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Why Do People With Addictions Seek to Escape Rather Than Connect? A Look at the Approach to Addiction Treatment

Robert Weiss, LCSW, CSAT-S

Volume 56 - Issue 9 - September 2016

ABSTRACT: A strong belief exists among addiction treatment specialists that the primary reason addicts remain addicted is less about pleasure-seeking and more about their need to escape and dissociate from the pain of his or her (often trauma-based) emotional isolation. In short, all human beings crave deeply intimate, dependable, empathetic relationships. Addicts, however, have learned, typically through traumatic experience, that others cannot be trusted to reliably meet their need for intimate connection. Essentially, they learn to fear emotional vulnerability, and they therefore distance themselves from other people, turning instead to addictive substances and/or behaviors as a way to “not feel” their unmet emotional dependency needs. As such, a primary part of treating addicts, regardless of the nature of their addiction, is helping them develop healthy and supportive emotional bonds, initially in a treatment/recovery setting, and eventually in the world at large. This approach—not willpower or babysitters or threatened consequences—is most likely to lead to lasting sobriety, emotional healing, and a happier, healthier life.

KEYWORDS: Substance use disorder, alcohol, alcoholism, drug abuse, drug addiction, sex addiction, love addiction, gambling addiction, compulsive spending, eating disorders, Internet addiction, attachment theory, intimacy disorders, addiction treatment, primary care

 

Nearly every medical and psychological clinician, regardless of his or her area of specialization, encounters addicted patients or clients on a relatively regular basis. Nevertheless, few health care professionals receive adequate training about the etiology, nature, and long-term treatment of addictive disorders. This article is an attempt to address this shortcoming. In particular, it discusses the belief that addictions are less about the pleasurable effects of addictive substances and behaviors and more about the need to “not feel” the emotional discomfort that arises in response to a lack of healthy intimate attachment.

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Put very simply, when addicts face challenges and become emotionally needful—as a result of stress, losses, anxiety, depression, and even joyful experiences—they automatically and without conscious thought turn to an addictive substance or behavior as a source of emotional distraction. (Meanwhile, faced with identical stimuli, nonaddicts typically seek support through emotional connection with compassionate and loving people.) Thus, addicts are most often individuals who lack, fear, and avoid emotional intimacy, and who therefore seek comfort and soothing elsewhere, typically from sources that do not require emotional vulnerability.

After almost 25 years as an addiction treatment specialist, I cannot recall a single client who had not learned early in life (through abuse, neglect, and further traumas) that turning to other people for support, validation, and comfort would leave them feeling worse than before they had reached out. So these individuals learned to avoid the deep relational connections that, for healthier people, bring needed consolation, emotional resolution, and reward, instead finding it easier and emotionally safer to escape and dissociate through the abuse of addictive substances and behaviors. In short, addicts engage in their addictions as an adaptive distraction from their painfully unmet womb-to-tomb emotional dependency needs.

Recognizing this, I will go so far as to suggest that addictions may be improperly classified as “use disorders” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 From my perspective, it would be more accurate to refer to (and treat) addictions as what they really are: adaptive coping responses to complex childhood trauma and related attachment disorders.

To be clear, I am not talking about a purely physical dependency, which is something any mammal can and will experience if exposed to an addictive substance for long enough. For example, people who are prescribed heavy doses of opioids can become physically dependent if they take these drugs for a long enough period. But that kind of dependency is readily reversible. In fact, so long as withdrawal symptoms are properly managed, ending that type of substance abuse is a short-term and relatively painless process, and the dependency is not likely to recur. For true addicts, however—that is, those persons whose dependency extends beyond the physical—getting away from the opioids (or whatever the addiction happens to be) is merely the tip of the iceberg. Their lack, fear, and avoidance of vulnerability and emotional intimacy must also be addressed.

NEXT: Addiction Diagnoses; Trauma, Shame, and Fear of Intimacy, and more

 

Addiction Diagnoses: DSM-5 vs Reality

The DSM-5 recognizes only substance use disorders (alcoholism and various forms of drug addiction) and gambling disorder as diagnosable addictions.1 Nevertheless, primary care clinicians should understand that researchers have identified numerous other addictions and compulsions, including sex addiction, love addiction, compulsive spending, food addiction, online gaming addiction, Internet addiction, social media addiction, and more.2 Essentially, any intensely pleasurable and therefore potentially distracting/escapist substance or activity can become an addiction, regardless of the DSM-5’s circumscriptions.

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The DSM-5 lists 11 criteria for a substance use disorder (ie, alcoholism and drug addiction), at least 2 of which must be present for a diagnosis.1 More generally, addictions of all types are diagnosed based on the following 3 factors:

  • Ongoing preoccupation to the point of obsession with the substance or behavior of choice
  • Loss of control over use of the substance or behavior, typically evidenced by failed attempts to quit or cut back
  • Directly related negative consequences, such as relationship difficulties, problems at work or in school, declining physical health, depression, anxiety, diminished self-esteem, isolation, financial woes, loss of interest in previously enjoyable activities, and legal trouble.

Any patient who presents with concern for these consequences or similar problems, regardless of the clinical setting, should be fully evaluated for addiction. Primary care physicians should pay particular attention to patients concerned about depression and anxiety, or with unexpected or unusual ailments, since these problems often are linked to addiction.

Trauma, Shame, and Fear of Intimacy

Addicts almost universally report multiple instances and forms of early-life neglect, abuse, and family dysfunction.3 For example, one study4 found that survivors of chronic childhood trauma (4 or more significant trauma experiences prior to age 18) were:

  • 1.8 times as likely to smoke cigarettes
  • 1.9 times as likely to have severe obesity
  • 2.4 times as likely to have anxiety
  • 3.6 times as likely to have depression
  • 3.6 times as likely to be sexually promiscuous (30 or more partners)
  • 7.2 times as likely to have alcoholism
  • 11.1 times as likely to use injected drugs.

Thus, we see an undeniable link between childhood trauma and numerous adulthood symptoms and disorders, including addiction.

Another relatively common environmental risk factor is early exposure to an addictive substance or behavior.5-7 At times, the age of first use and the presence of familial instability (which can lead to various forms of early-life neglect and abuse) are directly related, given that addictive substances and/or activities may be readily available within a dysfunctional home. In such cases, the primary environmental risk factors such as abuse, neglect, and inconsistent parenting probably are the overarching factors.

Attachment Theory

To fully understand this idea, we need to examine the basics of attachment theory, initially discussed and developed as a psychological construct by John Bowlby in the 1940s and 1950s.8 Bowlby studied, among other populations, European World War II orphans, finding that even though these children had been provided adequate food, shelter, and general physical care, they did not seem to thrive like other children. In fact, some developed so poorly that they died. Based on this research, Bowlby began to think that the development of emotional bonds might be an evolutionary survival mechanism.

Initially, Bowlby’s theories were almost universally dismissed. (This was an era when coddling children was thought to be counterproductive to their long-term well-being.) Nevertheless, he and a small group of likeminded clinicians conducted experiments on various populations, including nonorphaned infants,9 war widows,9 juvenile delinquents,10 married couples,11 and even monkeys.12 And the results were always the same. Those who did not feel securely emotionally attached ultimately became depressed, anxious, and self-destructive.

Today, it is widely accepted that humans, especially children, have an innate, hardwired need for emotional closeness, and we ignore this necessity at our peril. As such, it is no surprise that we consistently find significant links between early-life family dysfunction/trauma and later-life emotional and psychological disorders.13 Essentially, when children do not feel safe or as if their caregivers will consistently meet their emotional needs, they lose their ability to trust and effectively attach. Even worse, they develop a shame core—internalizing blame for the dysfunction and trauma they experience and thinking that something must be inherently wrong with them that makes them unlovable and unworthy of healthy emotional connection.

Think here of the chronically physically abused child who, showing up at the doctor’s office, explains his broken wrist by saying he fell down (instead of telling the truth about what his caregiver did to him). This is not uncommon, because children often will protect their caregivers absolutely, even when the caregivers are abusive. They do this because they need those caregivers on multiple levels. So when a caregiver fails them through neglect or abuse, they tend to blame themselves rather than the adult. They think, “If I weren’t such a bad kid and didn’t need so much, Mommy/Daddy wouldn’t yell at me and hit me. So next time I’ll just keep quiet, and this won’t happen.” Thus begins a lifelong struggle with shame (feeling defective, not good enough, and unworthy of love) and the avoidance of emotional vulnerability.

As attachment research predicts, neglected and/or abused children generally fail to thrive (as children and also as adults). They become shame-based, disconnected, depressed, anxious, angry, fearful, etc. Mired in emotional discomfort and not trusting others to alleviate this discomfort in a healthy or timely way, they automatically seek other forms of emotional regulation. Often they turn to an intensely pleasurable (and therefore numbing/escapist) substance or behavior—food, cigarettes, alcohol, drugs, sex, gambling, etc. In time, they learn that this maladaptive coping mechanism is the quickest and easiest way to not feel the pain of their emotional disconnection. As they turn to this coping mechanism over and over, they become addicted. And as their addiction worsens, they become even more disconnected, increasing their sense of shame and their emotional isolation.

In this way, addiction is a vicious and self-perpetuating cycle that typically starts very early in life. In a nutshell, children are emotionally and physically vulnerable, needing healthy and reliable care on multiple levels. If they are physically and/or emotionally neglected and/or abused, they learn that their caregivers (and others) either cannot or will not meet their emotional needs. This creates emotional distress, self-blame, and a deeply internalized sense of shame. In time, these individuals learn to avoid and dissociate from the emotional discomfort wrought by their shame and their unmet dependency needs via an addictive substance or behavior. Brené Brown, PhD, LMSW, describes this process succinctly, writing, “For me, vulnerability led to anxiety, which led to shame, which led to disconnection, which led to Bud Light.”14

This desire for escape and self-managed emotional regulation, rather than a desire for pleasure, is the crux of addiction. So addiction is not about feeling good, it is about feeling less. Addicts are looking to escape the pain of their unresolved childhood trauma and their adulthood lack of emotional intimacy and connection by turning to an intensely pleasurable and therefore escapist substance or behavior over and over, eventually becoming addicted. In time, as their addiction escalates, they become increasingly disconnected, deepening their shame core and increasing their emotional isolation, thereby creating an even greater need to escape.

When addiction is conceptualized in this way—as an intimacy disorder—it opens the door to conclusions such as, “The opposite of addiction is not sobriety. It is human connection.”15 And while this may be an overgeneralization that ignores the physical aspects of drug/behavior dependency, the idea that addiction is linked to an inability to seek and maintain emotional intimacy is spot on, as is the belief that the most effective way to combat addiction is to bring addicts back into the world by connecting them with safe, supportive, empathetic others.

NEXT: Examples and Conclusions

The Rat Park

One of the all-time great illustrations of addiction as an intimacy disorder occurs in Bruce K. Alexander’s famed “Rat Park” experiments. Prior to Alexander’s work, it had been generally believed that pleasure, as wrought by addictive substances and behaviors, is the primary driver of addiction. Bolstering this belief was the fact that most early research on the root causes of addiction centered on the neurochemical pleasure response, typically focusing on the ways in which addictive substances activate rewards pathways in and around the nucleus accumbens, and on the fact that laboratory rats, when given the choice, almost always chose to drink opiate-infused water over regular water. For a long while, even the National Institute on Drug Abuse espoused this view.16

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However, based solely on the fact that most people do not become addicts—while almost every American adult has tried alcohol, the Substance Abuse and Mental Health Services Administration estimates that only 6.8% of them become heavy alcohol users17—it was clear to some addiction specialists and researchers that pleasure is not the primary driver of addiction. In short, the desire for pleasure is not what causes some people to return to an addictive substance or behavior over and over, compulsively and to their detriment.

Recognizing this, Alexander looked at the results of rat studies, where test subjects were placed in empty cages, alone, with 2 water bottles to choose from—one with pure water, the other with opiate-infused water. In those experiments, the rats uniformly got hooked on and eventually overdosed on the opiate water, leading researchers to conclude that the out-of-control search for extreme pleasure drives addictions. This led to a belief that, essentially, addicts were just weak-willed, and if they could only develop some willpower, things would be OK.

Alexander disagreed. In particular, he was bothered by the fact that the cages in which the laboratory rats had been isolated were small, with no potential for stimulation beyond the opiate water. He thought, “Of course they all get high. What else are they supposed to do?” 

In response, he created the rat park, a cage that was approximately 200 times larger than the typical isolation cage, with hamster wheels and multicolored balls for the rats to play with, plenty of tasty food to eat, and spaces for mating and raising litters.18 And he put not one rat, but 20 rats (of both sexes) into the cage. Then, and only then, did he mirror the older experiments. And guess what? Alexander’s now apparently happy rats ignored the opiate water, expressing much more interest in typical communal rat activities such as playing, fighting, eating, and mating. Even rats that previously had been isolated and had been drinking the drugged water left it alone when they were placed in the rat park. With a little bit of social stimulation and connection, addiction in the rats disappeared.

The Human Rat Park

One of the reasons that rats are routinely used in psychological experiments is that they are social creatures in many of the same ways that humans are social creatures. Happy rats require stimulation, company, play, drama, sex, and social interaction to stay happy. Humans, however, add an extra layer to this equation, also needing to trust and to emotionally attach.

The level and caliber of trust and connection experienced in early childhood carries forth into adulthood. Those who experience secure attachment as infants, toddlers, and children carry that into adulthood, and they are naturally able to trust and connect in healthy ways. Meanwhile, those who do not experience secure early-life attachment tend to struggle with trust and connection later.19 In other words, securely attached individuals tend to feel comfortable in and enjoy the human rat park, while insecurely attached people typically struggle to fit in and connect. Guess which group is more vulnerable to addiction?

This highly empathetic way of conceptualizing addictive disorders allows us to view them not only as a physical dependency, but also as a set of adaptive, learned responses to early-life dysfunction and abuse. When seen in this light, addiction is no more and no less than the deeply layered negative outcome of disordered intimacy.

The good news is that people with insecure attachment are not locked into a state of isolated self-soothing and self-regulation for life. With proper direction, support, and a fair amount of conscious effort, those who have not experienced secure childhood attachment (and therefore the ability to easily and comfortably connect in adulthood) can learn to securely attach—usually via long-term therapy, 12-step and related support groups, and various other healthy and healing relationships—creating over time what is known as “earned security.”

For human addicts, earned security is a very important concept. Rats do not really need it. Put an addicted rat into the rat park, and it will quickly and easily assimilate, abandoning its addiction in favor of healthier rat connections and activities. But people? Not so much. With human addicts, more work is needed, with “connecting addicts to supportive others” as a key to healing and recovery.

Interestingly, addiction treatment specialists and the 12-step community have operated with “addictions are an intimacy disorder” as an underlying principle for decades. In fact, much of what occurs in well-informed addiction treatment programs and 12-step recovery programs (after first putting a stop to the addictive behavior) is geared either directly or indirectly toward the development of reliably healthy emotional bonds, recognizing that this, rather than willpower and/or the fear of future consequences, is the ultimate pathway to lasting sobriety and a happier life.

Connecting and Reintegrating Addicts

Typically, this reintegration process starts with individualized addiction treatment, expanded to addiction-focused group therapy and 12-step recovery as soon as the person can tolerate it. Although the addict may feel more comfortable (safer) in a one-to-one therapy setting (since many addicts are looking for that one situation or person to “fix” them), group settings in which addicts learn to interact on an emotionally intimate level with other recovering addicts (people who understand exactly what they are thinking and feeling) are most effective. Without fail, the more people an addict connects with and learns to trust, the better off he or she will be. In time, most recovering addicts are able to develop earned security, greatly reducing their sense of shame, their emotional discomfort, and their desire to escape and dissociate through an addiction. In other words, the maladaptive lessons learned by addicts in childhood are unlearned (experienced differently) via empathetic and supportive adult emotional interactions.

Society at large can also play a helping role in this process. Consider Portugal. Since decriminalizing illicit drugs in 2001, Portugal has tried very hard to reintegrate addicts into their communities, offering not only traditional treatment and counseling, but also subsidized jobs and social programming. Essentially, Portugal has made a nationwide effort to help addicts connect with the world and the people around them. And it is working. Problematic drug use is down, including adolescent drug use and drug-related deaths.20 Admittedly, cannabis use is slightly up, but that may be a matter of people choosing to smoke rather than drink, now that marijuana is legal.21 So in general, Portugal’s strategy of connecting instead of incarcerating addicts has been effective.

It is part of the human condition to emotionally attach and to lean into our attachments. This emotional need is as basic to life, health, and happiness as the need for food and shelter, and without it we are certain to struggle. In other words, as Sue Johnson, EdD, writes, “We need emotional attachments with a few irreplaceable others to be physically and mentally healthy—to survive.”22

However, developing these connections can be difficult, especially for addicts, who nearly always have a history of childhood trauma and other forms of early-life dysfunction. For addicts, learning to trust, reducing shame, and feeling comfortable with both emotional and social vulnerability takes time, ongoing effort, and a knowledgeable, willing, and empathetic support network (eg, therapists, fellow recovering addicts, family, friends, employers). The good news is that both research and hundreds of thousands of healthy, happy, long-sober addicts have shown us that such healing is not only possible but also incredibly worthwhile, in that it can turn an isolated addicted life into a life of joy and connection. 

Robert Weiss, LCSW, CSAT-S, is senior vice president of national clinical development for Elements Behavioral Health in Long Beach, California, and is the founding director of the Sexual Recovery Institute in Los Angeles, California.

References:

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  2. Rosenberg KP, Feder LC, eds. Behavioral Addictions: Criteria, Evidence, and Treatment. Waltham, MA: Academic Press; 2014.
  3. Ford JD. Neurobiological and developmental research: clinical implications. In: Courtois CA, Ford JD, eds. Treating Complex Traumatic Stress Disorders: Scientific Foundations and Therapeutic Models. New York, NY: Guilford Press; 2009:​31-58.
  4. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):​174-186.
  5. von Diemen L, Bassani DG, Fuchs SC, Szobot CM, Pechansky F. Impulsivity, age of first alcohol use and substance use disorders among male adolescents: a population based case-control study. Addiction. 2008;103(7):1198-1205.
  6. Dawson DA, Goldstein RB, Chou SP, Ruan WJ, Grant BF. Age at first drink and the first incidence of adult-onset DSM-IV alcohol use disorders. Alcohol Clin Exp Res. 2008;32(12):2149-2160.
  7. DeWit DJ, Adlaf EM, Offord DR, Ogborne AC. Age at first alcohol use: a risk factor for the development of alcohol disorders. Am J Psychiatry. 2000;157(5):745-750.
  8. Bowlby J. Attachment. 2nd ed. New York, NY: Basic Books; 1982. Attachment and Loss; vol 1.
  9. Ainsworth MDS, Blehar MC, Waters E, Wall SN. Patterns of Attachment: A Psychological Study of the Strange Situation. New York, NY: Psychology Press; 2015.
  10. Bowlby J. Forty-four juvenile thieves: their characters and home-life. Int J Psychoanal. 1944;25:​107-128.
  11. Coan JA, Schaefer HS, Davidson RJ. Lending a hand: social regulation of the neural response to threat. Psychol Sci. 2006;17(12):1032-1039.
  12. Harlow HF. The nature of love. Am Psychol. 1958;​13(12):673-685.
  13. Courtois CA, Ford JD, eds. Treating Complex Traumatic Stress Disorders: Scientific Foundations and Therapeutic Models. New York, NY: Guilford Press; 2009.
  14. Brown B. Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. New York, NY: Avery; 2012.
  15. Hari J. The likely cause of addiction has been discovered, and it is not what you think. Huffington Post website. January 20, 2015. http://www.huffingtonpost.com/johann-hari/the-real-cause-of-addicti_b_6506936.html. Accessed August 5, 2016.
  16. Bejerot N. Addiction to pleasure: a biological and social-psychological theory of addiction. In: Lettieri DJ, Sayers M, Pearson HW, eds. Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: National Institute on Drug Abuse, US Dept of Health and Human Services; 1980:246-255. NIDA research monograph 30.
  17. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Dept of Health and Human Services; 2008:264. NSDUH Series H-34, DHHS Publication SMA 08-4343.
  18. Alexander BK, Beyerstein BL, Hadaway PF, Coambs RB. Effect of early and later colony housing on oral ingestion of morphine in rats. Pharmacol Biochem Behav. 1981;15(4):571-576.
  19. Bretherton I. The origins of attachment theory: John Bowlby and Mary Ainsworth. Dev Psychol. 1992;28(5):759-775.
  20. Hughes CE, Stevens A. What can we learn from the Portuguese decriminalization of illicit drugs? Br J Criminol. 2010;50(6):999-1022.
  21. Hughes C, Stevens A. The Effects of Decriminalization of Drug Use in Portugal. Beckley Foundation Drug Policy Programme; December 2007. Briefing paper 14. http://beckleyfoundation.org/wp-content/uploads/2016/04/paper_14.pdf. Accessed August 5, 2016.
  22. Johnson S. Hold Me Tight: Seven Conversations for a Lifetime of Love. New York, NY: Little, Brown and Co; 2008.