Our concept of addiction is changing. Many people, driven by self concern and bombarded by the popular media, are beginning to regard an increasing number of their behaviors as addictions. Six months ago a patient who had been recovering from chemical dependence for quite some time came to my office for a therapy session. "I'm about to enter into a serious relationship with a woman," he said "and I'm paralyzed by fear. I want the relationship to work out, but it seems like I worry about it a lot. Am I developing another addiction: co-dependence?" His recovery was strong, but all the media hype about the pervasiveness of addiction turned his normal apprehension associated with this most human event, falling in love, into an overwhelming fear.
The concept of addiction has moved from the fringes of our society into the mainstream of our lives over the past twenty years. in the 1970s you would never hear the average American say, "I'm addicted to my morning coffee," or "I'm hooked on racquetball." To some degree this newfound awareness is healthy, fostering introspection and self evaluation. But, when so many addictive behaviors have become part of our daily vocabulary, what truly are obsessive, destructive addictions begin to take on an air of normalcy. I see an increasing number of addicts who resist treatment, maintaining that, "Everyone has one addiction, and this one is mine!"
How Did We Get Here?
Addiction is an evolving concept. As society validates each successive facet of addictive disease, it expands and deepens our understanding of the process of addiction. In this article we will review the growth of the addiction movement and extract the essence of each developmental change. If we add together each of these truths, we will arrive at a robust and profound awareness of what addictive disease is and what it is not.
Recovery, defined as the state of emerging growth away from addiction is rooted in a lay organization called Alcoholics Anonymous. Organized treatment for alcoholism began outside of the scientific community. In 1949, two brothers who were recovering from alcoholism, bought a piece of land in Minnesota that became the Hazelden Farm, and began drying out alcoholics. This farm grew into the Hazelden treatment center. In Georgia in the 1960s, a recovering physician, John Mooney, began bringing alcoholics into his home to treat them for what was thought of at the time as an untreatable disease: alcoholism. Over time, this home-based treatment program expanded into Willingway Hospital. Alcoholics Anonymous was the only focus of these early programs; these recovery-oriented treatment programs shied away from individual psychotherapy, couples therapy, insight-oriented psychotherapy. Patients were encouraged to become involved in the recovery movement, centered around Alcoholics Anonymous.
Most alcoholics who entered these programs had seen therapists or psychiatrists, or had sought spiritual counsel to stop their drinking. These alcoholics found that changing their mind about alcohol ("Maybe my alcohol use is the problem") never seemed to help them stop drinking. Alcoholics who had tried using psychotherapy to quit drinking learned that insight into their alcoholic behaviors ("I guess I do hide my problems with alcohol") often inflamed rather than cured their alcoholism. Alcoholics Anonymous taught them that the first step in recovery is to admit that they were defeated by alcohol and that no matter what problem they had, alcohol consumption would only make them worse.
Alcoholics Anonymous did not stop there, however. During the course of the illness, alcoholics commonly stop consuming alcohol for limited periods of time. Addiction is a disease whose symptoms wax and wane. The real problem is remaining off of alcohol, while at the same time finding significance and contentment in life. Before Alcoholics Anonymous the gnawing problem for most abstinent alcoholics was that their lives felt empty when alcohol was removed. The stories of the first alcoholics in A.A. demonstrated that, to truly recover from addiction, one must undergo a transformation. Transformations are the most complex type of change, a radical reorientation of what the person believes is real about his life. Alcoholics Anonymous and other early treatment programs had the aura of a religious sect; its devotees appearing to be "saved" from their alcoholism. This aura was the product of the transformations that most alcoholics must have in order to maintain their recovery.
In the 1970s, treatment centers began admitting drug dependent patients into their alcohol-only treatment programs, which sparked a hue and cry from the medical community. Many doctors feared that drug addicts and alcoholics suffered from such different illnesses that combined treatment would be impossible. What they found, however, were many similarities, and this combination quickly became the norm across all of the nation's treatment centers. Placing drug addicts in alcohol treatment programs showed that recovery was generalizable. Although the behavior of the alcoholic patient appeared different from that of the drug addict, the recovery process was remarkable similar.
In the 1980s more and more addiction treatment centers began addressing other addictions that were either underserved (such as gambling dependence) or treated with mixed results (such as eating disorders). This, too, was met with much resistance from the medical and treatment communities. Interestingly enough, the patients themselves seemed to understand the concept that alcoholism and other addictions seem to be related, not by the substance but by the behaviors and attitudes that typify all addictive diseases.
As we have gained more experience in treating patients with eating disorders and gambling dependence alongside those suffering from chemical dependence, we learned that addiction is an internal process that does not necessarily need a chemical agent to become active. A psychological process, eating, could become an addictive process, binging and purging, in a vulnerable individual. Treating patients with eating disorders by the addictive model focused our treatment efforts for all addictions inward, away from the substance and towards the thoughts, feelings, and actions that precede the compulsive consumption of alcohol, drugs, or food.
In the late 1980s, co-dependence was defined in addiction treatment programs as the illness affecting family members who live with chemically dependent individuals. For example, as an alcoholic becomes addicted to alcohol, his wife may develop co-dependence: losing track of her own needs to attend to the addict's chaotic life. Co-dependence quickly took on a broader meaning, describing the unhealthy behaviors of anyone caught in a self-abusive relationship with someone with an addictive personality. The co-dependent individual manifested all of the typical behaviors of any other addicted individual: obsession with the object of the addiction with a disregard to self, obsessive thoughts about the addiction with a narrowing of other life patterns and attempts to overcontrol their environment and those in it. However, co-dependence shed a new light on addictive disease: the co-dependent person is not addicted to a substance, but rather to a person. Co-dependence taught us that the addictive drive is an internal compulsive drive, one that need not be attached to a substance. In the case of the co-dependent, the addictive drive becomes attached to another human being.
The addictive drive may expand and generalize as well. Many addicted individuals whose primary addiction is co-dependence develop a secondary addiction to drugs, alcohol, or food. Both aspects that addictive disease, co-dependence and chemical dependence, continue without further contact with the relationship that initially triggered the primary addiction.
The co-dependence movement also taught us that childhood trauma is frequently central to addiction. Many addicts, recovering from all types of addictive diseases, describe their lives as being meaningless and hollow. Other addicts are unable to recover, returning to alcohol, drugs, bulimia, or co-dependent relationships again and again. Addicts, alcoholics, and patients with eating disorders have discovered the child within, a child that has often experienced the trauma of emotional, physical, or sexual abuse. The intensity of childhood trauma fuels the addictive process. Addicts respond to the ongoing pain of the past trauma by numbing it with alcohol, drugs, or food. Thus, the exposure and healing of childhood trauma is the key element in addiction recovery for such individuals.
In the past few years, the concept of sexual addiction expanded our understanding of the origins of the addictive disease once again. In 1983, with the publication of Out of the Shadows, Patrick Carnes, M.D., gave a name to the previously unspeakable difficulties of the sexual addict. Rather than viewing compulsive sexual behavior as the act of opportunistic pleasure seekers, Dr. Carnes described the internal lives of sexual addicts as secretive, shame-bound, and conflicted. Often abused themselves, sexual addicts began seeking a drug-like experience from their compulsive sexual rituals to hide from their own injury. The taboo nature of their acts produces secrecy, which in turn adds to the excitement and escape. The dynamics between the secrecy, excitement, and shame produces intense reinforcement and addiction in a susceptible individual. As the sexual addict attempts to control his behavior, he soon finds that it controls him; he becomes bound in an addiction of his own behavior.
The last frontier of addiction treatment has been a return to a substance dependence: nicotine addiction. Addiction to nicotine has been acknowledged as a problem for some time, but was not given importance by the medical community until the former Surgeon General, C. Everett Koop, M.D., declared in May 1988 that nicotine dependence was, indeed, an addictive illness.
Several recent studies describe the diversity of smokers who try to quit. One, appearing in The Journal of the American Medical Association, described a small percentage of smokers as having an entrenched illness that seemed to respond only to aggressive treatment. This group suffers from an addiction as florid and destructive as heroin or cocaine addiction. These deeply addicted smokers, even if they suffer from heart and lung disease, are unable to stop smoking on their own. They repeatedly fail to recover when treated in outpatient stop-smoking programs. It is time we recognize these individuals as needing the same kind of help that we give to alcoholics- that their disease is indistinguishable from the other types of addictive disease.
Society condones nicotine addiction. Most people would not shun the cigarette smoker with lung cancer, who is just as clearly dying of their addiction as the cocaine addict in a crack house. However, as cigarette consumption is banned in more and more places, individuals who are nicotine dependent find themselves going to greater lengths to smoke. The response to nicotine restrictions--guilt, apologies, and indignation--illuminate the intensity of their dependence on nicotine. The changing attitudes of society towards smoking reveal how nicotine dependence is only different when it is socially condoned.
What Has All This Taught Us About Addiction?
Each development in addiction treatment has expanded and deepened our understanding of addiction. Alcoholics Anonymous made clear that alcoholics must undergo a transformational change to recover; that attitude change or therapeutic insight was never enough to instill recovery. Drug addiction introduced the theory that addiction was generalizable beyond alcohol dependence. The treatment of eating disorders emphasized that addiction is a process within certain people, not an inherent property of certain substances. Co-dependence treatment focused on the process of developing addiction, an ever increasing series or compulsive behaviors and thought distortions that result in delusional reality; the addict rearranges his life to support his habit, and at the same time blocks himself from knowing that the habit has any importance at all. Co-dependence and eating disorders treatment pointed out that emotional, spiritual, physical, or sexual trauma establishes a breeding ground for all types of addictive illnesses. Sexual addiction treatment illustrated how addicts are bound tightly between the excitement and the shame created by their behavior, and that the interplay between shame and excitement implants the addictive drive in the susceptible individual.
To a large degree, this expanding view of addiction came from treatment providers breaking away from the mindset of conventional psychiatric care. Most early treatment programs involved few, if any, psychotherapists, psychologist, or social workers. In an effort to de-stigmatize addiction, many mental health professionals tried to place addiction outside the realm of other psychiatric diseases. Although I applaud their efforts to establish addiction as a primary disease, this approach has confused the public about the central role addiction plays in the psyche of the addict. Addiction is a primal drive that causes complex cognitive, behavioral, and dissociative defenses- just the stuff of a psychiatric disease.
Research about the genetics of addiction has been accumulating in parallel to the expansion of treatment. Like many other chronic diseases, the etiology of addiction is in part hereditary. Although every addict does not come from a family of addicts, many do. Addicts do not inherit addiction from their biological parents. Whether they actually become addicted depends on the complex interplay between the hereditary trait and their personality, family structure, and environment.
Through our observation of the treatment process, we have learned much about the nature of the addictive drive. Early in the history of addiction treatment, therapists noted the phenomenon of cross-addiction. Alcoholics who discontinue drinking may become dependent on pills or other drugs and vice versa. When we placed eating disorders, gambling, sexual, and nicotine addicts together, we noted a natural extension of cross- addiction- that many addicts, if left unchecked, will become cross-addicted to other addictive behaviors once his or her primary addiction has been interrupted. Addicts become increasingly anxious when the therapist or treatment team gets close to closing the door on their last addictive behavior. We believe that shutting that last door is very important, that as the last door closes, the addict instinctively moves through a previously unseen portal into the true transformational experience called recovery.
We see treatment as a golden opportunity to interrupt a patient's addictive drives so that his/her true self can emerge. In this time of increasing concern over health care dollars, it makes fiscal as well as psychological sense to use available treatment dollars to their fullest- to interrupt all of a patient's addictives behaviors. Some experts in the addiction field believe it is not right to take away all of the addict's addictive behaviors at once. They believe that this leads to relapse. Our experience has been just the opposite. For example, when a cocaine addict stops smoking, he comprehends that nicotine cravings are similar to cocaine cravings, and by managing the craving for one of these substances, he teaches himself a valuable lesson in craving management for the other drug.
Sensationalist stories and television shows about addiction become less overwhelming the more we understand the true nature of addiction. Some people, try as they might, will never develop an addiction. Such individuals do not have the genetic tendency, the family shame, or the environmental history that induces addiction. Other will become addicted to an ever-expanding array of substances and behaviors until they learn to remain addiction-free through treatment and recovery programs. When the media glamorizes the "latest" addictive process, it turns our attention away from the true nature of addiction. We may find it more helpful to remember that addiction is a powerful drive that, once present in an individual, can manifest itself in many different ways. The "newest addiction" becomes nothing more than another facet of addiction.
My recovering patient, the one who was falling in love, did have the potential to develop a co-dependent relationship. I was careful to examine his motives, and the direction of his current relationship. Was he able to balance his own life while working on this relationship? Was his girlfriend involved in an addictive illness, one that my patient could "rescue" her from? Upon close examination, it became clear that my recovering addict was simply in love, and involved in a healthy, happy relationship. I allayed his fears, and encouraged a continued balance in his life and love affairs.
As we get closer to understanding the true nature of the disease of addiction and the best methods of treatment, we will view addiction as a multi-determined disease that manifests itself in multiple ways. Recovery is a complex but life-enhancing process. Media coverage and the increasing public attention should never trivialize addiction or its recovery, but simply underscore the importance of recovery.
This article originally appeared in Insite Magazine from Ridgeview Institute, 12:3, Winter 1992.
 Neill, J.R. (1991). 'Addiction' phenomenon. Southern Medical Journal, 84(8), 1003-1006.
 Goodwin, D.W. (1991). Impatient treatment of alcoholism- new life for the Minneapolis plan. New England Journal of Medicine, 325(11), 804-806.
 Cross, G., Morgan, C., Mooney, A., Martin, C., and Rafter, J. (1990). Alcoholism treatment: A ten-year follow-up study. Alcoholism: Clinical and Experimental Research. 14(2): 169-73.
 Berenson, D. (1987). Alcoholics anonymous: from surrender to transformation. The Family Therapy Networker, Vol. 11(4): 25-31.
 Earley, P.H. (1991). The Cocaine Recovery Book and The Cocaine Recovery Workbook. Newbury Park, CA: Sage Publications.
 Carnes, P. (1983). Out of the Shadows: Understanding Sexual Addiction. Minneapolis: CompCare Publications.
 Koop, C.E. (1988). The Health Consequence of Smoking: Nicotine Addiction. U.S. Dept. of Health and Human Services, Annual Report, Office on Smoking and Health Publication DHHS #88-8406.
 Fiorere, M.C., Novotny, T.E., Pierce, J.P., et al. (1990). Methods used to quit smoking in the United States: do cessation programs help? Journal of the American Medical Association. 263(20): 2760-2765.
 Slade, John. (1991). Is nicotine more addictive then cocaine? British Journal of Addiction. May, 1986; (5): 565-569.
 Goodwin, D.W., et al. (1973). Alcohol problems in adoptees raised apart from alcoholic biological parents. Archives of General Psychiatry, 28: 238-243.
 Goodwin, D.W. (1986). Genetic factors in the development of alcoholism. Psychiatric Clinics of North America. Sept; 9 (3): 427-433.