Stereotypes? Yes. Deliberately provocative extreme examples, setting up Aunt Sallies in order to knock them down? Yes. None the less, sufficiently familiar to make us uncomfortable. But what is the reality?
One in five of all hospital beds in the UK are occupied by people with alcohol-related conditions. One in two people attending accident and emergency departments are there as a result of something to do with alcohol or drugs. The police and the Samaritans estimate that alcohol is the major scourge of our social fabric, although drugs are now progressively taking over that unenviable position. Each day in the UK one person dies of Aids, five people die of the effects of illegal drugs, 100 people die of the effects of alcohol and 300 die of the effects of nicotine. Yet expenditure on obvious clinical disasters, like Aids and Creutzfeldt-Jakob Disease, is vast, while a frequently unrecognised killer in our midst, addiction, is largely ignored, misunderstood and even, to some extent, encouraged. The production, distribution and supply of mood-altering substances of one kind or another are among our major industries. Then, there's the National Lottery.
To many people mood-altering seems like a very sensible way of dealing with difficulties: when things have been hard at work, a glass of wine when you get home can make the world seem a lot less bleak. Indeed, cheering ourselves up - be it with a drink, a flutter, a bar of chocolate, a new dress or making love - is as natural as breathing. Stepping aside from our problems is often the sensible thing to do: that way we gain some perspective and things don't seem so bad. The problem arises, however, when we do this perpetually and when damaging situations and attitudes are never looked at or changed. We may say to ourselves that we will sort ourselves out some other time, when we are less busy and pre-occupied, when the weather changes in the spring, when we get the promotion we hoped for, when grandma dies and leaves us the inheritance. But for some of us, that time never comes. Avoidance of emotional pain can become a habit.
In some families we see specific patterns of behaviour designed to avoid emotional pain. Some will be highly analytical in their approach to life, always using intellectual approaches rather than acknowledging that feelings have a place in making decisions. Others will try to work everything out through physical exercise, total commitment to professional work or voluntary causes, a passion- ate belief in health foods or pre-occupation with food allergies; all this in the pursuit of "health" while disregarding that the process of any pre-occupation is decidedly unhealthy.
Each and every one of us has a natural tendency towards doing nothing: solving problems requires effort, and we would rather avoid having problems in the first place. We wish that they would simply go away. Failing that, we do something or take something "in order to take the edge off things". As the American psychologist and bestselling author, M Scott Peck says, in the opening sentence of The Road Less Travelled (Century, pounds 5.99), "Life is difficult." But some people fall into patterns of behaviour, whereby problems are never addressed, and the avoidance itself eventually becomes the problem. Sometimes this behaviour is by choice, sometimes it is to do with psychological or psychiatric problems and sometimes it is due to the development of addiction.
Part of the difficulty in identifying this pattern in ourselves is that the basic psychopathology of addiction is denial: the psychological state in which the sufferer simply does not (cannot) see that he or she has a problem. As a GP, I see denial to a small degree in many clinical conditions: human beings have a natural reluctance to face reality. In addicts, however, denial is the dominant and universal feature. Thus, the sufferers themselves are the last people to recognise that they have problems. They do not learn from experience as others do. They cannot escape from their inner emptiness simply by growing older and wiser and learning the error of their ways. Nor can they be helped by loving families, supportive friends, healthy pursuits or new insights into their childhood development. They do not see that they have a problem in the first place: they see everyone else as having problems, particularly those other people who persist in interfering in a person's right to do as he or she pleases.
There is considerable epidemiological and, more recently, genetic evidence that addictive disease runs in families. The form the addiction takes may be different among family members, and from one generation to the next. That is partly because of prevailing, culturally acceptable behaviours, but also because there are so many things and processes people can become addicted to. Here is an incomplete list: alcohol, nicotine, caffeine, recreational drugs, mood-altering prescription drugs, sugar, bingeing or starving, exercise, shopping or spending or stealing, work, gambling, using sex purely to alter one's mood rather than as a mutually enhancing process, addictive relationships in which one uses the other person as a drug, or compulsive helping in which one uses oneself as a drug for other people. Not all members of the family will necessarily inherit the predisposition to addiction, just as not all children of sufferers from diabetes or heart disease will necessarily develop those conditions, even though they too run in families. None the less there is increasing evidence that addictive tendencies (which I define as the inability to predict or control further use after first use of a mood-altering substance or process in any day, ie, one drink leads to another) may be genetically inherited and, therefore, reasonably seen as a "disease" rather than simply a depravity.
This clearly has disturbing implications and, unsurprisingly, the concept is often vehemently resisted, particularly on the grounds that saying they are suffering from a "disease" lets addicts off the hook for their behaviour. It does nothing of the kind: it simply explains the extraordinarily self-destructive nature of their condition. (Why is it that the alcoholic who has lost everything will promptly go to the pub for comfort?) They should none the less still be held responsible for their behaviour towards other people.
Environmental factors in childhood certainly play a part in the development of addictive behaviours, but they appear to be a necessary and not a sufficient condition. Thus, women suffering from bulimia have a very high incidence of sexual abuse in early childhood and this is often used to "explain" the bulimia. Yet significant numbers of young girls who have been sexually abused never develop bulimia or any other form of addictive behaviour. (And not all bulimics have been abused in this way.) It would therefore appear that the development of an overt addiction requires a three-stage process: i) genetic predisposition; ii) the emotional trauma that stimulates it; iii) the environmental discovery of a mood-altering substance or process that "works" for that individual.
Research that we have carried out at the Promis Recovery Centre, a treatment centre that deals with all forms of addiction, on 1,400 in-patients over the past 10 years shows that addiction very rarely has only one outlet. Addictive behaviour commonly comes in clusters characterised by a particular emotional pattern. There is what I term "hedonistic" use, which covers recreational drugs, prescription drugs, nicotine, caffeine, gambling, sex. There is "self-nurturing" use: food bingeing or starving, work, shopping, spending and exercise. (Interestingly, alcohol is commonly associated with either hedonistic or nurturant tendencies, which is not altogether surprising as it acts both as a stimulant and as a depressant.) The third common outlet for the "addictive" nature is compulsive helping. The central statement of hedonistic or nurturant tendencies is "I need you to fix me", whereas the equivalent for compulsive helpers is "I need you to need me". Clearly these two statements are a "perfect fit" for each other, and compulsive helpers often make relationships with other addicts.
These findings were based on my own questionnaires in How to Identify Addictive Behaviour (Promis Books 1988). The questions, covering 16 distinct potential addictive behavioural outlets, are designed to establish the presence or absence of eight characteristics common to any addictive substance use or behaviour. Rather than simply asking, for example, how much someone drinks, the questions look at the internal thought processes (not the external social rationalisations) of why he or she drinks. The eight primary addictive characteristics are: 1) Pre-occupation with use or non-use of the addictive substance; 2) Preference for, or contentment with using alone; 3) Use as a "medicine", to help relax, sedate or stimulate; 4) Use primarily for its mood-altering effect; 5) Protection of "supply", preferring to spend time, energy or money in this way; 6) Repeatedly using more than planned, in that the first use in any day tends to trigger the next; 7) Having a higher capacity than other people for using the substance or process without obvious initial damaging effects, although in time this "tolerance" is lost; 8) Continuing to use despite progressively damaging consequences.
People who have significant addictive tendencies will usually have at least four of these characteristics with respect to one or another addictive substance, behaviour or relationship. Those requiring in-patient treatment will usually have five or six of these characteristics in three, four, or even more addictive outlets. Thus addictive disease varies in intensity from one individual to another, just as many other genetically based conditions (such as short sight) vary in intensity. The Promis questionnaires are therefore used not only for diagnosis but also to determine the intensity and length of treatment. Furthermore, they also demonstrate that the vast majority of the population have no addictive tendency, irrespective of the universal capacity to be foolish.
The analogy with short sight is useful when it comes to treatment: there may be nothing one can do about having the condition but there is a great deal that can be done day-to-day which takes into account this predisposition so that it no longer disrupts one's life. The first essential in the treatment we offer at Promis is abstinence. There is no point in trying to reason with someone who is drunk, nor with trying to get someone on Methadone maintenance (or for that matter someone on regular prescriptions for tranquillisers or anti-depressants) to express subtleties of feeling. Fortunately, getting off addictive substances or behaviour is generally the most straightforward part of treatment: staying off is the difficult bit. The two exceptions are tranquilliser addiction and anorexia. People who have tried to give up smoking know that nicotine chewing gum or patches may become simply alternative addictions. None the less, it is perfectly possible simply to stop smoking one day and endure the decreasing physical withdrawal symptoms over the next five days. The emotional emptiness and vulnerability that follow putting down the "drug" then illustrate why the addict smoked or used other addictive substances and processes in the first place. But one can not simply stop tranquillisers nor desist from anorexia. Sudden withdrawal from chronic tranquilliser use has a significant risk of suicide and therefore needs to be done gradually over a period of three months. By contrast, intravenous heroin addiction can be safely and comfortably detoxified (on reducing doses of oral Methadone) over five to 10 days, while cocaine, even crack, addiction usually requires no detoxification at all (hence dispelling the belief that addiction is partly defined by withdrawal symptoms). The double negative of anorexia (how do you get someone not to not do something?) could theoretically best be treated with Naltrexone, blocking the mood-altering effect of starvation for one month while the patient becomes used to group support and to three structured meals daily (excluding sugar and white flour because their mood-altering properties will in due course cause a craving for more, so that anorexia would simply turn into compulsive over-eating or bulimia).
In the longer term, the emotional emptiness that underlies all addictive behaviours requires a substitute method of mood alteration, a way of coping with the vicissitudes of life without resorting to blocking out the feelings. This is where the long-term work comes in. The treatment we offer at Promis is based on the "12 steps" of Alcoholics Anonymous, a self-help fellowship founded in the United States 60 years ago by alcoholics helping themselves, and each other, to stay sober. The principles encapsulated in this programme of recovery address the physical, emotional and spiritual nature of the difficulties in which addicts find themselves. The foundation, and indeed the first "step", is a recognition that there is a problem. This might seem obvious to everyone else, but the person caught up in the addiction is practised in blaming everyone and everything else for their inability to manage their lives. Once acknowledged, sustained awareness of the tendency to avoid emotionally challenging situations goes a long way to opening the door to alternative behaviour.
One of the biggest changes addicts of any kind need to make is to take responsibility for their lives. This means acknowledging what it is that they are doing in situations that are causing them pain; and recognising what it is that they can change - which is usually their behaviour and attitudes - and what it is they can only accept - usually external circumstances and other people's attitudes and behaviour. This doesn't mean that nothing can be negotiated, but simply that things outside ourselves can't be controlled. Part of the process involves allowing that everyone makes mistakes (addictive natures are often perfectionist); we can learn from them and we can apologise when we hurt others.
All human beings can benefit from creative work, healthy hobbies, supportive friends and a loving family. When things go wrong and things become too hard to bear or when childhood influences still dominate adult behaviour to an inappropriate degree, all can benefit from any number of therapeutic approaches. For addicts, however, the nature of their disease is compulsive and without constant vigilance and support, they will always return to their preferred (or an alternative) "comfort". This is where Alcoholics Anonymous and the fellowships that have grown up to help people with other addictive disorders come in. They offer a nationwide network of self-help groups where people are able to receive and give support. When addicts give up their closest "friends" (their mood-altering substances and processes) they need first of all to use the substitute mood-altering process of reaching out to help others. That done, however, they then need to learn the emotional and social skills that everyone else has had to learn growing up, in order to survive and flourish in adult society.
! The Promis Counselling Centre is at 2a Cromwell Place, London SW7 2JE, tel: 0171 581 8222. The centre is private, but it does take NHS referrals. It also has a 24-hour, Freephone crisis helpline: 0800 374318. For information on Alcoholics Anonymous meetings and other `Anonymous' fellowships, tel: 01904 644026
DR ROBERT LEFEVER
Dr Robert Lefever has been a GP for 30 years and founded the Promis Recovery Centre in 1986. The centre, which treats addictive/compulsive disorders, operates from London and an in-patient clinic in KentReuse content