Addiction and Psychotherapy
Dr Jonathan Haverkampf
An addiction means that there is a strong urge not to stop a certain behavior, even though it can lead to costs to one’s health and social relationships that outweigh the benefits in the long-run. Often an addiction is seen as medical condition which needs to be treated, without creating the motivation and future outlook in the patient to make an addiction no longer ‘necessary’. This requires looking at the patient’s values, interests and aspiration to develop a better future which can be a strong motivating factor to develop new behavior and communication patterns with the world.
Addiction consists of administering a substance or using a behavior that brings pleasure and reduces pain in the short run. Some examples for addictions are:
- computer games
- the internet
Some of these substances or behavior might even be necessary for survival and success in relationships or at the work place. In the case of an addiction they are, however, used in ways which lead to problems in the long-run. They no longer support communication with one’s environment or one’s values, interests and aspirations for the future. It is as if the past and th future have shrunk, and the present moment is the only time frame that counts.
A reluctance to talk about an addiction is one of the reasons why addictions often become chronic and cause significant individual hardship. One reason is that our society taught us not to show weaknesses, coupled with equating mental health problems and weakness.
The brain has a reward system that identifies behaviors and substances that feel good, and tries to get more of them. Biologically the reward system can be compromised and lead to wrong information. Reasons can be transcriptional and epigenetic, or exposure to addictive stimuli over an extended period of time. Addiction has been shown to be linked to the genetic overexpression of ΔfosB, a gene transcription factor, in the D1-type medium spiny neurons of the nucleus accumbens. ΔFosB expression in these neurons directly and positively regulates drug self-administration and reward sensitization through positive reinforcement, while decreasing sensitivity to aversion
Addiction means to compulsively activate rewarding stimuli, even though they have adverse consequences in the long-, or even the medium-run. The stimuli are all pleasurable and rewarding in the short term, while the costs will only be felt in the long-run. The negative consequences may even be suppressed for a while by using more of the drug or the behavior used to get immediate satisfaction. Once the behavior has been reinforced and rewarded by relieving negative feelings, stopping or pausing the behavior leads to withdrawal symptoms, which can be a more intense version of the suppressed negative feelings.
If a certain pattern has been learned, it takes our higher cognitive functions to tell us not to use a substance that might be harmful in the future, because only our higher brain functions let us plan for the future. Most animals which are provided with a drug will not stop consuming it. Only humans can do a cost/benefit analysis with respect to the future, and this is why it is of paramount importance in the treatment of addictions to help the patient engineer a sense of the future and to fill it with aspirations and goals that are true to his or her values and interests.
In order to establish a long-run change in the behavior it is important that the patient has a strong sense of a future without the substance worth living for. Often there is no longer a sense that acting according to one’s values and interests leads to a desirable future. This is often the case if someone does not have much confidence in an efficient communication with the environment.
Internal conflicts, and especially unmet wishes and needs, can maintain an addiction. The use of the addictive stimulus helps quench the unpleasant feelings that come with these unresolved conflicts. Such a conflict might be the experience of having one’s wishes and feelings not been noticed in the past and committing to a relationship in the present. Or conflicting emotions for oneself, such as the need for respect and admiration for oneself and anger at oneself. Here the root for the addiction is the inability to solve these conflicts in the normal way, by becoming aware of them and communicating them to others.
Apart from medication, which in the case of substance addiction aims either at providing a safer alternative or blocking the effect of the addictive substance, there are a number of behavioral approaches to deal with addictions. However, they usually address short run learning rather than changing how the patient deals with his or her future.
A fruitful first stage is to examine the communication and interaction environment of the patient. Patients with addictions are often individuals who could not express their feelings, needs, wants and aspirations openly or so no point in doing so. Often people suffering from addiction, especially if it is augmented by depression and anxiety, feel disconnected from their environment. This can lead them to withdraw rather than shape their environment. So in therapy it is important to show the client in the therapeutic relationship that changing one’s communication patterns with the environment can bring about real change. This can often be done by exploring held beliefs and helping the patient to subject them to rational thought and how he or she feels about them.
A next important step is examining basic values, interests and aspirations. Establishing greater clarity about one’s values provides direction, because doing things one believes are ‘valuable’ makes one feel better about oneself. In many cases this requires questioning unreflected thoughts and beliefs to look at one’s true values and interests underneath. Acting from one’s true values and interests can be a source of enormous happiness. Especially in the case of addictions, this not only reduces anxiety but also provides an attractive long-run alternative to the limited relief of the addictive substance or behavior. It also provides greater stability because one’s fundamental values are not going to change much over time.
Many people never identify their values. Often they are scared that they either might not find anything or something bad. About not finding anything I can say that if one really begins the exploratory process I have described elsewhere it is impossible not to find them. Everyone has them because they derive from the simple evolutionary concept that we strive for what is in our self-interest, and our self-interest and humanity as a whole are tightly connected. From my observations in forensic psychiatry I believe that a murderer, rapist or bank robber, who around the time of his or her crime was in full and true contact with his or her innermost values, does not exist. This is one reason why in fiction and films the villain always has a psychological dark spot and often an apparent physical deficit, such as missing a limb or an eye. The deficit or dark spot symbolizes the core deficit, the disconnection from one’s true values.
Addiction is not different. Dealing with negative feelings or tensions with a maladaptive behavior, such as gambling or taking drugs, means the compass that shows the direction towards one’s core values and happiness is not accessible. The addictive substance or behavior then provides short-term positive reinforcement. The time axis shrinks as the future becomes increasingly less important. Once the time frame becomes very small people can become suicidal or accidentally inject an overdose because the future is no longer of any relevance or consequence. To break out of this vicious cycle it is important to lengthen the time axis again. This can be done by exploring with the patient his or her fundamental values, interests and aspirations. There is a fear that this might make patients more depressed. However, while it may transitionally increase feelings like sadness, feeling oneself again provides greater stability and leads to an irreversible self-healing process.
Medication or substitution as a support should not be ruled out. Many patients see it as a way out rather than a new addiction, a point that should be emphasized.
© Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling; Dublin, Ireland
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.