Is everything you know about addiction *really* wrong?
Johann Hari’s TED talk from 2015 famously claimed that everything you thought you knew about addiction was wrong. But is that true?
We’ll come on to Hari, and his claims about the links between addiction and human relationships.
His talk was widely shared and lauded, but also critiqued as being simplistic and patronising. And in many ways, that’s the point. Addiction is an area of mental health that drives people to extremes of moral certainty unlike any other. 12 Step programmes are too easily dismissed as cult-like secular replacements for religion, regardless of the evidence base that patients in 12 Step are significantly more likely to remain abstinent than those in other treatments. In the opposite direction, those in favour of abstinence-based treatments too easily resort to dismissing other forms of treatment. Russell Brand, a famous beneficiary of abstinence-based treatment, said in his evidence to the UK Parliament, “maintenance of drug addiction, through state-sponsored substances, like methadone, should only be deployed as part of a reduction, with the ultimate aim of abstinence-based recovery.” Note the certainty here: abstinence is the only goal that should be sought. Harm reduction and consumption reduction are dismissed as second best, regardless of what addicts themselves want or desire. This simplicity gets in the way, and leads to unhelpful polarisation.
Even the definitions here are tortuously and furiously debated at times. What is an “addiction”? Does it require a chemical substance that causes a physical withdrawal in its absence? Is any compulsive behaviour with negative consequences an addiction?
Here at LCAP, we’re trying to help you cut through the complexity and ideological certainties to bring you the basics of what you need to know about addiction to treat it successfully. This article offers an introduction, but join us on our addiction training course to ensure you are fully up to speed with what you need to know.
Let’s start with the thorny area of definitions. Some focus on behaviour. The NHS defines an addiction as being a compulsion around “doing, taking, using”. The psychiatrist’s bible, the DSM-5, focuses more on the neural pathways that link various types of compulsive behaviour, bringing them under an umbrella term of “addictions”. Alcoholics Anonymous (AA) - those of the 12 Step Programme - instead focus on the “physical compulsions” at the heart of substance abuse. Others, such as Maia Szalavitz, in her excellent book “Unbroken Brain: A Revolutionary New Way of Understanding Addiction”, focus as much on the negative harms and consequences of compulsive behaviours than on the physiological mechanisms underlying them. In terms of working with our clients, this feels right. They’re in distress. They can’t control their behaviour. Their behaviour is having negative impacts on their health, their relationships, their work. If that client’s behaviour is rooted in using substances, or in more modern manifestations such as compulsive online gambling or porn use, does it alter how we treat that behaviour and work with them to change?
There are some findings in the research that point to helpful interventions specific to substance abuse. But the principles of working successfully with addictive behaviours are consistent, from alcohol use to porn use.
To understand how to work with addiction, it’s important to know what likely causes it. Somewhat inevitably, despite the strong opinions from all sides of the debate, there are multiple potential factors that predispose someone to addictive behaviour. In his TED talk, Johann Hari describes the experiments led by Bruce Alexander - the so-called “Rat Park” studies - which showed rats did not typically become addicted to opium if they were immersed in a cage with other rats. Basically, the argument goes, if rats have strong social connections, they are less prone to addiction. These studies supported similar evidence from returning Vietnam War veterans in the U.S., which suggested a link between social support through family, friends and community and withdrawal from narcotic addiction. We also know that Adverse Childhood Experiences - such as experiencing abuse, witnessing violence in the home, having a family member die by suicide or, of course, having a family member with a substance abuse disorder - contribute to the likelihood of developing an addiction. A recent study showed that those who suffered childhood maltreatment were three times more likely to develop a substance use disorder.
So, we know that social connection, attachment relationships - particularly our earliest relationships - and wider socioeconomic factors contribute to the development of addictions. However, it would be wrong to therefore conclude that there is no physiological basis at all for some addictions. Some people become addicted no matter how socially connected they are, or how full their life is. Again, complexity where others would prefer simplicity.
What do we draw from this research? Firstly, and most importantly, we should treat addiction less as a moral failing or a failure of willpower, nor as an inherited brain disease. Addicts are best understood not as pleasure seekers nor self-destructive, but as people in significant and unbearable pain, seeking comfort. Because the causes of addiction are complex, somewhat inevitably we see high levels of comorbidity with other mental health struggles - depression and anxiety, for example. Half of those with an addiction have another significant mental health condition.
We also know that we can treat addiction successfully. NICE guidelines state that Cognitive Behaviour Therapy (CBT) usually has the best results and that third-wave CBT treatments such as Acceptance and Commitment Therapy (ACT) can be particularly effective. NICE guidelines also recommend treatment based on 12-step principles.
The NHS describes addiction as ‘a treatable condition’, and the evidence suggests that there are some key principles that work in treating it. For example:
- Don’t immediately refer on clients with addictions. Research shows that therapists in recovery do no better than other primary care providers. There is no evidence that intensive, residential treatment is more effective than regular psychotherapy (which makes sense given recovery is long-term work involving a number of factors in someone’s life). You might be very well placed to support a client with an addiction - but do of course refer to someone better placed if you don’t feel confident.
- Your relationship with your client is crucial - do they feel you ‘get them’ even if you don’t have first-person experience of addictions?
- Provide a structured treatment with agreed goals (but not a rigid or formulaic one). What does success look like - is it reduction in consumption; more fulfilling relationships; or complete abstinence.
- Provide challenge, but not to the extent that it puts clients on the defensive.
- Work with any ambivalence about change by exploring the consequences of addiction and the value of stopping.
- Pay attention to clients’ relationships and wider lives, sometimes advising on possible changes to it.
- Organise treatment around developing a meaningful, rewarding life which reestablishes social connections. This can include promoting 12-step groups as a readily available source of social support. You can support your clients by being intensely practical: “which meeting and when?”.
- Be ready to teach coping skills and social skills, to help with re-establishing a good life.
In short, we know a lot about what contributes to the development of addictions, which should challenge any notions we hold about those with addictions being weak or morally worse than us. We also know a great deal about what support offers addicts the best chance to recover, and the importance of allowing them to define recovery in their own terms.
LCAP’s training course on addiction offers a concise but practical run through of the evidence and offers practical interventions and techniques for working with addicted clients, based on some of the principles outlined above, and more. It will leave you feeling more confident not only in understanding addiction, but also in knowing how you can best help your clients who struggle with addictions. Join us!