Wednesday, March 12, 2008

Drug Addiction and Dissociation

Where does the “self” go during active addiction?

Where does the everyday self go during active cycles of addiction? Addiction sometimes seems to resemble a waking trance, or autohypnosis. Psychologically, it is akin to a state of dissociation. The sense of self becomes impaired through the processes of intoxication, denial, neuroadaption, withdrawal, and craving. This impaired sense of self causes behavior that is baldly contradictory to the addict's core beliefs and values. Honest men and women will lie and steal in order to get drugs.

Webster’s Unabridged Dictionary defines dissociation, rather vaguely, as “the splitting off of certain mental processes from the main body of consciousness, with varying degrees of autonomy resulting.” How autonomous were you, consciousness-wise, the last time you got drunk and parked your car somewhere you couldn’t remember?

Dissociation may be part of the way consciousness itself adapts to chronic drug use. Richard S. Sandor, a thoughtful Los Angeles physician, helped to clarify many of these issues in an excellent essay some years ago in Parabola Magazine.

Sandor compares the addictive state to a form of hypnosis accompanied by posthypnotic amnesia. This automatism, this subsequent amnesia about the drugged “I” on the part of the sober “I,” is highly reminiscent of the consequences produced by state-dependent memory:

"A hypnotized subject is instructed to imagine that helium-filled balloons are tied to his wrist; slowly the wrist lifts off the arm of the chair. The subject smiles and says, ‘It’s doing it by itself!’ The ‘I’ that lifts the arm is unrecognized (not remembered) by the ‘I’ that imagines the balloons.... One part denies knowledge of what another part does. A cocaine addict, abstinent for a year, sees a small pile of spilled baking soda on a bathroom counter and experiences an overwhelming desire to use the drug again. Who wishes to get high? Who does not?"

“Interestingly,” Sandor says, “this type of amnesia is very similar to that seen in the multiple personality disorder (see Jekyll and Hyde), in which one entire ‘personality’ seems to be unaware of the existence of another. Even more interesting is the fact that confabulation, rationalization, and outright denial are also prominent features of the addictive disorders.” Dissociation, then, can occur without the intervention of anything as dramatic as hypnosis. The common quality is automaticity, the experience of “it doing it by itself.”

Sandor points to the inability of prevailing behavioral models to produce a comprehensive framework for effective addiction treatment. “None of the current treatment methods based upon the positivist scientific paradigm—be it psychodynamics (Freud, et al.) or behavioral (Pavlov, Watson, Skinner)—has demonstrated any particular superiority in the treatment of the ‘addictive disorders,’” he writes. “Many psychoanalysts readily admit the uselessness of that method for treating addicted individuals (the patient is regarded as being ‘unanalyzable’).”

In addition, says Sandor, “It appears that the most successful means of overcoming serious physical addiction is abstinence—very often supported by participation in one of the twelve-step groups based on the Alcoholics Anonymous model.... The basis of recovery from addiction in these nonprofessional programs is unashamedly spiritual.”

All addictions, Sandor argues, more closely resemble “the whole host of automatisms that we accept as an entirely normal aspect of human behavior than to some monstrous and inexplicable aberration.” Bicycle riding is a good example of an automatism, because once learned, “…it no longer requires the subjective effort of attention; more importantly, once learned, it cannot be forgotten. It is as though the organism says to itself, ‘Riding this thing could be dangerous! It’s much too important to trust that Sandor will pay close attention to it.’”

So what does the mind do? It creates a new state called bicycle riding:

"Number one priority in this state (after breathing and a few other things, of course) will be maintaining balance. In much the same way, the organism recognizes that mind- and mood-altering chemicals disturb the equilibrium of functions and are therefore potentially dangerous. In response, it may form a new state in which the ability to function is restored, but in which a new set of priorities exerts an automatic influence. Just as one’s only hope of not riding the bicycle again (if for some reason that is important) is to never again get on one, once a particular addictive state has developed, there is no longer any such things as “one” (drink, hit, fix, roll, etc.). Addicts begin again when they forget this fact (if indeed they have ever learned it) and/or when they become unable to accept the suffering that life brings and choose to escape it without delay. Addictions can be transcended--not eliminated."

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.


Anonymous said...

Addiction to hard drugs need in house rehab. There are numerous centers out there, how does one find a reliable center? Here are some of the questions to ask before choosing one.

Do not fall for the pressure tactic like "there is one last place available" or "no opening for for 1week" but when you say you decided to choose that institution, miraculously a vacancy appears!.

Ask all the questions before making your decision. Be weary of institutions which have a “no refund” policy. Because there are plenty of others who will refund prorate, a better choice. Some institutions will let you pay month by month, sort of a 'pay as you go'. This way you do not have to pay a large lump sum and your money is safe.

Ask about the consequences if the client breaches one of their ‘policies’. If they say that they will be thrown out automatically, steer clear of this one. Drug abusers need help because they make mistakes. If they are thrown out because they made one, they are not being helped in their recovery. And if they keep the balance of the money, a princely sum of $15,000 to $30,000 it is obvious that these people are not in it to care for their clients. Their main interest is the bottom line.

Also find out if they provide regular feed back on the client’s progress. Without that, you might get a call one day like I did, saying, “I have bad news for you, your son was dropped off at the airport because he violated one of our policies”. That was the only call I got in 5 weeks!

Is the program medically based? This is important because a staff that is not knowledgeable can create a life and death situation as this incident illustrates: A client was placed in a room with fluorescent lights. The man had a history of epilepsy and he promptly had seizures. Fortunately for him, his neighbors heard some strange noise and came to his aid.

Finally, think twice about choosing a foreign country, even if it is Canada. People with drug / alcohol dependency are already irritable and / or depressed, the last thing they need is to have

Anonymous said...

Then there is the reality of substance abuse treatment.

Refunds are not possible most of the time and even if they were- I would oppose that concept. Addiction treatment centers can be of great help, but they do not take the responsibility off of the addict for their recovery. A refund policy implies otherwise and should be avoided for that reason. You cannot assume that someone will simply recover because they have gone to a treatment center. It doesn't work like that- at all.

It is a necessity that clients follow the policies- not a preference. The alternative is for no center to exist. Though I agree they should be given more than one chance to do this- these chances must be limited in most cases simply due to the practical needs of the center to function and the other clients to be in a safe place. There are many people who will consistently disregard policy and this is not always a result of their addiction. This is sometimes a result of behavioral problems and sometimes a simple lack of personal responsibility. These people often need to be referred to an institution or they can jeopardize all of the other clients. Sometimes they just need to learn that the policies are not suggestions but actually rules. It is not typical for someone to be kicked out for violating policy once although this happens occasionally, I'm sure.

As far as feedback- this is constrained for numerous reasons. Basic confidentiality laws limit feedback in many cases. If there is a release, there may be still more limitations. In some cases, talking to friends and family is not the best thing for the client. In other cases, the client themselves do not wish for feedback to be given regarding their treatment and this should be respected.

There are many options for paying and I do agree that paying as you go is a good idea. And medical safety is paramount.

As far as pressure tactics- it seems that you be unaware of how little treatment is available compared to how many actually need it. You can probably expect this trend to continue. Treatment centers are not always lying when they say they are full. Like psychiatric wards, it is getting more and more apparent that the need outweighs the resources in this area unless you have good amounts of money to spend.

Finally, I would not encourage people to be picky about their treatment. This only gives the addict another reason to avoid it -often they do not actually want treatment but desperately need it. Substance abuse treatment is almost never ideal unless, again, you have a good amount of money to spend. For the vast majority of addicted people who have little to no money, there needs to be an expectation that one will not be happy at first. This is because withdrawal is rarely pleasant. Therefore, the clients may not like the staff, may not like the policies and may come quickly to the conclusion that the center wants only to make money and does not care. I have seen even the most impoverished of publicly funded centers being accused of being 'just out for a buck.' This kind of thing is typical because when someone is in withdrawal, they are not happy. Furthermore, loved ones of the addict are equally unhappy because they do not understand the reality of substance abuse treatment.

The reality is that the centers often have to play the role of the bad guy and challenge the behaviors of the addict. The addict needs to reach an understanding of personal responsibility to stay clean- plain and simple.

It is already difficult to keep treatment centers staffed and in the end this most negatively affects the people who need treatment. This is it is important to be realistic about treatment centers and be aware of personal responsibility. I suggest you think long and hard about suggesting that people expect a refund if their loved ones fail to maintain sobriety. If you believe that, you have much to learn about recovery.

Anonymous said...

Richard S. Sandors new book "Thinking simply about addiction" is great!

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