I often wonder how the whole field of counselling and psychotherapy could help to better address the needs of those who are essentially most in need of psychological support. Men, for instance, who suffer from depression often present as angry individuals but the anger is often hiding the pain of depression. Depression in men is so often difficult to identify as it can be accompanied by displays of angry behaviour in social situations. Men, in effect, can more easily end up in prison than in a therapist’s room.
The stigma for men surrounding not only drug use but also gay sex can act as a barrier for individuals who really need help accessing psychological support services. The drug-fuelled party lifestyle associated with chemsex can destabilise the mental health of those already suffering from pre-existing mental health problems. These issues will be presenting more and more in the coming years in counselling rooms with the advances in mobile telephony and hookup apps. But a prevalent culture of silence, secrecy and stigma in the chemsex world can keep individuals isolated from accessing services. Chemsex users perhaps need to be reassured, more than any other client group, that they will be understood, and not judged, if they do end up presenting for help.
Therapy can offer people a vital place of safety to unravel their story so that greater insight can be obtained for problem behaviour. It can be common for attachment issues to get played out in all forms of addiction, as well as past traumas and previous psychological wounding. Therapists need to be even more aware of their need to make personal connection with the presenting issues with such clients. An abstinence based approach might not always be appropriate for them, at least initially, as the thought of complete abstinence might make them run away. Harm reduction and psycho education could be useful areas to cover as well as the principles and ethos of motivational interviewing. These clients are often in a contemplative mode when assessing the options about their future intentions. Chemsex users are familiar with high adrenaline excitement as a means of mood regulation and will be easily frightened about slowing down and getting in touch with difficult personal material that might threaten their equilibrium.
Chemsex parties offer excitement and the apparent lure of social connection. However, for those vulnerable to psychological wounding the lifestyle can be a dangerous playground and chronic feelings of aloneness can persist. Addiction can be viewed as a search for emotional satisfaction, as a place of safety, balance and comfort. If the connection in the consulting room is robust the underlying psychological issues will get played out in a safe environment through projections and transferences.
An addiction disorder can be very distressing for an individual as well as their partner and family. Active addiction involves loss of ability to choose freely whether to stop or continue the behaviour (loss of control) and leads to experience of behaviour-related adverse consequences (Schneider & Irons, 2001).
The disease model of addiction underpins the enormous rehab industry whereby addicts get treated at the hands of so-called ‘experts’ at very expensive units, and often within residential retreats. The treatment team at such places invariably consists of medical experts (including psychiatrists) but also the burgeoning band of treatment personnel who report to them (a lot of whom are low paid staff or trainees on placement). The most common interventions are group process dynamics as this represents the most cost effective treatment plan. The success rate for these places in effectively treating addiction is poor as the rate of relapse amongst patrons is quite high. So, you might ask what is the theoretical foundations of their addiction treatment?
Addiction treatment is largely based on three broad categories that underpin addiction recovery treatment programmes. They overlap to some degree, but each model has unique implications for research, funding, and care, from the level of government policy to that of treatment options for individual sufferers. The three categories are:
1. The Brain disease model
Advocates of the disease model maintain that there is ample scientific evidence from PET scans to believe that the brain changes as a result of substance abuse and that because it changes it must, therefore, be evidence of disease.
The disease model of addiction is essentially a biological explanation for the causes of addiction. Drinkers and drug users follow a pathological road to destruction and have lost control as a result of their using. Proponents of this outlook see addiction affecting the brain in similar ways that physical illnesses produce changes to vital organs. For example, diabetes changes the way the pancreas works and hepatitis changes the way the liver functions and this is the same for alcoholism, in that it changes the manner in which the brain functions.
Alcoholism was officially designated an illness by the American Medical Association (AMA) in 1967. Seeing addiction in this way, rather than as a weakness by self-indulgent moral degenerates, has brought benefits to the medical community for it has stimulated research as well inspiring the development of useful medications that have helped ease the symptoms of withdrawal.
The disease concept of addiction has formed the basis of the 12 steps of recovery from Alcoholics Anonymous (AA) and Hazelden’s ‘Minnesota Model’ and contain key concepts of powerlessness around alcohol (and drugs) and personal unmanageability in life. These concepts form the bedrock for an abstinence based approach to treatment, for life, albeit one day at a time. AA’s 12 steps are a combination of cognitive and behavioural tools and techniques and have a concept of a mental and spiritual malady at its heart. AA’s founders Bill Wilson and Dr Bob Smith were heavily influenced by Carl Jungin embracing the idea of a higher power to stimulate personal and spiritual ‘recovery’. The 12 steps state that the chronic alcoholic must undergo an entire psychic change in order to recover from a seemingly hopeless state of mind. People attending AA meetings see themselves in perpetual ‘recovery’ from an illness and observe total abstinence for life.
search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life
The Diagnostic Statistical Manual of mental Disorders (DSM), currently in its fifth iteration, is the psychiatric bible for clinicians and states the following: a “substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.” The present trend in psychiatry is to also classify gambling and even excessive internet use as disorders (as listed in DSM5), which others see as a vague term that overlaps with “disease”. Critics of the disease model ask where it will stop when defining symptoms of disease. They ask whether net surfing, hoarding, unrequited love and compulsive shopping might also be classed as diseases or disorders. Stanton Peele, a big critic of the 12 steps approach, argues in his book The Diseasing of America (1989) that addicts can recover without so called treatment, and that it is wrong to build into treatment the notion of character flaws (one of the steps in AA is to undertake a personal and moral inventory and to start with a form of confession in relation to the 7 deadly sins). Peele argues that numerous studies have demonstrated that people can drink socially again at a point in the future. He rejects the idea of personal powerlessness, opting instead for the concept of personal empowerment, as a more robust and positive approach to addiction treatment. For Peele addiction is the search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life. Peele explains that addicts tend to display susceptibility to diverse addictions, in sequence or at the same time. However, the gratification turns out to be temporary and illusory and the addictive behaviour results in more and more self-disgust, reduced psychological security and a poorer ability to cope with stress. In the attached clip (below) Peele expands on his ideas about addiction with particular reference to the neuroscience of addiction.
Marc Lewis agrees with Peele in rejecting the disease model by pointing out that whilst the brain does indeed change in response to addiction, so the brain changes in response to falling in love. The brain will change in response to learning activity and, therefore, brain change itself should not be used as evidence of disease. He points out that the hippocampus of London cab drivers expands by learning The Knowledge Test (see Maguire and Woolett). Indeed, Lewis argues that advocates of the disease model need to prove that brain change in addiction goes beyond what would occur in response to normal learning and development. Rather than the 12 steps of recovery Lewis prefers the notion of motivated self-directionfor treating addicts, when the addict finds greater meaning and purpose in their life to sustain a healthier lifestyle. For Lewis addiction is motivated repetition that gives rise to deep learning as he explains in great detail in his recent book The Biology of Desire: Why Addiction is not a disease. Addiction can also be seen as recurrent desire towards a single goal. In the attached clip (below) Lewis expands on his ideas about addiction.
2. The Choice model
The choice model was the theoretical basis of the War on Drugs campaign and the popular slogan “Just Say No”. Users do not consider addiction a good choice, but they often consider it a rational choice, at least in the short term – as when the relief gained from the addiction outweighs other possible choices.
Gene Heyman, is his book Addiction – A disorder of Choice, argues against the conventional psychiatric view that addiction is a disease. For Heyman, addiction is entirely voluntary and he sets out to demonstrate that drug use, like all choices, is influenced by preferences and goals. In the attached clip (below) Heyman articulates his ideas on addiction.
The Choice Model explains why people suddenly stop being addicted in response to a change in environment. An example would be when Vietnam veterans suddenly stopped abusing heroin when they returned to their homes after the war. This idea builds on the Bruce Alexander “rat park” experiments which showed that rats did not consume drugs in controlled trials in response to an improved social environment. In the attached clip (below) Alexander expands on these ideas of the need for an improved social environment.
Proponents of this model point to economic and environmental factors beyond the addict’s control such as poverty and social isolation. However, when conditions change with time and circumstances, then so do choices. Users see a different outcome to their predicament and change their behaviour accordingly.
The choice model explains better than the disease model how addicts suddenly quit but advocates of this approach risk viewing addicts as selfish and self-indulgent moral degenerates.Rather than being victim of a biological condition they are personally responsible for bringing on their misfortune in life by bad choices.
Treatment in this model could involve reviewing one’s beliefs and changing one’s perspectives, using tools and techniques offered by cognitive behavioural therapy (CBT) and motivational interviewing. Treatment invariably proposes total abstinence.
3. Self-medication model
The self-medication model is not a coherent approach as it is grounded in developmental thinking and conflicts with the notion that addiction results from an allergy. As children and adolescents develop, emotional problems can erode their sense of well-being. Trauma, either social, psychological, or sexual, is a buzzword for early adversity and post-traumatic stress disorder (PTSD) is often found to underlie anxiety and depression. Researchers have found that substance abuse among those with PTSD is as high as 60-80% and the rate of PTSD among substance abusers is 40-60% (K. T. Brady and R. Shina, 2005).
Taking drugs and alcohol make you feel better until they don’t. A nasty side effect of addictive drugs is that the addiction itself becomes a source of stress.
Treatment, according to this model, stresses the need to protect people who are vulnerable to psychosocial pressures and to diagnose and treat underlying developmental issues that have predisposed someone to addiction. Gabor Mate in his book In the Realm of Hungry Ghosts skillfully made a case that addicts seek relief from drink and drugs in response to early bonding experiences that were difficult and painful. In the attached clip (below) Mate expands on these ideas on the power of addiction.
Treatment options cover a range of holistic tools and techniques including CBT, attachment theory, object relations theory, creative imagination and mindfulness for addiction can be viewed as a loss of connection, or meaning in life. It could also mean loss of soul in transpersonal terms. Counsellors and therapists in this theoretical model might advocate total abstinence but not necessarily so as working therapeutically on past trauma can potentially see a transformation that entails social drinking at some point in the future.
ITV’s Good Morning Britain featured the story in their edition yesterday and invited me onto the show to talk about addiction to smartphones and digital detox. They also invited a family who had undertaken an experiment of having dinner but only communicating by messaging around the dinner table as an attempt to understand how we miss out on social cues by engaging exclusively by electronic means.
I am often asked what constitutes addiction. For me, addiction is a serious bad habit, can be highly condensed, reinforced and consolidated across many neural networks. Fear is a huge factor in all addictions and every addiction has a stress factor. Addiction can be present when you are doing something repeatedly and negative effects start to occur in other areas of your life. You find it very difficult to cut down the activity when you seek to regulate the behaviour. But according to the medical view, Gambling disorder is the only behavioural (non-substance related) addiction, as it’s the only one included in the Diagnostic Statistical Manual(DSM), currently in its 5th iteration. DSM is how psychiatrists diagnose ‘mental disorders’. As an aside, pathological gambling had long been considered by the American Psychiatric Association to be an ‘impulse control disorder’, rather than an addiction. Internet gaming disorder(psychiatrists just love to pathologize with words like disorder, don’t they?) is, however, listed in section 3 of DSM-5 as “conditions for further study”. So, presumably there may be room for smartphone addiction in future iterations of the Manual.
How do you know if you have a problem with mobile devices?
Here are a few general questions you could explore about your relationship with your smartphone:
Do you use your smartphone more than you are comfortable with?
Do you panic when there is no cell coverage or wifi connection?
Do you neglect social interaction with friends and family by spending excessive amounts of time on your device?
Do you lose interest in having sex with your partner?
You may have a problem if you are finding it more difficult to concentrate on daily tasks at home or at work, if you are concealing the amount of time spent on mobile devices, if you have a fear of missing out (FoMo) and have a sense of dread or panic if you leave your phone at home. Common withdrawal symptoms from smartphone addiction are anger/irritability, restlessness, sleep problems, difficulty concentrating and craving access to your device.
We all need to use online services from statutory services so a complete abstinence based approach is problematical. Indeed we need to be online to progress in careers and to connect with people. However, we can take steps to reduce our reliance on our devices. We can try to set goals for device-free times. We can set our phones to airplane mode during the day and especially at night. We can try to avoid reading work emails beyond certain times,as well as turning devices off two hours before sleep so we comply with sleep hygiene requirements.
If you think you have a problem, you could also consider not bringing mobile devices to bed and removing social media apps from phones. Maybe you could try to refrain from the constant checking of social media updates. See how you cope. If you begin to feel empty, moody and depressed as a result of putting in boundaries you could be experiencing a form of withdrawal.
Considering doing these steps might tell you all you need to know. How does it feel to potentially implement some of these suggestions? Does it seem reasonable or do these suggestions fill you with dread?
Seeing a therapist can be useful to motivate you to set boundaries with your mobile device usage and to address problem behaviour. You could explore what is behind your intense need to feel connected and learn to cope better with everyday anxiety. Therapy could be a means of building your coping skills to better help you to deal with boredom, rejections, loneliness and worry. There can, of course, be underlying issues with depression which might be worth exploring so it may be appropriate to go and see your GP too.
Are you in a relationship with someone who has an active addiction? Addiction can be chemical, alcohol and drugs, as well as behavioural, such as gambling and sex/porn. It can be difficult to know what to do and what to say when someone so close to you is losing themselves in a web of destruction. For helpful tips and guidance see my latest article on what to do when your partner has an active addiction.
Check out my latest article on how to help your child if they are addicted to computer games. In the article I outline the nature of the addiction, the brain changes that occur in adolescents, the practical steps you can explore and the support networks that you can tap into. The key is to help your child engage more widely with the social world rather than the virtual world. That might mean encouraging them to secure employment or to join social groups. Too much time spent in the bedroom on devices is not a healthy place for anybody.
Creating greater connection with essence to better cope with
triggers to addictive processes
What?an experiential workshop
Where? CCPE, 2 Warwick Crescent, London W2 6NE (see map below)
When? 29 & 30 November, 2014
Having gained insight from how to deal with addictive processes, are you now ready to look deeper within?
Would you like to connect more with your essence so that you can better deal with difficult reoccurring feelings and explore how such difficult feelings can impact on your sense of a safe place within yourself?
Would you like to gain greater clarity about your triggers to addictive behaviours using creative imagination, music as a symbol and drawing?
If you answered “Yes” to any of the questions above then this workshop may be for you. Connecting with your essence will allow you the opportunity to see your struggles in a different, clearer light and enable you to find inside yourself the guide you need. In this workshop, you will use visualisation, image work and music as a symbol to identify with different states of consciousness to get to know a deeper part of yourself in a simple and safe way.
The workshop will be facilitated by myself. I am a trainee psychotherapist with more than 20 years of experience in 12 steps recovery, and this project is part of the requirements for my final year for the Diploma in Psychotherapy at CCPE in London.
The cost for the two day workshop is £80, or £60 if booked by 3 October, 2014. In order to book a place, please contact Noel Bell at email@example.com or call 07852 407140
This workshop is limited to six participants.
Requirements: You will need to be in personal therapy in order to attend the workshop.
Meditation is not just for new age spiritualists or oddballs but should be seen as a practice for everyone, even for children. It is easy and simple and can be done anywhere. Meditation is a powerful antidote to the threats posed by addictions.
There are many great resources on the Internet and from books on how to meditate and on the benefits of meditation. See the list of resources at the end of the post.
Addiction has nasty associations these days. However, it originally merely mean’t something you liked. It was only in the 20th century that it became to be known as a slave to drugs. Addiction is a devotion to yourself. We are really attached to ourselves but in a dangerous way. Recuperation, or recovery, comes from the Latin word “recupare” meaning “to regain.” Through meditation we can regain consciousness and reach a certain peace with ourselves. When we are hooked we lose consciousness, as we become obsessed with ourselves. To recover is to push back the border of our consciousness, to know more and to regain interests in relationships. We begin to feel more present and happier in the here and now,
The important aspect of meditation is to do it on a daily basis. Here, the fidelity of the practice is important. Do it even when you don’t want to do it. It is by the practice of a good habit that gradually outweighs the power of a bad habit. You don’t even need belief, just faith, to do the practice.
Despair and Acadia will try to tell you to give up hope, that you are no use at the practice. Acadia had been one of the deadly sins but did not make the final 7. You should not, however, look for anything dramatic in meditative practice. Instead, concentrate on the daily practice without expectation.
Meditation has given me glimpses of a new way of being. Through the alchemy of transformation I can uncover a lot of my negative past or my shadow in the nigredo stage, similar to undertaking personal inventory work, and through to a brighter stage of albedo. Citrinas is largely unconscious and rubedo is an emerging new life. I have spent most of life struggling in nigredo and flipping between one addiction to another. I have received glimpses of albedo through therapy and meditation but sometimes it can be fleeting and any attempts at acquiring serenity can feel like pushing water uphill. For me, personal transformation is predicated on the willingness to “let go”. How can I achieve this if I am nursing unhealthy fantasies and active addictions? I do not have much experience of mastering. In my meditation I can feel great resistance as my ego defences are very solid. Mastering for me would represent being able to sit with my feelings and not have some manic activity consuming my attention. Is this what we are all searching for? A peace to be with our own feelings and not having to have any manic activity going on?
My own personal therapy is a journey of letting go, acquiring a new rhythm, keeping an open mind, trusting the process and developing new layers of honesty with my therapist. Freedom is when we are free of our history, or at least when our personal history is not the primary reference in our lives. We no longer react in the instance but can provide a considered response to the events in our lives.
Meditation calms you down. The practice of meditation eases you into a new state of calm mindful being. It helps in brain training. However, the higher benefit of meditation is that we are led to the ultimate truth of our own being. Try it. It might even work.
Resources Learning to meditatePractical guide Meditation booksUseful list of books on meditation 21 AwakeExplores authentic 21st century meditation practice, written by a London Insight regular AA Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism GAMeetings for problem gamblers Narcotics Anonymousnon a nonprofit fellowship or society of men and women for whom drugs had become a major problem. Recovering addicts who meet regularly to help each other stay clean SLAASex and Love Addicts Anonymous is a Twelve Step, Twelve Tradition-oriented fellowship based on the model pioneered by Alcoholics Anonymous Silence in the City Meditation in London The 12 steps of recovery