For the recovering person, for the professional, for the student and for those people wishing to improve the quality of their relationships.

1. How well does the disease concept apply to addiction?

The disease concept had a humanizing effect and lessoned the impact of the stigma attached to alcoholism/addiction. This shift in perception ran counter to the prevailing ignorance at a time when alcoholism/addiction problems were associated with a lack of willpower and/or moral character.

However, while the medical model led to a more compassionate and enlightened approach, it left gaping holes in our knowledge base. The disease concept doesn’t adequately explain what an addiction is, how it works (in terms of emotional and psychological dynamics); nor does it adequately account for etiology (why people become addicted.) In terms of treatment implications, it makes for a short-sighted vision as to what treatment and recovery entail.

The relationship aspect and emotional dynamics of the disease were never included by the medical establishment as these issues are not befitting of the scientific method; viewed as subjective in nature and therefore untreatable.

Extending the relationship concept to the disease merely implies that a relationship is established, a pathological relationship – not with another person (although it could be with another person), but rather with an object, a source of relief; in other words, a substance or activity. It may not be a relationship with a person, but it is a real relationship nevertheless.

This relationship takes over the person’s functioning. It is a survival-based attachment, the primary relationship in the addict’s life, more powerful than any other. There is no emotional nourishment provided in this relationship, only relief: relief that is artificially induced and short-lived. It’s a relationship that is emotionally-driven, not physically – especially in the earlier stages, before a physical tolerance develops. It may be likened to falling in love – or, more accurately, to a secret love affair.

Understanding etiology (why people become addicted in the first place) is another area that is not adequately addressed by the traditional medical model. The medical model explains etiology in terms of genetics and chemical imbalances, when these are really only correlates, not causes. The countless number of addicts who don’t necessarily fall into those categories remains unaccounted for. Why do people get into pathological relationships? Why do people get into relationships with sources of relief rather than emotionally nourishing ones?

Addiction can be sourced back to the existence and preponderance of non-emotionally nourishing relationships, both past and present, and to the residue of pain they leave behind. We may describe the psychosocial context of addiction as widespread and pervasive emotional deprivation.

The greater the level of pent-up pain from unmet emotional needs, the greater the need to relieve that pain, and the more susceptible one is to a source of relief, to getting involved in yet another non-emotionally nourishing relationship.

From a relationship perspective, it becomes clear that the need to relieve the backlog of emotional pain from non-emotionally nourishing relationships is the driving force of addiction.

There are treatment and recovery implications when using this relationship model for understanding the emotional dynamics of addiction. Traditional recovery and treatment approaches target restoration of behavioral stability and baseline functioning as primary goals. These approaches also include the need for lifelong participation in a 12-step fellowship, which is integral to any recovery program. It is clear that the fellowship is a vital and indispensable source of sober support, a place to go for a sobering reminder about what it means to be an addict.

However, for many addicts, many questions remain unanswered. What’s next? What is beyond sobriety? Based on this relationship model of addiction, the ability to create emotionally nourishing relationships is key to a quality, sustained recovery. Getting beyond sobriety means gaining the experience and skills necessary for transforming the quality of one’s relationships.

2. When does the addict actually become addicted?

The usual response to this question is that there is no way to truly know. Words like ‘when’ are speculative, there is no way for anyone to really know. How long had s/he been addicted before there were visible behavioral changes and resultant problems?

Common sense would tell us to assume that the addiction had been present long before anyone noticed anything awry. But how long before?

While one may want to discard the notion of when – because there will never be any proof, it is still possible to make inferences based on some very strong circumstantial evidence.

It’s certainly possible, more times than not, that the addiction began the first time the person got high via a substance or particular activity. The discovery of the mind/mood-altering effect, a “rush,” as it is commonly called, and the immediate relief/pleasure derived was extraordinarily gratifying.

The question of when refers to the moment a “discovery” is made, that s/he suddenly has the power to feel any way he or she wishes to feel whether that is “better than before” or a burst of confidence or freedom when one feels insecure and shut down most of the time.

Unbeknownst to the addict, an irreversible relationship is established at the point of discovery. This new relationship is overpowering and takes precedence over all others. As s/he gets more involved in this relationship, s/he becomes less involved in all other relationships – and, thus, more emotionally malnourished.

The backlog of pain actually increases over time, which is why the addict is becoming increasingly addicted. While the high provides relief on the front end, it makes the addict feel worse in the long run (when the effect wears off, the addict seeks relief again – only to feel worse after it wears off, and so on). So begins a vicious cycle.

3. What is emotional withdrawal?

While physical withdrawal is clear-cut, evident by physical symptoms and is treated with medication; emotional withdrawal is subjective in nature, evident by disclosures regarding emotional changes, and is not treatable with medication. It is, however, no less real.

Here again we might be bumping up against the influence of the traditional medical model orientation that does not give the concept of emotional withdrawal much thought.

Since emotional withdrawal is not something that is easily observable, the only way to know of its existence is by hearing addicts describe what happens to them emotionally or experientially during and subsequent to getting high. The after-effect or when the high wears off, a state of insatiability starts and continues. The addict will find him/herself in a worse mood than before getting high and not know why.

After coming down, reality becomes a less than experience - one’s problems and limitations become more pronounced. The addict subconsciously measures how s/he feels when sober against how s/he feels when high, focusing entirely on the difference – without considering the source of the relief attributable to the substance or activity. The addict has no idea that s/he is trapped in a cycle of perpetual insatiability.

4. Why do some people get addicted while others do not?

Evidence suggests a strong correlation with genetics – a history of addiction in one’s family of origin or prior generations ¬– and/or biochemical factors (a chemical reaction in the brain that brings about extraordinary relief and strong cravings). However, the number of exceptions makes us wonder whether there are other factors. There are many who, given their family background, are at extremely high risk, yet who do not become addicts. Conversely, there are those without a history of addiction in their family who do become addicts.

From the standpoint of healthy relationships, or the lack thereof, we can better understand why some people are more predisposed than others and some are less. The key variable is the existence of emotionally nourishing relationships, both in the past and in the present. When one has sources of emotional sustenance, as opposed to being or having been emotionally deprived, there would be less of a need (for relief), the initial high wouldn’t hold the same irresistible charm, and there would be no incentive to get involved in yet another non-emotionally sustaining relationship.

Perhaps the simplest explanation is that when the right person discovers the source of relief, whether substance or activity, a dependent relationship is established. The right person is anyone whose level of pre-existing pain is high enough to potentiate an extraordinarily gratifying experience, discovery. Anyone could become addicted at any time, depending on the level of pre-existing pain; and there is no way to tell who is more or less predisposed.

Susceptibility is often a matter of timing as well -- how much one needs relief at any given point in time. Is a person’s level of pre-existing pain increased in the face of recent events and stressors? There are certain conditions that make one more susceptible.

Someone whose self-esteem is low to begin with would be more at risk than someone whose self-esteem is relatively high. Someone who is stressed out on the job or is in a deteriorating relationship is obviously more at risk than someone who looks forward to going to work and who is in a stable relationship. People who are struggling with depression, anxiety, or post-traumatic stress are more at risk.

On the other hand, when someone’s level of pre-existing pain is fairly well managed or not high, and that person is relatively stable and emotionally fulfilled, we wouldn’t expect getting high to become a life-changing event.

5. How do we tell whether someone is addicted or not?

It is a relatively simple to diagnose addiction or to know when one’s addiction related activities are problematic. When there are objective, irrefutable indications, including the amount of time and energy spent acquiring a substance, thinking about the substance, getting high, being high, etc. – in other words, the extent to which his/her life revolves around a mind/mood altering chemical or activity, and how one’s life is impacted, i.e. health, relationships, occupational, academic, legal or financial problems, etc.

When there is marked evidence of problems or deterioration, it is almost certain that there is a pathological dependence, and that these problems will sooner or later precipitate treatment. We may call this an objective dependency.

It’s important to keep in mind the distinction between the existence of an addiction and its severity because there are profound treatment implications. The severity of resultant problems usually corresponds to the severity of the addiction.

When there are few or no objective indications, it becomes much more difficult to know whether someone is addicted. When there is a lack of irrefutable evidence, the tendency is to discount the existence of an addiction. “If there are no problems or consequences, there must not be an addiction.” One might wonder whether it even matters.

What if a person doesn’t care whether s/he is addicted or not and as long as s/he is maintaining a high level of functioning, and is choosing to maintain his/her involvement? It is certainly possible be addicted and remain relatively high functioning.

The challenge is still to determine whether there is an addiction or ‘subjective’ dependency. A subjective dependency requires accurate interpretation of subjective indications to know whether or not there is an addiction.

In order to make a diagnosis as soon as possible, during the early and mid ranges of an addiction’s progression and before it reaches its destructive potential, subjective criteria must again be applied. For example, when there are obvious addiction-related problems, but the person is not willing or able to even entertain the possibility of an addiction, the possibility of undesirable consequences, or the possibility of needing help to address those problems.

Take the case of a relatively high-functioning addict who claims not to be addicted, and sees no ill effects. S/he claims to be using the substance recreationally; but it becomes apparent that his/her recollection of facts regarding amounts, frequency and duration of use is inconsistent. It becomes further apparent that the person is making an effort to conceal, cover up, minimize or justify his/her use to him or herself and to other people, but isn’t aware of doing so. It finally becomes apparent that this person is in denial. The person’s story is a denial-laden story. At this point, a bell rings and we know.

The rule of thumb is that wherever there is denial, there is dependency – otherwise, there would be nothing to deny. One doesn’t exist without the other.

6. Is it true, once an addict, always an addict?

It’s probably every addict’s dream to one day be able to use a substance or engage in an activity recreationally or in a controlled manner. The only problem is that it is impossible to do so. Forgetting that addiction is permanent can (and often does) occur at any time during sobriety. It is also common for the addict to forget that, regardless of how many years one has been sober, one-time use means relapse.

Forgetting, disbelief or doubt is denial rising to the occasion, in synch with the dependency. They work in tandem; one never exists without the other. The longer time the addict stays sober, the easier it is for him or her to forget that s/he will never be able to use without getting hooked all over again.

However, at any moment, the thought could pop into one’s mind: I could use on a once-in-a-while basis without any consequences. The addict will then go on to prove him/herself wrong, but not until s/he bottoms out.

The addict will always be susceptible to relapse. The effect or high is irreversible; that is, the substance or activity forever remains as an extraordinarily powerful need-gratifying agent guaranteed to provide extraordinary relief.

Consensual agreement (or group confirmation) is a key factor in the development of dependency and denial. Who was present during discovery? Who does the addict use with, or engage in the addictive activity with, on an ongoing basis? As the disease progresses, addicts tend to relate to people who, in some way, support their addiction.

When there is consensual agreement, the people in the group act as mirrors for each other. They reflect each other’s wishes and delusions, redefining reality in their own terms. The group’s celebration of the drug-induced experience reinforces a “reality” predicated on denial.

The addict’s relationships with significant others decrease in importance, while relationships with using cronies become increasingly important. The addict becomes increasingly removed from those prior relationships; anyone who doesn’t support his or her addiction is avoided.

A stigma is a visible or known attribute that relegates a person to a substandard or less desirable category of people. Addiction may be either visible or invisible, depending on how much visual deterioration has set in. The person is labeled as defective and is subsequently branded an outcast, an example of what not to be. The person’s status, how s/he is seen through the eyes of others, and how s/he will ultimately feel about him or herself are under assault. Other people respond to the addict with avoidance, indifference and disdain.

Despite the disease concept, addiction still carries a huge stigma. The moment the label – ‘addict’ – is applied, the person is categorized, and all kinds of images are conjured up, as the addict is perceived as weak or bad, part of a less-desirable group. In our culture, there is also a strong stigma associated with having a problem, with needing and reaching out for help, albeit to a lesser extent than the stigma attached to having an addiction. Exposure, therefore, poses a huge risk for the addict and presses the button of internalized shame along.

It is not at all unusual for the influence of stigma to still spill into therapists’ and treatment practitioners’ laps. Certainly they are not exempt from being affected like everyone else. Unless educated about stigma, and aware of his or her own reactions, the helping professional can easily lose objectivity, which will ultimately hamper his or her ability to identify and discuss addiction.

Codependency is an addiction, an addiction to another person. Just as an addict is driven by his need for relief through mind/mood-altering substances, the codependent person derives relief in the relationship s/he has with the addict. Codependency is putting someone else’s wants, needs, feelings and problems above one’s own, taking care of someone else, while neglecting oneself. The codependent’s judgment is impaired, s/he is out of control, and has a distorted view of the relationship. One is a sinking ship, the codependent stays on while the others would jump off. The co-dependent depends on others who are unable to provide or care for themselves. The addict’s problems actually feed the codependent in a variety of ways.

The codependent’s caretaking prevents the addict from bearing the responsibility for the consequences of the addiction and from recognizing the need for outside professional help. The emotional gain derived from ‘codepending’ (i.e., caring, helping, rescuing) is the feeling of being needed, making a difference and deserving of being loved and special.

A codependent relationship is a symbiotic one. Codependent people have tremendous difficulty separating themselves, setting a boundary between where they end and their partner begins, and between what is and is not their problem to fix.

The driving force of codependency is a deep sense of powerlessness, invisibility, worthlessness and fear of being left alone. Like all the other addictions, codependency serves as an escape from one’s own pain.

10. What are the keys to a quality sustained recovery?

Coping with all of life's stresses is a difficult for anyone, but more challenging for the recovering person. Not only is the recovering person learning how to deal with being sober/abstinent (something s/he is unaccustomed to doing,) s/he must also gain the necessary experience and skills to transform the quality of his/her relationships and develop new sobriety-supportive and emotionally nourishing relationships.

Recovery must become a top priority, to be practiced and applied every day. It requires strong motivation, commitment and discipline to stick with the trial-by-error learning process. Without a spiritual program or strong sense of self, and a healthy support system, it's usually just a matter of time before anyone (addict or not) will resort to the easiest and most immediate means of relief to cope.

Relapse and Recovery

Relapse is a natural and common part of the ongoing recovery process. The risk of relapse is based on how motivated and disciplined the addict is about working a program, and the extent to which he or she has developed and uses sober support. The veteran addict with years of sobriety is aware of the possibility of relapse at any time. The veteran knows his or her triggers, and takes precautionary measures to avoid them.

However, despite all best efforts, an addict can wear down under stress. The addict’s ability to cope, to stay sober, often depends on the level of stress s/he is dealing with. It’s quite common to become overwhelmed by stress, which leads to the need for relief and increased likelihood of acting impulsively. In no way does this mean the addict is no longer in recovery. It’s just a matter of getting back on track, maintaining sobriety and working a program.

11. What is an intervention?

An intervention is a step-by-step, rehearsed process whereby significant others confront the addict about his/her addiction and need for immediate treatment. Significant others meet with the therapist for an assessment and to guide the process. The interventionist provides psycho-education about addiction and codependency. Then each family member recollects events that provide irrefutable evidence of the consequences of the addiction. Then the confrontation -- an outpouring of love long overdue and affirmation that they will no longer stand by helplessly watching the addict self-destruct.

Relational Recovery

Clearly delineated guidelines for dealing with the challenges inherent in creating intimate relationships.

Demystifying Addiction

Establishes a new standard for understanding the emotional dynamics of addiction with treatment implications.

Mastering the Art of Intervention eBook

How to do an Intervention...A guide that details the step by step procedure, includes a case example and analysis...Add this invaluable tool to your clinical repertoire.

[Details]