Part 3 of “Addiction, Biological Psychiatry and the Disease Model”
Part 1 of this series critically examined how the disease model of addiction, including current forms of accepted treatment protocols, intersects with the genetically based “mental illness” theory and practice propagated by Biological Psychiatry. Part 2 analyzed the serious limitations, and sometimes harmful effects of the domination of addiction treatment by the Twelve Step (disease model), and how Biological Psychiatry has both seized upon and expanded the culture of addiction in this country by promoting its related “disease/psychotropic drug model”. What follows will be a presentation of some alternative methods for overcoming addiction problems that focuses more on individual choice and skill building (within a social support setting) as opposed to becoming subservient to any group or “higher power” or accepting any labels denoting personal defects or some type of disease process.
In recent years (and on the MIA blog) many people have written about the nature of “hearing voices,” including what can be learned from this phenomena and how to gain more control of its effects on thoughts and behaviors and on one’s overall life process. For certain people their “voices” were thought to come from outside themselves and represent something unknown or even scary, especially when it involved concepts of “good vs. evil.” Others have suggested that people can eventually become aware that their “voices” represent certain internal personal or moral conflicts that can often get expressed or represented by familiar people in their own lives, such as a critical mother or father, or on the positive side, a more inspirational voice of a key figure from their present or past. The ultimate goal for such people is not necessarily to make the “voices” go away but instead to more deeply understand what they represent in their lives and what they can learn from their presence. And in some cases people are actually encouraged to talk back to or even confront their “voices.” This can become a way of gaining self-empowerment and also as a way of redirecting their thoughts and behaviors in a more positive and healthy direction.
In a similar vein the “addiction voice” (along with the “negative voice,” the “procrastination voice” etc.) is one of many other “voices” that people can choose to identify as part of the normal human process of “internal self-dialogue.” In this case the “addiction Voice” is a particular form of self-dialogue related to conflicting choices over what repetitive thoughts and behaviors will either benefit or harm us, or perhaps end up dominating our lives at any given time. We may all be familiar with this particular voice; you know the one that says “you’ve had a hard week …; you deserve to reward yourself…; You can just do a little…; this time will be different….”
In opposition to the “disease model” of addiction, cognitive/behavioral therapy approaches have historically focused more attention on a person’s thought patterns that actually precede a choice to continue an addictive behavior, rather than on any underlying disease process. In 1986 Jack Trimpey, a social worker from California who conquered his own longstanding alcohol problem after dropping out of Alcoholics Anonymous (AA), developed something very new and revolutionary in modern addiction treatment. He adapted and modified some principles of Albert Ellis’ Rational Emotive Behavior Therapy (REBT) to start Rational Recovery (RR). He viewed this as a clear alternative to the disease model of continuous recovery promoted by AA, an approach that he stated clearly never worked for him and many others he had encountered in Twelve Step programs.
Trimpey developed “Addictive Voice Recognition Therapy” (AVRT) which encouraged people to first recognize that they have an “addictive voice,” and then develop the skills to outsmart it and put it in its place. This meant that people could use both their own willpower together with various cognitive skills to rationally examine any thoughts justifying further substance use, and then ultimately choose, once and for all, to stop permanently. Therapy or any group attendance was not essential in this process, and in later years he determined that it would only get in the way of permanent recovery.
In 1989 Jack Trimpey published the The Small Book ; this promoted the new Rational Recovery approach together with the an alternative form of group meetings which first started in California and gradually spread across the country. These groups were still tiny in number compared to Twelve Step groups but their presence created an immediate stir in the recovery community. Rational Recovery together with the important writings of Stanton Peele, such as The Diseasing of America (1989) and The Truth About Addiction and Recovery (1991) sent powerful shockwaves throughout the entire Twelve Step disease oriented movement and treatment industry (see Part 2 of this blog series for a critical analysis of Twelve Step theory and practice).
In 1994 Smart Recovery was formed as a split off from Rational Recovery due to Jack Trimpey’s desire to maintain control of the RR’s (AVRT), which he patented and wanted to personally financially profit from its growth. Smart Recovery has since gone on to become a non-profit self-help group in the tradition of AA, but of course with a program opposed to the Disease Model and employing many addiction breaking skills modified from Rational Emotive Behavior Therapy. Smart Recovery.com can be accessed online and provides many helpful resources, including online meetings, for those in need.
Jack Trimpey, in this writer’s view, has since gone on to become quite dogmatic in his views and has adopted a “one road” and “my way or the highway” approach to recovery that reminds one of the very Twelve Step programs that ironically led him to create an alternative to AA. Some people have also questioned some of his political views, and I would certainly question the fact that he has had (in the mid 90’s I questioned him about this at a presentation near Boston) no criticism of the abuses related to psychotropic drugs. Nevertheless, he remains a very good read due to his no nonsense style of writing and his AVRT approach to challenging and defeating self-destructive thought patterns.
There have been other groups and individual writers who have questioned the disease model of addiction and provided useful alternatives to Twelve Step philosophy. These books can be found in most libraries or the self-help section of any bookstore. There are also numerous recovery related blogs online that can be accessed with the simple click of a finger. What follows will be this writer’s attempt at combining some of Jack Trimpey’s AVRT approach together with other cognitive behavioral techniques, including some of my own additions and modifications for breaking all types of addictive behaviors.
Confronting the Addiction Voice
People with addictions are usually “of two minds.” That is, one side of them knows they have a problem and is contemplating stopping, and the other side wants to continue the behavior. Speaking for the “old self” that wants to continue the addictive behavior is the “addiction voice.” The “addiction voice” is very demanding and manipulative and thinks in the short term very much like a child; “I want what I want when I want it.” It speaks for a more primitive part of the brain that desires to only repeat behaviors that provide immediate pleasure regardless of the long term consequences.
The “addiction voice” can be clever at times but ultimately it is very stupid when it is finally put to the test of rational thinking. The “addiction voice” will usually have “kernels of truth” in what it says, such as, “you’ve had a tough week… you deserve to reward yourself and get rid of your stress…” but of course there will be major “lies of omission” in the content of its seductive thought patterns. It will not want you to think beyond the next few hours, and it will not tell you of the ultimate consequences of your choice to engage in an addictive behavior. Two questions the “addiction voice” will not want to answer are the following: “How long will I feel good?” and “What price will I pay for my choice?”
These questions are like holding up the cross before the addiction Devil. But these questions must be asked, and yes, answered accurately and truthfully in order to successfully change addictive behaviors. Put the benefits (of the substance or behavior) on one side of the scale and the negative consequences on the other. If and when the negative consequences significantly outweigh the benefits, it’s clearly overtime to end the behavior in question.
The “rational voice” or “voice of sobriety” represents the “new you” that knows it is time to make a change and permanently stop the addictive behavior that is causing so many problems in your life. While the “addiction voice” has major “lies of omission” in its content, the “rational voice” has all the truth and facts on its side. The “new you” knows the true answers to the two questions posed above. If one were to take out a microscope and carefully examine one’s true relationship with the identified addictive behavior, it is clear that in the final analysis any enjoyment will be very short-lived and the price paid will be extremely high when the dust settles. The “addiction voice” is always more focused on the “euphoric recall” of short term pleasure memories, and has “selective amnesia” when it comes to all the negative consequences related to the addictive behavior.
Recovery (here defined as: permanently ending an addictive behavior pattern) usually involves a person going on a detective mission learning the modus operandi (or mode of operation) of their “addiction voice”, that is, how does it set up the crime (convince you to start the addictive behavior), carry out the crime (keep you engaged in the addictive behavior), and cover up the crime (make excuses and rationalizations for the behavior after the episode ends). The more knowledgeable a person becomes about these specific aspects of their thought patterns supporting their addictive behavior, the better chance they have to end it once and for all.
When confronting your “addiction voice” treat it like a hostile witness, as if you were a prosecuting attorney tearing apart the testimony of a key witness in a very important trial. The “addiction voice” deserves no respect; it is up to no good and wants to harm you. Early in your battle with the “addiction voice” you might give it some “tactical respect”; that is, if you feel particularly vulnerable at any given moment, you might employ some “thought stopping” techniques and distract yourself with another activity or engage in contact with a supportive person. But ultimately we will all end up (sooner or later) in a conversation with the “addiction voice,” and strategically we have nothing to fear, because the truth is on our side.
Once again the “addiction voice” can only tell “lies of omission” and distort the nature of your relationship with the substance and/or behavior. Even in the most desperate of circumstances when a person is down and out and has a bad case of the “f… it’s,” the “addiction voice” might say “you couldn’t feel any worse than you do now and at least you will get a few hours of pleasure or numbing if you engage in the behavior.” Even this is a bold faced lie, because when all is said and done you most certainly WILL do more damage and END UP feeling worse; a careful examination of your own past experience will tell you this over and over again.
The “addiction voice” doesn’t always just rush in the front door and say “Let’s go get some cocaine, or let’s go gamble.” Quite often it will try a “side door” or “back door” approach. That is, it might suggest you go to a certain location or visit a certain person you haven’t seen for a while, “you know just to see how they are doing.” Now of course that person 50 percent of time will have one of your drugs of choice, and once you are there and these substances are now likely offered to you (sometimes for free if you haven’t been around for a while) your “addiction voice” will now say “Gee, you can’t really pass this free opportunity up, and after all you can do just a little, just this one time…” Knowing all these “side door” and “back door” approaches can also help people avoid various addiction “triggers” that can contribute to a relapse.
The “addiction voice” will most likely never completely go away, but as your state of permanent abstinence continues it should talk at you less often, perhaps even weeks or months may go by without a significant discussion/confrontation with your “addiction voice.” As your combative skills develop and you are successful in confronting it over and over again, so will your overall confidence grow stronger in the direction of having a life totally free of addiction. You will definitely make other mistakes in life, but relapse does not have to be one of them.
It can be helpful to make a distinction between “addictive thoughts” on the one hand and major “urges and cravings” on the other. Mere thoughts are normal given that the past addictive behavior may have continued for years; there may be literally hundreds of associations with these old behaviors in your everyday life. These types of thoughts may often come in one’s mind and be pushed out quickly with seemingly little effort. Major “urges and cravings,” however, are more serious and need to be dealt with quickly and decisively, otherwise they can become more dangerous. “Urges and cravings” are actually addictive thoughts that a person ends up playing with for an extended period of time.
The longer you give a “dark thought” or any “addictive thought,” (advocating for a self-destructive behavior), permission to circulate in your brain, the more dangerous it becomes. Those types of thought patterns (and by the way, no one is immune from having them) should not be allowed any credibility to rent space in our heads; for the longer we think about them the more likely we are to act on them; the eviction process needs to start as soon as they enter one’s conscious thoughts.
Confronting and defeating the “addiction voice” is one of the most powerful weapons we can use against addictive behaviors. Even in Twelve Step programs there are occasional references made to people knowing how to talk back to the “Shit Fairy on your shoulder” or the “monkey on your back” that promotes “Stinkin’ Thinkin’.” It has yet to be proven, but I believe regardless of what approach for recovery a person chooses to use, those people who get better skilled at both recognizing and confronting their “addiction voice” are going to have the most success at achieving permanent abstinence.
As an aside, similar things can be said about confronting the “negative voice” and the “anxious voice” for those people experiencing chronic depression or anxiety. And yes, sometimes the “negative voice” and the “addiction voice” can seem like they are working together. That is, if you start thinking too negatively about life it can be easier for the “addiction voice” to convince you that a drink or a drug looks good, or that gambling makes perfect sense. In the long run it is important to learn how to manage ALL these “voices” in order to maintain a safe and productive lifestyle.
In addition to the above mentioned cognitive skill building, there are other necessary and related components to ending addictive behaviors. Stanton Peele in his book, 7 Tools to Beat Addiction (2004), identifies the following important tools:
1) Values: Building on Your Values Foundation.
2) Motivation: Activating Your Desire to Quit.
3) Rewards: Weighing the Cost and Benefits of Addiction.
4) Resources: Identifying Strengths and Weaknesses; Developing Skills to Fill the Gaps.
a. Support: Getting Help from Those Nearest You.
b. A Mature Identity: Growing into Self-respect and Responsibility.
c. Higher Goals: Pursuing and Accomplishing Things of Value.
My last point regarding different cognitive approaches briefly focuses on a psychodynamic analysis of the potential danger of not coming to terms with early trauma experiences. Dr. Lance Dodes in his interesting book, The Heart of Addiction (2003), makes the following powerful observation: “Virtually every addictive act is preceded by a feeling of helplessness or powerlessness. Addictive behavior functions to repair this underlying feeling of helplessness. It is able to do this because taking the addictive action (or even deciding to take this action) creates a sense of being empowered, of regaining control-over one’s emotional experience and one’s life.”
According to Dodes this can be true even when the actual behavior is self-destructive in nature. Dodes’ analysis goes on to relate how this feeling of powerlessness prior to an addictive behavior is closely related to similar feelings that actually first originate out of earlier trauma like experiences. He goes on to explain how vital it is for a person with an addiction to make these connections in their own life experience in order to work towards finally gain control over their behavior. My own experience working in the counseling field tells me that unresolved trauma issues can sometimes lead to core low self-esteem that can contribute to thought patterns that justify or “trigger” a relapse back into addiction, even after a significant period of abstinence. Trauma work can be an important and sometimes necessary part of the process of successfully ending all addictive behaviors.
Overcoming addictions and other forms of extreme states of psychological distress requires working on two fronts of battle; both the “cognitive” AND the “physical.” Having already focused mainly on the “cognitive” front, let’s take a quick look at the “physical” side of the transformation process. I would definitely add the following activities that seem to have some scientifically proven benefits: regular exercise, including walking, running, yoga, weight resistant training, together with frequent meditation. These CANNOT be underestimated in their overall importance as part of any recovery program. These are all proven antidepressants combined with anti-anxiety qualities without the harmful side effects and major withdrawal syndromes.
While the focus of Part 3 of this series was clearly on developing cognitive skills, it is not in any way meant to diminish the significance of combining cognitive skill building with physical skill building (and meditation involves both the mental and the physical at the same time). Many of you may recall one blogger on this site devoted an entire blog to the powerful benefits of walking for his withdrawal program from psychotropic drugs, especially benzos.
Research so far has determined that no particular recovery method or therapy approach has proven more successful than another. Developing a positive working relationship with both caregivers and other social supports has been identified as perhaps the most vital factor leading to successful outcomes. The “Many Roads, One Journey” approach may best describe how each person seeking an end to their addiction should view their own recovery process. So find good social support and then fill up your tool box with as many tools and weapons as possible; find the ones that work best for you, and then go to work; your life may depend on it.
In Part 1 of this series I stated: “Addiction and extreme states of psychological distress can become more humanely treated through some reforms, but they will never be fully eradicated, or humanely treated on a broad scale, until the material conditions from which they have emerged are transformed in a truly revolutionary way.” To more forcefully make this point, if every community in this country practiced “Open Dialogue” and had Soteria House type programs available for everyone in extreme psychological distress; and with addictions, if everyone who had a problem was exposed to the best help possible in the most supportive environments with all the best treatment methods available, would all this significantly eradicate the symptoms labeled as “mental illness” or those labeled as major “addictions?” I believe the answer is “no, it would not.” Yes, some people would definitely benefit and resolve their problems, but the reality is that all these reforms will NOT eliminate the daily trauma experiences endlessly spewing out of this system. Poverty, racism, patriarchy, and other forms of mental and physical violence that are so endemic to modern capitalist society will all still be here. This system has a way of crushing human resilience even where there are great efforts to sustain and build it up. We must never forget this. We must continue to fight for reforms, but only as part of the struggle for more fundamental revolutionary transformation. There is much work to be done.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.