement these behaviours into their life, the more the structure and chemistry of their brain will change. At The Cabin, we integrate these three approaches into one model.
So it’s a brain illness! Problem is, even when we agree with that intellectually, we often don’t in reality practice addiction treatment that way. For me, the disease model of addiction is anything but a dry, reductionist view of the etiology of addiction. It actually promotes and re-emphasizes the importance of behavioural, psychological and social treatments in conjunction with medical interventions, and what’s more it explains to a considerable extent why they work. We humans have an amazing capacity to change the structure and function of our own brains, by repeatedly talking, feeling and behaving in a particular way. For me the teachings of the 12 step movement and pioneers such as Albert Ellis are clearly vindicated through an understanding of the principles of the brain’s plasticity. Recovery is self (and other) directed neuro-plasticity.