We Need to Change Our Thinking About Addiction

We have been doing a terrible job helping people who struggle with addiction.

Posted Apr 22, 2019

We Need To Do the Opposite of What We’ve Been Doing to Solve Our Addiction Crisis

Why have we been doing such a terrible job of helping people who struggle with drugs?

Most addiction treatment in this country is not appealing to or effective for the vast majority of people with problematic drug use.

As a psychotherapist working on the front lines of addiction treatment for over 35 years, I am happy to report that we are in the midst of a scientific revolution in our understanding of drug use and addiction.  And it is paving the way for widespread acceptance of a new and effective approach to treatment—harm reduction.

Addiction is one of America’s most urgent humanitarian crises. Today, 100 million Americans struggle with problematic drug and alcohol use. 72,000 Americans died from accidental drug overdoses in 2017, and 2018 is likely to have been worse. We spend $500 million annually on our drug problem, but only 2 cents on the dollar goes to prevention and treatment. Most people who need treatment don’t get it and treatment in this country is failing on nearly every level.

Our Thinking About Addiction Is Wrong

Thinking of addiction as a disease is largely responsible for our failure to effectively treat it. This narrative and social responses based on it have arguably been more harmful than drugs themselves.

The disease model presumes that addiction is primarily a biomedical phenomenon, a permanent condition that is arrested only by complete and total abstinence from all mood-altering substances. Much data contradicts this view. Studies show that many of the brain changes associated with chronic drug use are reversible. And many formerly addicted people are able to moderate drug use.

The disease model sees addiction as a problem isolated within the person’s biology separated from their personal psychology, relationships, and social context. This model closes down the exploration and discovery of the meaning and complexity that is contained and expressed in substance use.

Disease model addiction treatment, the dominant approach, is oriented around the requirement of abstinence. Abstinence becomes the only measure of success, and clients who continue to use drugs are considered failures. In fact, the majority of problematic drug users, like the majority of people who engage in many other risky behaviors, are not ready to change their drug use—for complex reasons that often must be addressed before the behavior can be addressed directly.

Shifting the Addiction Paradigm

If addiction is not a disease, what is it? My experience in treating thousands of people with substance use problems has taught me that addiction is a natural and meaningful response to the conditions of people’s lives and their emotional and physical impact. The physical effects of drugs are pleasurable and rewarding in relation to how we feel emotionally and physically in the context of our relationships and social lives. This view re-humanizes addiction as a psycho-biosocial (PBS) process that reflects a dynamic interplay of psychological, biological, and social factors (PBS) that are unique for each person.

In his book The Biology of Desire: Why Addiction Is Not a Disease, developmental neuropsychologist Marc Lewis says that the repetition of effective coping behaviors does change the brain—the same way that all learning does. From his point of view, addictions are previously helpful coping strategies that have become “really bad habits” embedded in neural networks that are difficult to change. However, in contrast to the disease model, this model explains how they can be changed: The brain has a built-in capacity to continue to learn new and more effective behavior throughout one’s lifetime.   

The more extreme forms of addiction are on a continuum with experiences that are universally human. Who hasn’t felt all of the hallmarks of addiction: craving, compulsion, out of control and being unable or unwilling to give something up in spite of its negative consequences? A lover, sugar, binge-TV watching, coffee, cigarettes, surfing the web? We all engage in attempts at self-care and self-soothing, which, at times, can feel deeply compelling to us even when the activity is in conflict with our values.

It is possible to change behaviors that are no longer useful or that have become harmful and develop more effective ways of coping and caring for ourselves. Disease suggests permanence and powerlessness, but this is an empowerment model that inspires hope and motivation to do the work of pursuing positive change.

Often, a user needs to understand the purpose drug use serves for him or her in order to stop use and develop more effective solutions to life’s problems. It is unreasonable to expect people to give up chemical coping strategies until they have found better alternatives.

Toward a Culture of Compassionate Pragmatism

This new view of addiction supports a transformation from a culture of stigma and punishment into one of compassionate pragmatism in which treatment is guided by a desire to reduce the suffering of people who struggle with drugs in ways that actually work.

Harm Reduction Psychotherapy

The psycho-biosocial model suggests that effective treatment for problematic drug use must bring together therapeutic strategies that facilitate the exploration of the personal and relational meanings of addictive behavior with active strategies that support positive behavior change. The essence of harm reduction is to reduce the harms of drug use and other risky behavior without requiring that people first stop the behavior. This makes treatment accessible, relevant and appealing to the entire spectrum of problematic drug users at whatever point they are ready to begin their journey toward positive change—whether desiring safer use, reduced use, moderation or stopping altogether.

Harm reduction “meets people where they are” with empathy, acceptance, and compassion in a non-presumptive, collaborative spirit. This facilitates the development of positive therapeutic relationships and enhances motivation to change. Many “unmotivated” addicted people become highly motivated when they hear that this harm reduction alternative is available.

Integrative Harm Reduction Psychotherapy (IHRP) is a treatment I developed. It is documented in a number of professional papers and described in my book Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems. IHRP brings together relational, dynamic, cognitive, behavioral and mindfulness strategies in a harm reduction frame. IHRP’s core tasks can be applied to therapy or self-guided change. Each of its tasks involves specific skills and strategies that will be discussed in future posts:

  • Create a compassionate relationship with yourself or the person you are helping as the prerequisite for making positive change
  • Strengthen emotion-management skills for sitting with uncomfortable feelings and interrupting the addictive process
  • Discover the meaning and function of addictive behavior
  • Embrace ambivalence about change and dialogue with the part that wants to change and the part that is invested in the addictive behavior to increase motivation to change
  • Develop new solutions to this dilemma: healthier, coping strategies for what’s being addressed by the addictive behavior that will support positive changes in addictive behavior
  • Create a personalized positive change plan for achieving one’s goals

Advancing New Treatment Methods

The new way of responding to addiction is being increasingly accepted by a growing global movement across the planet at a grassroots level with increasing support. The Center for Optimal Living in NYC advances this new approach to healing addiction. Established eight years ago, it offers therapy to individuals and families and training to therapists and has trained people in 17 countries.

I invite you to join the movement and be part of the solution.