Addiction is a condition that results when a person ingests a substance (e.g., alcohol, cocaine, nicotine) or engages in an activity (e.g., gambling, sex, shopping) that can be pleasurable but the continued use/act of which becomes compulsive and interferes with ordinary life responsibilities, such as work, relationships, or health. Users may not be aware that their behavior is out of control and causing problems for themselves and others. Let's see how understanding the critical role of context and expectation in addictions makes them easier to treat.
"Over the wine-dark sea they called. Horribly irresistible; monstrously attractive. A spinning vortex of mounting want. 'I must have them!'" —The Odyssey, Homer In his epic poem, Homer describes the enchanting and seductive song the Sirens sang to lure passing sailors to their doom. Mesmerised sailors would steer toward the rocks of the Sirens' island, only to hit them and sink. Odysseus knew the dangers, but so eager was he to hear the Sirens' song that he had the other sailors tie him to the mast. All the other sailors plugged their ears with beeswax, and so they passed by safely. But the song is still with us. Maybe you can hear it sometimes in one form or another. For example:
A billion people around the world smoke
240 million people are addicted to alcohol to the extent they feel dependent on it
Around 15 million people self-inject addictive drugs such as heroin regularly
These are just some of the addictions we know about. These people are recognized as addicts. Prescription painkiller addiction is a deadly epidemic accounting for many deaths. And blurry definitions abound as far as porn, gambling, and eating disorders go. Are these also addictions? Well, they do share common elements, and they can certainly feel like addictions to those who suffer from them. The Siren of tobacco is set to kill one billion people by the end of the 21st century. One billion souls lured to their doom, smashed and torn apart by a call that seemed impossible to resist. But are we doomed? Or is there something we can do about it? To begin with, let's talk about how expectations can drive 'addiction’. The vital role of expectation in addiction A thought experiment: You smoke 30 cigarettes a day and are racing towards those fatal jagged rocks. Someone in a white coat tells you there is little you can do because you have a physical disease. No, not cancer or emphysema – not yet – but the disease of addiction. Does that help you expect to be able to walk away from smoking? Or does it make you feel powerless in the grip of a chemically disordered brain? Actually, the disease metaphor (taken literally by millions) is more often applied to alcohol and heroin addiction. If people feel they were born to be an addict, they probably expect to die one. Beliefs shape expectations, and expectations often shape behavior. If you give someone with Parkinson's disease a placebo medication that they believe will reduce their symptoms, in many cases they will actually shake less. Expectations are powerful and psychological. And all addictions work through expectation. So, is it possible that addictions could be powerful, yes, but not physically driven? Might they be more to do with psychological association than predetermined genetics? The accidental experiment that shows how psychological addiction can be Some smokers are wedded to the idea that smoking is physically addictive. When a smoker – or an alcoholic, a heroin addict, or any other addict for that matter – is told they have a disease and always will have, their expectations are shaped for them. They believe their addiction is incurable, partly because they have been told that, partly because it's easier to believe that than it is to actually stop, and partly – maybe mainly – because it feels like such a powerful urge. Well... some of the time. If we pay close enough attention, we find that context is really important. Even a 40-a-day smoker won't have the urge to smoke when they're sitting in a movie theatre – because they don't have an association between smoking and movie theatres. I met a heavy gambler who told me he didn't feel the urge to gamble even for a second when he drove a school coach on a vacation for a couple of weeks. Why? Part of the reason was that he felt needed: his emotional needs were met. But perhaps even more importantly, the context was so unfamiliar that the gambling pattern had nothing to latch onto, even when he was in towns with casinos. But these are just anecdotal reports. To challenge assumptions about addiction as a disease (regardless of context) we need results on a much greater scale. And in 1971, that's exactly what we got. How context can drive addictive behavior During the Vietnam War it was found that 19% of US servicemen had developed a heroin addiction. When the war ended, America was faced with accepting many thousands of seriously addicted US soldiers back into society. Nixon's government didn't know what to expect. Would there be hundreds of thousands of heroin junkies on the streets? The government wasn't willing to take the risk. And so a multimillion-dollar task force was created to track the lives of the returning servicemen. These men were seriously addicted; surely just returning from war wouldn't make them 'unaddicted’. But what happened flew in the face of popular and even scientific opinion. A staggering 95% of the heavily addicted soldiers just stopped when they returned home again. No withdrawal. No relapse. And of the 5% who did remain addicted, most lived in poorer neighborhoods, with a poor family support network and no jobs to go back to. These results make it pretty hard to discount life context as a driver of addiction. In fact, it seems that even with heroin – considered one of the most addictive drugs in the world – the psychological addiction (which does have a physical effect) is more powerful than the old reductionist idea of addiction as physical disease. The destructive role of dogmatic belief In order to be prepared to sacrifice yourself, or even injure yourself, you need to have swallowed some beliefs. Suicide bombers – they don't not believe in anything. They don't not believe in some cause. They have a set of beliefs, which are propelling them to act in these destructive ways. Japanese kamikaze pilots in World War Two believed their death would repay the debt they owed to their families and their emperor. Other people have been convinced that in giving up their lives they will be granted virgins in paradise. Or whatever. The point is, in order to be prepared to throw your life away you need to have swallowed some beliefs, some dogma that squares it in some way in your mind. Often those beliefs will sit in your unconscious mind and determine your behaviour. But those beliefs will be there somewhere, and that seems to make it okay on one level. Addressing erroneous beliefs So this one billion people prepared to lay down their lives potentially for the cause of the tobacco industry profits – what beliefs have they swallowed? We need to address these beliefs. Some people have swallowed them more than others. There are the standard smoking beliefs, like smoking gives you a more interesting persona, it's cool, it's more bohemian or whatever. That's generally an adolescent belief but it can stick around in the back of someone's psyche even as they get older. Sometimes they'll reluctantly admit that they still feel that smokers are somehow more exciting or more interesting, in a counter-culture, than non-smokers. Even though they're contributing to this culture of big business. Another belief may be a form of denial that it's not smoking that's rotting their lungs. I've had clients with grey sagging skin coughing their guts up and looking twice their age swear blind that the smoking is playing no part in their health. Other beliefs include that they could get run over by a bus tomorrow, so why not smoke? You've got to die of something. But around 1 in 20,000 people get run over by a bus and killed, whereas 1 in 2 smokers who smoke 20 a day are killed by the smoking. So that belief is erroneous. It doesn't hold water. Another belief is that smoking is needed to give you something to do with your hands, as if when we evolved as primates we needed something to do with our hands and tool-making wasn't enough, so we needed to invent the cigarette. These are hands that rely on the bloodstream to keep them active: the very blood flow the smoking is weakening. Another belief is that smoking relaxes them, which as a stimulant isn't really a belief that stands up either. And, as evidence seems to be pointing toward now, smoking is also implicated in poorer mental health, indicating that smoking isn't as good for the welfare of the mind as some smokers have been led to believe. Yet another belief, is that smoking is highly physically addictive. But, smokers contradict this belief by their own experience. They might sleep many hours without being woken up by the need to smoke. Search for the exceptions It's always important to ask for exception times. When don't you feel the need to smoke? One guy who smoked 60 a day said that he went to visit his brother in hospital; his brother was dying. He'd sit with his brother for hours and hours. Because you weren't allowed to smoke, and it wasn't appropriate to smoke in front of his brother, he wouldn't even think about it. Where had the physical addiction gone? Or a person might get on a long-haul, 12-hour flight. Because they don't have the psychological association with smoking on an aeroplane, the need doesn't really arise until they get to a smoking lounge, or they get to their destination. Or they might go to a cinema, and because the smoking association isn't there, they only feel a need to smoke when leave the theater after the movie. That contradicts the belief of physical addiction and shows how much of so-called physical addictions are really just learned associations. The effect of learned associations And this brings us to Pavlov's dogs, who were trained to salivate when they heard bells. At first they were fed every time they heard a bell. And eventually they weren't fed, but they still salivated on hearing a bell. There's no natural association between getting ready to eat and hearing a bell. But it had been 'learned' into them. So they had a physical response, but it was really through a psychological avenue, if you like. I will often say to a smoker, as a way of pre-empting the physical addiction belief, what if I were crazy enough to click my fingers a thousand times a day for twenty years every time I had a cup of coffee, every time I took a break at work, every time I met up with certain friends, every time after a meal? If I clicked my fingers at these times, pretty soon I would feel there was some kind of natural association between drinking coffee and finger clicking or standing outside in the rain at work and clicking my fingers. What's more, it might feel odd to stop clicking my fingers, as if it was some kind of physical need rather than just a learned bunch of associations and psychological expectancies. Challenge those beliefs We have to be very careful not to necessarily buy into the very beliefs that are enabling people to be prepared on some level to lay down their lives for this particular cause. Nicotine leaves the body fast. In around 24 hours you are starting to get clean of it on a chemical level. After that, all you have is association, which is a psychological expectation, not a physical need. I frame the promptings of the habitual smoking expectancies as the ex-partner calling you up and trying to manipulate you back. I don't suggest to a smoker that they'll leave here today and they'll forget about it entirely and they won't have any promptings. But I'll externalise those promptings. I won't use the metaphor of physical addiction, your body trying to trip you up. It's from outside of them. Just like an ex-abusive partner who used to steal your money, and your self-esteem, and your health, and so forth. You were a good deal for that person. They got a lot from you, and of course they're going to ring you up. Of course they're going to try and get you back. Maybe when you're bored one night, or maybe you're a bit lonely or a bit tired, or a bit drunk, they'll call you up and try and convince you. But what you'll find is that when they do that, then their voice is going to seem very weak and the more you refuse and the more you stand up to that, the weaker they're going to become, and they're going to go find someone else to manipulate, to bully, and to manhandle. Sometimes I'll reframe the idea of withdrawal as indicators of healing, but mainly I'll keep to the idea of a con man or a con woman trying to get you back because you are a good deal for it. It gets your health, money, looks, youth, and years off the end of your life. This kind of talk is aimed at preparing people for urges by externalising them and negating the need for the physical addiction idea, which is a belief of helplessness in a sense. "I'm in the thrall of my physical addiction. I'm helpless to it." So I think we need to be very careful about buying into that idea as much as some people have.