The most common question I get in my work and sometimes from my friends is “Am I an alcoholic?” This is usually followed by “Does this mean I have to go into rehab?” or “Will I ever be able to have a drink again?”
I believe that treatment for addiction should be individualized to take into effect each person’s individual needs, complexity, and readiness to change. Every case is different. Sometimes the answer is undeniably complicated. I was trained to apply systematic screening and assessment in order to determine if alcohol abuse vs. dependence is present based on Diagnostic and Statistical Manual of Mental Disorders criteria and make treatment recommendations based on the American Society of Addiction Medicine placement criteria.
But sometimes I encounter cases of addiction that do not fit anywhere. After the tragic death of Amy Winehouse, there was a lot of speculation online—even by professionals in the addiction field—as to who was to blame. There was actually one article I read that seemed to imply that if she had been able to drink in moderation maybe she would still be alive. I honestly cannot comment on that either way.
Understanding the Harm-Reduction Model
I will say the harm-reduction model of treating addictions is not popular among people who advocate for abstinence as the only acceptable treatment outcome and people who support the 12-step program approach. Having worked at a methadone clinic for years and witnessed powerful positive change, I am not a big fan of one-size-fits-all treatment approaches, nor am I into labeling.
I have found one view on addictions very helpful for people who do not seem to fit the traditional medical model of addiction: the Stanton Peele approach. Here’s a summary of his view on addiction:
intimate relationships are so closely interconnected.
“Addiction is not unusual, although it can grow to overwhelming and life-defeating dimensions. It is not essentially a medical problem, but a problem of life. It occurs for people who learn drug use or other destructive patterns as a way of gaining satisfaction in the absence of more functional ways of dealing with the world. Therefore, maturity, improved coping skills, and better self-management and self-regard all contribute to overcoming and preventing addiction. Addiction is a way of coping with life, of artificially attaining feelings and rewards people feel they cannot achieve in any other way.” —Stanton Peele
Jim always ends at the bar drinking after a fight with his wife. Anna’s drinking always gets out of control after a break up. John had experimented with pain pills on and off in college but did not get addicted to them until after the devastating loss of his long-time lover and best friend. Travis’s sex addiction gets worse after feeling rejected by a love interest.
In the words of one of the people in my therapy sessions, “I was lost before I found love. I was on a path of self-destruction with drugs, alcohol, and women; but with my wife I have found what I was always missing. I have been clean and sober since. Now I’m high on life.”
Addiction As a Way to Respond to Unsafe Relationships
By unsafe, I don’t mean physically violent—although that is the most obvious case. Unsafe means threatening to the ego as much as threatening to the body. What I’m talking about here is emotional safety. When we feel loved, accepted, nourished, protected, and part of someone else, we feel safe. That safety is often threatened when we feel unloved, not cared for, betrayed, lied to, yelled at, abandoned, neglected, rejected, and violated.
To understand where we are going, we have to understand where we came from.
Safety and the Primitive Brain
Let’s start with the evolution of the brain. In the base of our brain, we have the reptilian brain. We share this part of the brain with animals including alligators and lizards. The reptilian brain takes care of those things we don’t usually think about: heartbeat, digestion, and breathing. It also is concerned with survival, and if it’s dangerous, it will help us respond in one of five basic ways: fight, flight, freeze/play dead, submit, or hide. I also view these as the five basic survival skills of couples. Couples may fight, flee (leave), play dead (stare right through their partner), submit (OK, whatever you want, just stop the nagging!), or hide (go to another room).
On the other hand, if the reptilian brain is safe, we will do one of five things: play, nurture, mate, work, and be creative. Remember when you first met your partner? How you played, nurtured each other, and had more sex? Do you remember being more creative and productive at work? As animals evolved, a second part of the brain developed called the mammalian brain. This brain developed when animals began to live in groups and take care of their young. This is the part of the brain where feelings are stored. That’s why most animals experience some feelings and live in groups.
Several million years ago, a third part of the brain developed: the cerebral cortex. In humans, this part of the brain is five times bigger than the other two parts combined and is where all logical processes happen: speech, writing, logic thinking, math, etc. The three parts of the brain work together simultaneously. If a tiger is coming at you, your logical brain says, “That’s a tiger,” your mammalian brain says “I feel scared,” and your reptilian brain says “Run!” or “Freeze!”
But in relationships, it is often hard to articulate or identify who or what the “tiger” actually is. We know something is not right, and we are left analyzing the behaviors we can clearly see but can rarely understand. How is it, for instance, that when Jim and Linda fight, he ends up getting drunk at the bar even though he knows that is not going to help the situation at home but only confirm Linda’s insults?
Sometimes fighting, fleeing, or hiding involves addictive behaviors—particularly sexual behaviors, but also gaming, internet addiction, and alcoholism. Often past experiences with these behaviors make a person more susceptible to restarting (if they have stopped) or increasing the frequency of these behaviors. This explains why people engage in addictive behaviors even against their logical thinking. It appears that the primitive reptile brain has taken over the cerebral cortex. This is why people logically know it doesn’t make sense to engage in behaviors that often make the already troubled relationship even worse. They are “thinking” with their primitive reptile brain, which often means they are not actually thinking at all.
Sometimes we are not simply chasing a drink or a drug. Sometimes using is a maladaptive way of coping with unsafe relationships. In this case, treatment should focus on the relationship and reestablishing safety more than on changing addictive behaviors themselves. I have found that establishing safety and learning to evoke mental images of safe places/mental states is crucial in learning to calm oneself and coping with highly stressful situations, which in return helps the addictive behavior dissipate.
In my opinion, this should also be the main focus of relapse prevention in more traditional addiction treatment.
- Clifford, R. (n.d.). From Reptiles to Humans: A Three Brain Odyssey. Retrieved from http://www.starchiefpress.com/articles/article42.html
- Luquet, W. (2007). Short-term couples therapy the Imago model in action (2nd ed.). New York: Routledge.
- Peele, S. (1990, March 14). Cures depend on attitudes, not programs. Retrieved from http://lifeprocessprogram.com/lp-blog/library/cures-depend-on-attitudes-not-programs/
© Copyright 2011 by Elvita Kondili, LPC, therapist in Charlotte, North Carolina. All Rights Reserved. Permission to publish granted to GoodTherapy.org.
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