And it just spiraled down and I was very, very depressed and constantly hopeless I have emotional triggers that are problematic. Paige also described her addiction as a disease. For her, understanding alcoholism as a disease in need of treatment, just like her depression needed treatment, stripped away the moral judgment. I didn't just pick that up randomly, and I sometimes smoke like right now, I'm a little depressed so I smoked to kind of balance it. The rituals of gambling treatment were eerily similar to the rituals of video-gaming. Similarly, the demanding work of scrutinizing self-management processes among those who described the Punctuated Equilibrium theme, such as the administration of a salving substance, a drug to fight cravings, the pursuit of meetings, counseling appointments, vigilance to avoid environments where the substance is offered, or intensive treatment to control the substance use, could provoke enough anxiety itself to trigger a relapse.
To what extent did treatment provoke anxiety or emotional stress that could only be relieved by substance use, and then to what extent did substance use cause anxiety and stress that could only be relieved by going to treatment? I thought after treatment I could control my drinking, but as soon as I got out and I started drinking and I just was back in the same cycle again.
I fought with that, the first time I went to treatment because I thought I didn't believe the whole thing that with alcoholism you can't control it.
I didn't really buy into that. I thought a lot of people were using that as a crutch. Triggers that were more easily discerned were negative circumstances, specific events in time that offset equilibrium. Jerry, an aircraft mechanic, described his unprecedented abuse of alcohol within the last year as a result of an unfortunate series of events:. And then we lost the house to bankruptcy. My dad has health problems I wanna be able to drink with my friends in a bar Jerry believed that there was a place, a context, for healthy use of the substance, and had confidence that he would be able to return to that state.
Alcoholism, he thought, was an episodic anomaly created by circumstances, like a rude and unexpected episode of unbridled speciation to a stable ecosystem. Equilibrium would reestablish itself, with time. Alcohol use was not a part of his innate character, nor would it be something he had to constantly manage in the future.
Jerry did not consider himself an alcoholic but someone who had experienced a bout of alcoholism as one might experience a bout of the flu. Like a car coasting out of its lane, these participants described an awareness of addiction similar to drifting onto the warning track. After bumps and jostles, as Joe described in the encounter with his wife, he eventually straightened out and achieved equilibrium.
The drifting and realigning, as Rocky might predict, would all balance out in the end following the law of conservation. What seemed most harrowing about this narrative type was the struggle to maintain self-awareness of where one was on the continuum of illness and treatment. Self evaluation could be as difficult as driving in fog. I always felt out of place.
I always felt like I didn't fit into my skin. I was so afraid of people and of the world and I had horrible social anxiety and all I ever really wanted was to like, be a part of something, to have friends and to be comfortable with people, and I couldn't do it sober. And when I had my first drink it was like, Wow, this is what I've been looking for all of my life! She used alcohol as self-medication to regulate what seemed a more distressing disorder, social anxiety.
She felt more equal terms with others when intoxicated. This might be considered, for some, nothing more than a cultural ritual, and a positive one at that, but Julia goes on to discuss why, for her, it was a problem:. I remember that there was a line that I crossed where I suddenly realized that I had to keep drinking even when everybody else was done until I blacked out or passed out. But, I remember thinking to myself, I am only happy if I have a drink in my hand. For Julia, the warning track on the road was the line between being satisfied by the company of friends with whom she felt comfortable a feeling enabled by the substance and being satisfied by the comfort of the drink itself, with no regard for those in company.
As Joy deftly noted: Then, I don't feel so lonely, I don't feel so sad, I don't feel so bored, and I don't feel as hungry. For some addicted, there are no guardrails. This theme was typical of younger the twenty- and thirty-somethings polysubstance abusing men like Bill, a mid-thirties day laborer and smoker, whose story goes something like this:. I heard that you can't smoke like a pack the first time you smoke a cigarette, you know. But I smoked three packs the first night!
That is how much I loved it. And I never even coughed the first time I tried it. His use remained excessive thereafter, rarely if at all limited by his setting or circumstances. After his first use, addiction, for Bill, was a full acceleration and an insatiable appetite for the cigarette. And if I stay up all night I could smoke six or eight. Nora, a nursing assistant in her late fifties, discussed her view that she was predisposed to addiction from birth, perhaps genetically, and her pattern of indulging to excess was a personality characteristic.
I was an addict before I ever even had that first drink. And that first drink just sucked me in. I don't feel like I would have had the same unmanageability if I had never drank[sic], but I believe that I was an addict and an alcoholic waiting to happen I always wanted more of everything. Anything if it was like a food that I liked or whatever I want more than one I think it is part of my personality, but there was not a lot of progression for me. It was like once I discovered that I felt different when I drank or used drugs I wanted to feel that way all of the time.
But I was hooked on alcohol the minute I drank. It was always there. Users with this narrative described how, for them, quitting one substance could only be managed by starting another addictive substance. Physiologic withdrawal was a nearly universal experience for those describing this theme. They desired an external source of control while they regained trust in their own autonomy. It would be difficult to imagine people from this cohort would ever agree with Jerry, that addiction would resolve itself like a case of the flu.
These folks did not trust themselves anymore, and desired to check in to an in-patient treatment facility to receive the intensive care they felt they needed. The seemingly irreversible sabotage of the mind was a common theme in the Pedal to the Metal stories. It is as if they are being tricked by their own biology to get one more taste. We take one drink and that's all we want is more. It's a terrible disease, it really is. Matt, a custodian in his twenties in treatment for alcohol abuse, was having a hard time calling himself an alcoholic.
That stated, he observed that he could not seem to get himself to slow down when out at the bars with friends. Every time he drank, he drank to the point of black out, and yet he said:. I have more of a problem with it than I do an addiction I'm probably an alcoholic, but just as much a denier. So, my head is still having a very tough time talking myself into believing I'm an alcoholic I just don't think I was built to drink.
But yet, I would. You know, I would wake up and I would be hung over and miserable and puking and I would drink again. Then there are other people out there who get a little tipsy and they are like whoops, this is my drinking experience and stop right there! I don't know, that is just crazy to me that somebody can do that. My hat is off to them. Matt seemed to think the problem was just in his body's response to alcohol, that he was biologically less fit to tolerate the use. He acknowledged remorse after each binge, asking himself why he drank in the first place.
Yet, as though detached from conscious control, struggling for insight into the pattern and its consequences, Matt would find himself hung over and miserable morning after morning. If you have never tried [heroin] then don't because it is a very loving, encompassing drug that makes you feel that everything is okay for as long as it lasts. And then, of course, you are going to have the battle of getting more and then I had to work the job, to the get the money, to get more [drug], and then that cycle The cause is the cure and the cure is the cause. In Lily's case, and for others in Pedal to the Metal , their equilibrium was irreversibly reset, perhaps even obliterated, the moment they first tried the substance.
Their new equilibrium was not so much the oscillating dance to level a plateau, but the full throttle acceleration on an exponential curve to get more and more of the drug, chasing a failing high, never wanting to come down. Those with addiction more typical of Punctuated Equilibrium acknowledged a difference between themselves with and without the substance, and that the transition between states was reversible. Those with the Pedal to the Metal kind of addiction, on the other hand, could not re-identify with the person they were before the addiction.
Grady aptly described this transition. A child selling heroin on the streets, he tried his own product out of curiosity, and everything changed:. For me, I got addicted to it because I was selling it, you know I thought they was just partying, right, I didn't know that they was just coming sick everyday — coming to get it — I didn't know that. I tried to go without and I asked this older dude, I said, man, what is wrong with me?
Understanding Drug Use and Addiction
You know I was sick and didn't even know it. The rapid transition into a new biologic identity, a rewired brain, a new physiology dependent upon the merciful administration of a substance, was often a huge surprise, as Grady described. Everything comes down to those two things. And everything is secondary—way secondary, so For those with this tragic distillation of self, the language they used to describe their solitary obsession, their relationship with the substance and the powers it holds, shared vocabulary with magical fantasy and romance.
Mike spoke of his drug use as one would talk of romantic love:. It is your up, it is your down, I mean it is your happiness, it is your comforter, it is your sidekick, you know, it is I have always said that my three wives and other women I lived with for long periods of time and I didn't marry, but that they were really more my lovers and my using was what I was really married to. Similarly, John had a difficult time describing his love for alcohol and cigarettes, a love for which he felt he was predisposed. During the interview it was as if words were not powerful or poignant enough to convince the sober, presumably non-addicted interviewer of the character of his obsession:.
It affects me differently than people who don't have that predisposition, who just smoke socially, if you will, or drink socially. The first time I took a drink it was like the black and white world became Technicolor The first time I smoked a cigarette, I can act it out for you, but then you can't record that. It felt like this.
Demonstrates — sighs And I'm taking a deep breath and sinking into my chair like it was extremely relaxing. It relaxed my mind, my body, my breathing, everything. And that is what I was continuing to search for every time I smoked a cigarette after that. When addicts are broadly misconstrued as individuals devoid of control or agency, it is because of testimonies such as these. Such responses were a slim minority of our participant sample, so it is unfortunate that this theme has become something of a stereotype laid over all people who struggle with addiction. The Snowball Effect theme described addiction as a problem that gradually accrues over a prolonged period of time, often twenty years or more, until eventually the behavior gains momentum such that it is too difficult to stop.
A third of our respondents conveyed this theme, a cohort notably older than the other themes most aged mid 40s to 70 , and it was slightly more common in alcoholics, but not specific to gender or employment. In a way, this theme is something of a confluence of What's Normal? Isaac, a year-old business owner, described the slow progression of his alcoholism. It took me a long time to become an alcoholic. I had to work really, really hard at it I have been around people who drink, like all of my working life, and I can drink and not drink.
It was never a I mean I could drink on weekends and then not drink all week. I know where there would be consequences to drinking and not do it. I would never plan or necessarily look forward to it. And, I mean that was 25 years. I mean, and then all of a sudden it just run tough. At that point, you are making conscious choices to drink rather than do something else.
Or, plan to drink, start planning your activity around drinking, start planning your work day around drinking, start planning So, what I'm really saying is it is not like someone who takes their first crack and becomes instantly addicted. I mean there was obviously a I mean, there obviously becomes a psychological thing because you have been drunk over a period of time.
What happens to the brain when a person takes drugs?
You just regard it as an acceptable thing. You go to a ballgame, you have a few beers, you go to a barbecue, whatever; you have a few there. It is not like it is taboo thing. And it was never, actually, really a problem until I started working for myself. I mean it was like, shall I go to the liquor store now, or The Snowball Effect theme, hence the title, often included many different narratives of addiction experience.
Multiple constructs of self, various histories of use in different contexts, all rolled upon one another, generated something like momentum. The weight of all these stories and experiences over the years pulled the person toward more and more substance use. The hallmark of the Snowball Effect was the misassumption that after so many years of using without problems, addiction would never be an issue. The person was blind-sided with addiction. Over time, she started drinking earlier, and earlier. Then she was laid off:. I was so shocked that I ended up the way I ended up and I went downhill so quickly.
That is what kind of surprised me because I was the person in college who was pulling my friends out of bars or the designated driver. I mean, yes, we had a wine cellar, but was I drinking every day? Was I binge drinking? I guess my assumption was that since it was never a problem before it wouldn't become one. And then once I started drinking with regularity it became a problem pretty quickly.
I mean very quickly within a two-year span. And the last six months being really bad, meaning, I fell into an oven and those kinds of things. Those in the Snowball Effect theme tended to be highly cerebral and evaluative regarding their addiction. Their conversation yielded abundant debate on what addiction really is, with much questioning. When does one know if they are addicted? For example, Janet was inquisitive regarding the addiction status of her peers. She admitted that she drank alone, almost every day, and that was a problem.
You know, I look at these people who have been drinking for years and I go, okay, now what are they? I mean, they cannot be not an alcoholic, I wouldn't think. But I don't know. It is different for everybody I never really got totally drunk where I staggered and did all of this and blacked out. But I would be drinking all day—the slow drinking. You know, and not getting anything done. So I am an alcoholic. The Snowball Effect theme of addiction was laden with rationalization of why a substance was needed.
You know, if you are at work and you are having a bad day, you can't wait to get home and have a beer It starts out so simple and innocent and it gets into a great big mess! Of what use are accounts of illness such as these to those who care for the addicted? Narrative therapy explores how people give sense and meaning to their experiences by forming narratives Bruner ; Polkinghorne The goal of narrative therapy is to imagine, create, and promote the most positive, empowering conception of self Charon and Montello ; Ritchie, et al.
Alternative to the objective knowledge of addiction as a neurobiological disease Jellinek ; Volkow and Fowler or a rational product of the self-determining will Elster , narrative theories of illness offer a more subjective knowing. A myriad of factors influence this template, also known as a dominant narrative Payne ; White and Epston Summerson Carr's work, Scripting Addiction , explains this phenomenon in detail.
Patients may or may not find useful the particular dominant model of their treatment center. For example, when reliant upon the biological story of addiction, a treatment center may focus on a drug prescription for treatment, and underestimate the environmental and social circumstances involved. Or to the contrary, if focused inordinately on the psychosocial narrative, a treatment center may overwork to re-author a personal narrative or improve the quality of family dynamics as the solution for addictive behaviors, and possibly underestimate the extent to which the substance use has re-authored the physiology of the patient.
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Notably, some participants made use of biological understandings of self in their personal narratives, such as the easy assimilation of a genetic understanding of addiction in the What's Normal? One might expect to find themes clustering by the substance used or by the legal status of the drug. We expected the interview accounts to reflect those differences. That cigarette smokers would relate one experience, narcotic addicts another story, alcoholics yet a different narrative.
What was surprising was how the themes were not necessarily determined by substance. Some of our cigarette smokers had Pedal to the Metal themes to their addiction, and some heroin addicts had a Snowball Effect reaction to their drug. We are more unique than our DNA, more imprinted than the intaglio of our family crest, and more fickle than the times. The dynamism and fluidity of each person's self-narrative is not unlike the complexity of each person's genome.
An earlier era's view of the genome as fixed, unchanging, and immutable Keller is giving way to a more liquid understanding incorporating epigenetic phenomena. Our biology, psychology, society, environment, and circumstances are in a state of constant correction, in which, almost imperceptibly, addiction is simultaneously a cause and a result. People bear templates of DNA and experiences alike whereupon the epiphenomena of their unique biochemistries, cultures, and willful souls are entangled.
What might be of use for those working directly with addiction patients, in light of the mysterious and often unpredictable nature of nature, is adopting a perspective of negative capability as offered by the practice of narrative medicine. Negative capability is a state of mind in which an individual transcends the constraints of a closed intellectual system, such as a theory.
Narrative medicine is an emerging practice in the United States that uses literature and illness narratives as a touchstone upon which to build a moral imagination. Narrative medicine is a means to foster empathy as remedy for the counterproductive stigma that can burden the patient-provider relationship when together they face the challenges and frustrations of disease and illness.
Acknowledging the universal aspects of experiences like shame, anger, and grief narrows the gaps between self and other, patient and physician, patient and counselor, patient and family member in a relationship where both are able to empower one another in the process of recovery. Looking to our interviews for an example, grief was a common sentiment that emerged from the transcripts.
In the practice of narrative medicine, attuning to patient language is critical. For example, after listening to Nora's account of grief with quitting alcohol: The black wreath, a representation and externalization of the addiction suffered by the patient, can be examined as a subject that both patient and clinician recognize at the same time, as equals, as co-experiencers of grief.
Nora's image of the black wreath also evokes the loss of a friend, which should cause the listener to wonder in a state of negative capability about whom or what else Nora has loved and lost, and how other sources of grief may be entangled with Nora's emotional response to quitting alcohol. Michael Stein, an internist, recently authored a literary account of his clinical work with addicted patients, in which he weaves together representations of himself and his patients, melding his voice and theirs into one story with one common goal: In The Addict , Stein reflects on the unique stories of each of his patients, interspersing poignant self-reflection about his own biases and how, with humility, his struggle to attune to the needs of his patients continually challenges his understanding of the nature of addiction, as well as his understanding of his own role in offering care.
They teach us to suspend disbelief, to hold off the irritable reaching after fact; they discipline the listener, the reader, the witness, to honor the state of negative capability. Experiences are the human conduit for affiliation, and though in this paper the experiences as told by the addicted may seem disorderly or in disagreement with one another, perhaps this is an important aspect of addiction that should not be glossed over in favor of a unified framework. The diversity, then, of addiction narratives is now and always will be myriad and infinite, and the effort to understand them a noble foray into an ever deepening pool with the bottom always beyond reach—a problem that we believe is more awe-inspiringly Kantian than hopelessly Sisphyean.
While continuing to probe the intersubjective depths, attention to narratives can reduce stigma and promote affiliation between the provider and the patient while not delimiting the illness to a reductive explanation informed by a single scientific theory. Without patient voices directly represented in research Meisel and Karlawish , we may miss a relationship between the biological and social narratives of addiction that would better unite the efforts of all those who seek to care for those suffering the consequences of substance abuse.
The authors wish to thank the following for assistance with recruiting and interaction with participants, interviewing, coding, and analysis: This is an original manuscript; no part of this manuscript has been submitted or published elsewhere. Without help, that codependency follows the same downward trajectory of alcoholism.
There is hope, however, and there is help for the addict and for family members. The first step is to learn as much as you can about alcoholism and codependency. Many of the things people do to help an addict or alcoholic are counterproductive and actually can make things worse. Listen to the experience, strength, and hope of others in recovery.
Al-Anon Family Groups can help. There are meetings for friends, relatives and children of alcoholics. There is also Nar-Anon Family Group meetings for friends and relatives of drug addicts. Attend an Al-Anon or Nar-Anon meeting in your area or online.
Read and do the exercises in my book, Codependency for Dummies. There is no doubt that 12 Step programs have certainly reduced harm in our society over time, but there are alternatives.
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And I wonder if when we term dependencies as diseases we may in effect reduce hopefulness in sufferers because they are led to believe that they are inherently flawed, whereas other models recognize their potential and inner agencies. If, on the other hand we use a humanistic sociological paradigm, then we might alternatively frame the problem self-harm in context and in situ. Then we observe how, for example, emotional isolation, poverty, oppression, stress, toxic economic models, family dysfunction, unmet needs, etc, etc, all play critical roles in propagating self-soothing or coping mechanisms.
Harm reduction models are more elastic, less judgmental and actually seek to treat the antecedents of dependencies-the root causes. In that there is also the immensely hopeful power of community and relationships to facilitate an individual's wellness, but context is critical. Otherwise, social stressors may simply provoke the suffering once again. Healthful social networks which AA has been great for along with pro-social and progressive socio-economic systems need to work together to make dependencies unnecessary.
I don't disagree with you, but question your conclusion that the disease concept makes people feel "inherently flawed. A medical model is now widely accepted and often addiction is compared to a disease like diabetes, that needs treatment and is not a condemnation of the individual.
Harm reduction theory has been a helpful approach for some addicts, but not for all. It's certainly the approach for codependents, since slips are inevitable and also learning opportunities. It sure was a living hell for my Dad and I.
How to Be Human: Talking to People with Addiction or Substance Use Disorders
While the rest of the famly convinced themselves not to care, my Dad and I felt the weight of it. My older sister started drugs at 14 and never stopped. She's 26 now and really has very little to be happy about. My parents hated the drug use from the beginning but could not stop it.
My Dad feels his life is ruined but tries to go on. My sister works, but does nothing else. She wished she went to college but couldn't study. She used drugs every day. AlAnon helped my Dad. My Mom went 4 times and refused to go back. My siblings were effected by my sisters craziness. My sister never said drug use is a problem for her. In denial and never can get better. Darlene Lancer, JD, MFT, is a licensed marriage and family therapist and an expert and author on relationships and codependency.
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