At 6:30 PM, I’m standing in front of a blackboard, watching a lecture hall fill up. About seventy-five patients, and their families, partners, and friends—some with several days of sobriety, others with many years—are seated in rows of metal folding chairs in a small bungalow a short stroll from the unit. They represent all types, from businessmen to bikers, homemakers to high school students. They have come to listen to my weekly medical lecture, an in-depth discussion about their disease and its effect on their biology.
The hourlong presentation is aimed at giving them more insight into their disease. Few of them really understand addiction. They don’t know the roots of its biology. They don’t know why addiction is a disease. If asked why they use, they offer some variation on “I’m fucked up.” If asked why they can’t stop using, they reply, “I’m fucked up.” They cannot see themselves as anything but victims. I believe information is power. The more people understand, the less inclined they will be to blame themselves.
I start by asking, “Who can tell me the difference between abuse and addiction?” That begins a lively discussion. Eventually we conclude that abuse is “the use of any potentially harmful substance with no therapeutic value that affects the brain,” and addiction is “the continued use of a substance in spite of consequences.” They should give themselves a pat on the back, I tell them: It took the world’s brightest scientists decades to figure that one out. We did it in a few minutes.
“Now let me ask a harder question,” I say. “Can anyone define disease? Before you can say you suffer from a disease, you should know what one is.”
This sparks another lively discussion. Though it reveals how little average people know about biology, it is also a tough question. Until recently, experts didn’t understand much more than the layman about the secret relationship between drugs, the brain, biology, and disease. Think about it: For decades, drug abusers and alcoholics were thought of as people with low self-control. Even scientists and doctors thought they could control their problems by exercising more willpower. How many addicts were told to change their friends, move neighborhoods, or take a different way home so they wouldn’t pass the liquor store?
It got worse. For years, addicts were thought to be morally deficient people who could be saved if they would simply acknowledge and change their sinful ways. Well, in reality, no matter what they acknowledge addicts just can’t stop. That is addiction—the inability to stop, no matter what. Addicts know every consequence of their addiction: lost jobs, screwed-up relationships, squandered money, betrayed relatives, and so on. But they can’t help their behavior.
Eventually, though, studies began to show that addicts suffered from a disease, rather than a lack of self-control. And clinicians working with addicts and alcoholics began to recognized the difficulty addicts had in quitting. After former First Lady Betty Ford went public with her drinking problem in the late 1970s, there was wider familiarity, understanding, and even sympathy for people who checked into the Betty Ford Center, Hazelden, Cedar Hills, and other rehab facilities seeking treatment for alcoholism and drug addiction.
But misperceptions lingered. With the growth in the number of treatment facilities, many came to believe these problems could be cleared up in a mere twenty-eight days. But further study has shown the disease to be much more complex. By the early 1990s, new research allowed addiction to be defined more specifically as a biological disorder with a genetic basis, plus progressive use in the face of adverse consequences, and denial of a problem. More recent findings have focused on the relationship between addiction and the drives in the deepest brain structures that are outside of conscious volitional control.
As I talk about this, thought, I can see some eyes in the audience start to glaze over. All that scientific jargon—this is starting to sound like school. So I change tack.
“I’m really talking about three things,” I say. “Why you use drugs. Why you get addicted. And how you get better. Let’s start with why you use. Any guesses?”
“It feels good,” a young Latino teenager in front says.
“It lets me escape,” an alcoholic woman with a few years’ sobriety says from the middle of the room.
“Because if I’d done what I really wanted to do, I’d be in jail for killing my father,” a middle-aged man adds. He gets a knowing laugh.
I allow that all those answers are correct. “A healthy person, whether he realizes it or not, populates his emotional world with soothing or reassuring images that can be called upon in times of distress, need, or aloneness. But the individual who has suffered trauma during his formative years retreats from the world as a result of that abuse.” I pause. “Look around the room. Think of the people in treatment with you and those in your AA groups. What do you all have in common?”
“Bic lighters,” someone else says.
“Fucked up lives,” someone else says.
“Be more specific,” I say.
“Fucked up parents,” a college-age girl calls out.
“We’re just fucked up,” a guy says.
“You want to know the common denominator among my patients?” I say, turning serious. “They all had traumatic experiences in early life that caused them to feel helpless, powerless, and in grave danger.” I see some people nodding. “This feeling of helplessness creates an inability to process feelings and an aversion to exploring other minds. There’s no trust. If you can’t trust, you can’t connect with anyone. Without the capacity to activate the part of the brain that allows for connection and exploration of other people, an individual loses the main mechanism for discovering who we are and the ability to regulate emotions.
“Think about it,” I continue. “For all of us, other people function as self-regulating agents. We learn to identify ourselves when we recognize ourselves in others. We constantly think, ‘Oh, that’s exactly how I feel.’ Or you say, ‘I was thinking that exact same thing.’ Our experiences of ourselves become internalized as a result of this sort of interaction. We figure out who we are.
“But my patients—many of you—automatically take the emotional posture that the abuse you fell victim to was your fault. Why? Because at least then you avoid feeling the threat of the contents of the mind of your abuser. You don’t ask why Daddy hits you or Mommy’s passed out on the living room floor. If it’s your fault, you’re more in control.
“You’re sacrificing yourself in order to maintain the illusion of the control in a situation that otherwise you’d experience as irrational and unpredictable. Of course, if you’re at fault, you’re also feeling shame. In addition, your brain kicks into an automatic biological response that becomes a permanent mechanism for dealing with interpersonal stress. This is the action your brain takes to escape these situations from which there’s no escape, something called dissociation.”
A grey-haired man in mechanic’s coveralls raises his hand. I have treated him and his son.
“So what are you saying that I’m feeling?” he asks.
“What did I say all my patients have in common?”
“Helplessness,” he says.
“What do you feel when you’re helpless?” I ask.
“Fear,” he says.
“Right. The initial response to threat is fear. How does this happen? Well, chemicals flood into the brain as the flight-or-fight response is initiated. When escape seems hopeless, your brain switches into shutdown mode, releasing a flood of endorphins that provide a soothing numbness as you wait for the inevitable to occur.
“The experience that predominates this reaction is what?”
I call on a young guy seated on the side.
“I don’t even get what you’re saying,” he says. “But I’m guessing that it’s the sense that you’re somewhere else, gone, shut down.”
“Exactly,” I say. “Dissociation. You separate and isolate yourself from the world, from feelings, from others. While such a reaction may protect you from the horrifying experience—whatever that turns out to be—the price is a long-term difficulty in integrating emotional experiences. Think back to whatever age you suffered trauma. That’s when you shut down. That’s when you decided you were to blame. That’s when you stopped connecting with others.”
“You know what picture I’m getting?” A man in front says. “I see one of those Japanese soldiers coming out of the jungle after hiding for thirty years because he didn’t know the war had ended. You don’t know anything that’s going on. You don’t know who to trust or which side you’re on. Your instinct would be to turn around and run back into the jungle, where it was safe.”
“Kind of,” I say. “But let me go on. So what happens? The personality that accompanies you as you mature physically tends to have a hard time in relationships. In fact, the original victimization is often recreated over and over again. It’s the same problem repeated, and more problems ensue. You can’t trust someone with your tender needs in a genuine relationship. Why? It’s too dangerous. It’s too likely to expose you to trauma again.
“So your ability to develop brain mechanisms to regulate emotions is impaired, since we tend to build these through intimate connections with others. It’s a great big mess that causes you to enter your young life looking for solutions to those feelings of being, as most of you say, fucked up. You aren’t able to find any peace until you find drugs or alcohol. Then, suddenly, for the first time, everything seems all right.”
I see heads nod.
“Are you with me still?”
I get a chorus of yeses.
“Good. We just talked about the consequences of trauma, which basically set the stage for the addictive process. Let’s go to the next point: Why are you addicted? The simple answer is that some people are configured biologically in such a way to respond very positively to substances. That’s what gets you using. But what makes you an addict is primarily a change in a tiny region of the brain called the nucleus accumbens.
“This region of your brain has started to mistake the chemical message of survival with the message delivered by drugs. The drive to use becomes confused with the drive to survive. This drive overwhelms the centers of the brain where cognitive reasoning and will reside. This shouldn’t be confused with the feel-good part of addiction. These powerful drives that begin emanating from deep nonverbal drive centers of the brain and demand gratification with the same life-or-death intensity as taking a breath. This is what keeps you using even when it doesn’t feel good or work for you anymore.
“Interestingly, a certain percentage of people feel really shitty when they’re exposed to endorphinlike substances.”
“Then they aren’t real addicts,” a black woman who’s been in and out of treatment several times says.
“That’s partly true,” I say. “I had a patient come in with uncontrollable sobbing from, of all things, Vicodin.”
“Oh, please,” she says, waving me off.
“You’re like my addict patients,” I say.
“No, I am one of your addict patients,” she laughs.
“My addict patients feel incredible when they’re exposed to opiates or any other chemical that tickles the brain’s endogenous morphine system, like alcohol, cocaine, sometimes pot—”
“Heroin,” someone chimes.
“Yes. In fact, all drugs of addiction have in common that they stimulate the endorphin system. That’s the feel-good part of drugs. So these people configured to respond positively to substance feel great when they’re using. So great they keep using to regulate their emotional lives. As time goes by, all drugs of addiction cause depletion of brain chemicals.”
“What? one of my more vocal participants asks.
“The endorphin system alters itself in response to months or years of saturation, and so when the drugs are removed the brain is no longer able to screen out discomfort or pain. This of course happens at a time when the patient is trying to come to terms with the pain of acknowledging the consequences of the disease—destroyed relationships, legal problems, health issues, and so on. Not only is the endorphin system altered; the mood center, serotonin, is also depleted, as is the anxiety-regulating GABA system and the stress chemical cortisol. All are profoundly abnormal from drug use, leaving the patient in an impaired and terribly unpleasant brain state.”
“Welcome to my world,” a guy yells out.
He gets a big laugh.
“Remember, you’ve relied on drugs to deal with unpleasant or overwhelming emotions often since adolescence. Those same emotional conditions that started you using have remained unchanged. Not only that, the drugs have blocked you from tackling the usual milestones of development. There’s even some evidence that certain of these drugs actually impair the brain’s growth. And, finally, many of these drugs of addiction damage the brain, leaving biological impairments that affect mood, anxiety regulation, and memory.
“So you enter sobriety with this incredible set of biological and often psychological and developmental circumstances stacked against you. Throw in the misery of withdrawal, the social shame and stigma associated with the disease, the consequences of your behavior, and on top of everything the fact that you really love to do drugs—well, it’s no wonder people relapse.”
“Amen,” the black woman says, to a mix of laughs and clapping.
“But here’s the fascinating—or depressing—part,” I continue, “This is not the disease itself. What I’ve described are merely factors that come to bear on the disease. The disease is a disorder of the drive centers of the brain—specifically the so-called mesolimbic reward center, as I’ve explained, in the nucleus accumbens. The part of the brain is deep in the reptilian core. It doesn’t have language or logic. Just as with lower life forms, it exists merely to increase the drive that activates behavior fostering survival. It’s the survival center, and it’s gone awry.
“I’ll give you an example. Every cocaine addict knows that he or she will never get the same high they got from their first hit off the pope. In fact, they feel shittier and shittier with each hit, yet they continue to use until they’re floridly psychotic, sitting in a dark room by themselves, peeking out through the curtains at the black helicopters they imagine are hovering overhead.”
“It was army men for me,” a guy in a blue suit says.
“I heard paramilitary spacemen hiding in the bushes,” a car mechanic seated nearby adds.
“The point is, you continue to use because the drive centers command you to use. Your brain’s rational understanding is overwhelmed. Though you know perfectly well that you won’t get high and will end up feeling like shit, you can’t stop. You can’t stop, no matter how hard you try or how badly you want to. That’s addiction.
“There’s a lot of new science being done in this area, but basically what we have here is a set of very powerful drives being activated beneath conscious control in a region of the brain that can’t be influenced by reason, language, or will. We have a terrible time in this country accepting disorders of will. How often do you hear someone explain their behavior by saying, ‘Hey, it’s a free country.’ But as you well know, you’re not free from the grips of the biology of this region of the brain and the effect the disease has on it.”
I know this is all still pretty technical material, but I can feel a sense of excitement in the room, a tangible buzz as those listening acquire new or additional understanding about why they really are powerless over their addiction. Why does that create such a reaction? Because the first twelve steps in Alcoholics Anonymous is admitting that you are powerless over your disease. Now they can really believe it’s true, and we can start discussing how you get better.
“Powerlessness,” I say, gazing across the room to emphasize that each one of them has this in common. “What kind of feeling does that evoke in you?”
“Pain,” a young man in the back of the room says without hesitation.
I nod, smiling. I know the young man well: Patrick, a patient of mine who’s recently turned twenty. He’s been doing well in recovery. He’s even returned to college.
“I just feel pain,” he continued.
“Can I use you as an example?” I ask, aware that he has shared in previous groups with many in the room. He says yes, and I encourage him to fill us in on the details. Raised the only child of an alcoholic father and addicted mother, Patrick was on his own from the time he could walk, His life had little structure. He was neglected by his parents and abused by his neighbors. He started smoking pot at the age of ten. Two years later he was on coke. He was thirteen when his father died. His mother floated in and out, either ignorant of or indifferent to his drug use. By sixteen he was using speed. Still, against seemingly insurmountable odds, he managed to get into a city college. He was a major control freak—anything to avoid the instability of his childhood—and yet he couldn’t control his drug use.
“It was like I was running all the time,” he says. “Even when I was asleep I was still running.”
“Running from what?” I ask.
“A specific pain?”
“No, not really. It’s more like a feeling of pain that blankets everything. It’s just always there. My whole deal has been avoidance through control.”
He had articulated something that’s key: the fact that the pain that started with the traumas of his childhood was still ongoing in the present. It still felt raw and fresh. It had happened then, it was happening now, and as far as his brain was concerned it was going to keep happening into the future. He was in what some call the “running” phase of post-traumatic stress disorder.
They have no idea how much I relate personally. But ever since I saw the man with the red crosses in his eyes following my mother’s miscarriage, I’ve felt—no, I’ve known—that bad things are happening to me. Period. Then, now, and always. Like Patrick, I’ve tamed those feelings by maintaining control, striving for perfection, rescuing people. I even have a job where bad shit happens every day. It’s exhausting.
If I’d had the genetic disposition, I would’ve made a great addict.
“You can see how as a result of those early traumas you have difficulty trusting and opening up to another person,” I say. “If you’re a kid, why would you ever trust again? But without that capacity to trust, you can’t get an accurate read on your own self. You never learn how to regulate your own feelings.”
A hand raises from the middle, and a husky man with bushy sideburns and tattooed arms stands up to speak. “How do you learn?” he asks.
“That’s the getting-it part of recovery. You have to be willing—willing to follow directions, willing to trust, willing to form connections, willing to explore feelings. That’s the essence of recovery, of the twelve steps,” I say. “In recovery, you learn how to regulate your emotions without getting high. This is where you learn connection, the connection you didn’t learn when it was interrupted but trauma in childhood. The real work gets done when you sit down with a sponsor and trust that that person will be available without shaming or intruding as you express genuine and tender needs. Then, instead of suffering rejection, you experience relief and gradually a new sense of self. It’s only through relationships with others that we develop a sense of who we are and the ability to regulate our emotions.”