Addiction Recovery

[Introduction to, 9 Keys to Addiction Recovery: Health Psychology , ?2023]

Addiction, as anyone who’s ever struggled with it will know, is a tricky business.

In fact, we’re all addicted to something, aren’t we? Whether social media or Netflix binging, coffee or sugar, a hobby -- or a certain person, it’s easy to become obsessively attached, and often very challenging to change.

But that’s not quite what we mean when we use the word ‘addiction’.

Whether substance abuse – alcohol, nicotine, or a host of others, street or prescription – or addictive behavior – gambling, shopping, Internet, sex – addiction refers to the target substance or behavior now in control of the person. And that’s when it becomes uncomfortable.

No longer getting high, though always chasing that dragon, one now continues the substance or behavior just to feel ‘normal’. Tolerance, dependence, withdrawal have set in, and you’re not quite in charge of your mind, your body, or your life.

A cascade of consequences often results. You seek assistance, whether in a personal abstinence approach, a supportive friend or 12-step program, or a treatment facility. You manage to free yourself of this burden, now increasingly heavy – only to hear it whispering your name sometime down the road, especially if you find yourself under stress. And the cycle continues.

“Tell me,” the 54-year old former nurse asked me, inebriated but in a moment of crisp clarity, “do you honestly think I have any chance?”

A brittle alcoholic for more than 2 decades, in and out of treatment multiple times, she was familiar to those of us at the hospital and also in the local courts, now brought in by police once more. We were in a small room of the emergency department, she and I, where I was assessing her for admission – one more round of detox followed by the 28-day inpatient rehabilitation program.

And I looked her in eye and with deep compassion and conviction I replied, “For as long as you’re still breathing, Mary, I have to believe that you still have a chance.”

She was admitted to hospital. She successfully completed detox and the 28-day program, and continued to outpatient treatment. Within 3 years she was dead of an alcohol-related accident.

Addiction can be a harsh master.

But there is indeed hope. As long as we’re breathing, there’s still hope. And there are countless stories, all over the world, of those in long-term recovery.

A complex problem, several models of addiction have emerged. For a very long time, addiction was considered a moral issue of faulty character and lack of willpower; we know today that this is simply untrue, though it remains the tendency among those who are judgmental toward or lack compassion for – or have been hurt too many times by – the one who is addicted. A kinder version of the moral / spiritual model suggests that a sense of spiritual connection – whether to religion, philosophy, altruism, or nature, but in any case a sense of deep connectedness and presence of meaning – is missing, and if restored, can be very helpful to recovery. This is embedded in the 12-step programs, and many a religious approach to healing from addiction. Even the shaman, across indigenous cultures, would view addiction as ‘soul loss’ in which part of one’s soul has gone missing, perhaps due to tragedy or trauma; in trance, the shaman enters the spirit world in search of that lost part, in order to retrieve and reintegrate it so that the person may become whole again. This perspective of the model may speak to some who struggle with addiction today.

The biological model of addiction has existed for decades, remaining a primary focus of the medical approach to treatment and also of the 12-step programs; the addicted person is viewed not in terms of character but of someone struggling with a disease, as officially declared in 1956 by the American Medical Association. This too remains valid to a degree, and surely for alcoholism and substance use disorder, there is a very medical detoxification process while medication is often useful for treatment. The self-medication theory falls within this category, as initial substance use or addictive behaviors are seen as an unconscious attempt to relieve an often undiagnosed depression or anxiety, or as a form of pain management. It’s also worthy of consideration that long-term use of any addictive substance creates biological changes in brain and body, which can precipitate a host of other physiological conditions and which makes recovery especially challenging in the extended period of post-acute withdrawal symptoms. Addictive behaviors, too, create neurochemical changes in the pleasure / reward centers of the brain, again quite biological.

The chronic relapsing brain disease model, in the biological model category, suggests that addiction relates to a brain disorder or damage in circuitry of reward, stress, and control, leading to compulsive use irrespective of consequence. The model is based not only on the recidivist nature of addiction but also in its seeming hereditary component, in a view that some are simply more biologically prone to addiction than others by genetic defect. Lie et al. (2022) argue that this model, in ignoring psychosocial aspects and systemic inequities of addiction while emphasizing the addicted person as biologically flawed, serves to further marginalize those with addictions and discounts personal agency. Feingold and Tzur Bitan (2022), in contradiction to this model, propose that, in addition to the self-medication theory of attempts to regulate neurochemical imbalance, substance use may also constitute substitute behavior in which the addicted person is acting out negative emotions in this way; they advocate instead for a biopsychosocial model.

“Will it hurt?” the young man in the rehab unit anxiously asked, as he was about to be taken to the dentist. The social worker accompanying him found this odd; after all, he’d been injecting heroin for some time and living on the street, and surely, he was inured to pain. I later had a heartfelt discussion with her. Yes, the young man had endured his share of pain, but he usually had the heroin to take it away; what’s more, his pain receptor ‘locks’ had been so long blocked by the false ‘key’ of heroin that now they didn’t recognize their natural endorphins, and he was hypersensitive to pain as a result. (Not to mention, he wasn’t sure if he’d be allowed the local anesthetic – and, he was generally anxious and fearful of life at that early point in his recovery.)

The psychodynamic model views addiction as a byproduct of earlier events in one’s life. ‘What happened to you?’ is a question often asked of the person in early recovery, while cognitive-behavioral techniques are typically engaged to help change faulty thought patterns that may have emerged from the earlier events and become entrenched. The abused child, for example, may have learned helplessness and worthlessness, both relieved by the addictive behavior or substance. Self-soothing behavior fits this description, too; early and often repressed negative experiences may make one generally uncomfortable, and the substance or behavior soothes this discomfort. The trauma model (Ross, 2000) we’ll look at later on – which proposes that unresolved trauma, often from childhood, underlies substance use disorder and/or addictive behaviors, as well as most if not all other psychopathology – represents one of the more recent perspectives within this category. Gori et al. (2023) have suggested a comprehensive or ‘vulnerability’ model of addiction to include multiple psychodynamic aspects: childhood trauma, dissociation, and insecure attachment, as in Ross’ trauma model, as well as emotional dysregulation, impulsivity, compulsiveness, and obsessiveness.

“I can’t look at all this pain, oh, I can’t bear it, too much has happened to me, it’s all too much!” the young woman in a hospital detox bed wailed. I stayed with her a while, attempting to comfort her, telling her she didn’t need to look at any of it now – though it was all reemerging at once, as her previous numbing agent of choice leeched from her body – and she was overwhelmed. I quickly taught her a few breathing techniques for managing her emotional overload, then performed acu-detox, five tiny acupuncture needles in each ear, which soothed her as endorphins, and qi, began to flow. Learning a few basic coping skills is essential from the very beginning…as you may not know what painful memories will emerge, once the numbing agent – which also includes alcohol, nicotine, and addictive behaviors – is removed. ‘What happened to you?’ is a critically important question, though only after a base of emotional regulation and coping skills are in place. Meantime, self-compassion also goes a long way toward healing.

An environmental model of addiction suggests external influences, such as addictive behavior or substance use within the family, through the generations, or among peers. A plethora of research over many years has well established the influence of environment on one’s risk for addiction. The surrounding environment is equally influential in one’s recovery, and one is often encouraged to seek out supportive individuals and environments while avoiding those who are more likely to encourage and enable a return to the unwanted addiction; identification of external triggers for relapse is a common emphasis of treatment.

“I relapsed while I was in prison – for possession,” the man casually told me. “Surely drugs are banned in prison?” I replied, not naively, but to draw out his story. “Yeah, well, anything’s possible,” he went on, shrugging his shoulders, “and I was in bad company.” He then told me about his father’s frequent prison stays, and often finding his mother in an alcoholic stupor when he came home from primary school. “I guess I was in bad company from the time I was born,” he lamented.

Finally, we have a biopsychosocial model, which seeks to recognize the value in each of the others and to integrate them for a more comprehensive view of addiction, the person struggling with same, and the support or harm of the surrounding environment. This complexity can make addiction more difficult to treat, however, as recovery must be undertaken on not one but all levels at once. One step further and we have a ‘bio-psycho-socio-spiritual’ approach, perhaps the most holistic, whole-person view of all, and surely the one that this book will take.

We do well also to consider grief and loss in relation to addiction (Furr, 2022). Unresolved grief can surely precipitate the self-medication or self-soothing aspect of substance use or compulsive behavior that ultimately become addiction, an all too common story. Less obvious are the loss of the addiction itself; many a former smoker or alcoholic will readily say he or she misses and grieves the loss of the substance, in their longstanding relationship and the rituals and social life that accompanied it. Going into recovery also typically means no longer socializing with those who are still in active addiction, a major trigger, so it can lead to the loss of relationships as well. Perhaps paradoxically to those who have never experienced addiction, a certain sense of meaning can often be attached to the addictive behavior and/or substance, another aspect of loss when entering recovery – and an unsettling of one’s presence of meaning, which can be a risk factor for relapse in itself. Identity, too, gets wrapped up in the addictive life, and is profoundly shaken when in early recovery. And when in recovery, loss of a loved one or other major loss, in conjunction with the profound loss of the addictive life itself as outlined, presents high risk of relapse (Scroggs et al., 2022) – relapse in itself representing yet another grief or loss, that of recovery itself (Furr, 2022).

Older adults, often at a time of life when grief and loss are paramount, as peers die, chronic illness and loss of ability are present or increasingly likely, loneliness and isolation more common, and mortality looming, there is greater risk of alcohol abuse, or of relapse among those in recovery. In a review of 66 relevant studies, Megherbi-Moulay et al. (2022) determined the significance of biopsychosocial factors such as quality of life, wellbeing, emotional regulation, coping strategies, mood stabilization, and strong social support.

Children are not immune to behavioral addictions, especially internet and smartphone, gaming, and online gambling (Derevensky et al., 2022). Similar to substance use addiction, these addictive behaviors are accompanied by tolerance and withdrawal, emotional dysregulation, alteration in mood with possible disorder, and cycling recovery / relapse.

In an online survey study of 312 participants regarding social network addiction, risk was associated with perceived stress levels, cognitive absorption, and temporal dissociation (Cannito et al., 2022). Online behavioral addictions such as problematic social media use, gambling, gaming, and general Internet use was also studied by Zarate et al. (2023) among 462 adults (69.5% male, 28.5% female). Participants completed questionnaires twice, at a one-year interval; males showed greater tendency toward excessive online gaming, and females for disordered social media use, with associated mood changes and impairment increasing the risk of internet use disorders. And as we might expect, having multiple addictions represents a highly complex condition that is pervasive and persistent. Two large-scale 5-year Canadian adult cohort studies were conducted, within which a subset of 1,088 participants was assessed for substance use and gambling disorders, addictive behaviors, or a combination (Gooding et al., 2022); those with multiple addictions showed significantly greater chronicity.

Recovery capital encompasses the range of attributes and skills, and external support, one may have or can develop to achieve and maintain recovery from addiction. Such supports can be psychological, social, physiological in terms of health practices and lifestyle, and spiritual in a source of meaning. Recovery includes understanding one’s roadblocks or resistances, triggers, and enablers, along with identifying and attempting to resolve underlying trauma or attachment issues, loneliness or isolation, shame or grief. Aging brings its own concerns, and older adults are somewhat at risk for addiction; stress is of course a primary focus, with a need for coping skills and emotional regulation. Much of addictive behavior becomes ritualized, which can feel meaningful, and their loss mourned; filling this socioemotional gap, by replacing those unhealthy rituals with personalized ones for healing, can be beneficial. All of these and more constitute potential recovery capital.

As a model, recovery capital advocates for a self-driven approach to recovery when a reasonable level of such internal and external assets is coupled with a low to moderate addiction; if such assets are low and addiction is severe, professional treatment is recommended instead. When it comes to professional treatment for substance use disorder, Sang et al. (2022) interviewed 3 groups: patients, clinicians, and administrators, regarding effective treatment, challenges, and suggestions for improvement. While there was much agreement across groups, several themes appeared: there was general disagreement among groups regarding medication efficacy; clinicians identified barriers to treatment including trauma, stigma, uniformity of treatment approach, and insurance restrictions, while for patients, greater barriers were in difficulty handling emotions, feeling rushed into therapy, and lack of long-term recovery plans.

As part of recovery capital, we must assess our motivation; Williams (2023) outlines an automatic-reflective motivation framework, automatic in terms of craving, urge, or desire, and reflective as behavioral intention, with a focus on recognizing the former while emphasizing the latter.

Enter the health psychologist.

Health psychology is a specialty that operates within a biopsychosocial framework, often also integrating the spiritual dimension. The psychologist functions as part of a comprehensive medical team to help people deal with biological as well as psychological illnesses. For example, someone with diabetes may need the support not only of a physician and a dietician but also the health psychologist, who can support compliance with medical and dietary changes and also address fears and concerns, and possible concomitant depression or anxiety.

Addiction, including smoking cessation among all others, is a primary area of focus for the health psychologist, under the comprehensive and holistic biopsychosocial model. Other typical areas of focus for the health psychologist include eating disorders, weight control, pain management, chronic illness, unresolved grief, stress management, and preventive medicine including compliance with healthy lifestyle behaviors. Motivational Interviewing, in which aspects of as well as resistance to change are assessed, and mindfulness, a framework that includes meditation, attention, emotional regulation, body awareness, self-compassion, and more, are two primary approaches utilized by the health psychologist.

Above all, health psychology is a wellness and preventive model – while for the person already experiencing addiction, this would apply to the recovery process and prevention of relapse. Wellness can be viewed in terms of physical, mental, emotional, occupational, and spiritual aspects. Mental wellbeing generally includes life satisfaction, subjective happiness, and positive mood, all closely linked to recovery from addiction. In a study of people in recovery, conducted by Schick et al. (2023), happiness and life satisfaction were closely related to coping ability and decreased anxiety, while all three were associated with lower symptoms of depression and distress.

For those challenged by addiction, particular emphasis may be placed on stability and fulfilment; this includes a sense of meaning and purpose in life, work and/or play that feels satisfying, fulfilling relationships, and an increasingly healthy body and home (Delic, 2022). A wellness lifestyle encompasses a balance of healthy habits such as good nutrition, exercise, good sleep hygiene and sufficient rest, productivity and participation in meaningful activities, and social support with regular contact.

Our 9 keys, then, to addiction recovery, are these: meaning-making, or the search for and presence of meaning in one’s life, often equated with spirituality; self-compassion, one of the best medicines, and good to establish very early on; support system, your safety net, its importance and how to have, repair, reestablish one; body care, or the role of body therapies and a healthy lifestyle; mindfulness, a peaceful system of mind training and emotional regulation; the healing of nature, or nature-based therapy; roadblocks to recovery, including resistance, triggers, and enablers; healing the trauma, unresolved grief, and insecure attachment, that may underlie the addiction and contribute to relapse; and, the power of ritual.

Shall we begin?

9 Keys to Addiction Recovery by Anne Hilty, ?2023

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References:

Cannito L, Annunzi E, Viganò C et al. (2022). The Role of Stress and Cognitive Absorption in Predicting Social Network Addiction. Brain Sciences 12:5:643. https://doi.org/10.3390/brainsci12050643

Delic M (2022). Different dimensions of wellness in drug addiction treatment. European Psychiatry 65:S1, S829-S829. https://doi.org/10.1192/j.eurpsy.2022.2146

Derevensky J, Marchica L, Gilbeau L et al. (2022). Behavioral Addictions in Children: A Focus on Gambling, Gaming, Internet Addiction, and Excessive Smartphone Use. In: Patel VB and Preedy VR (eds), Handbook of Substance Misuse and Addictions. Springer, Cham. https://doi.org/10.1007/978-3-030-67928-6_161-1

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Megherbi-Moulay O, Igier V, Julian B et al. (2022). Alcohol Use in Older Adults: A Systematic Review of Biopsychosocial Factors, Screening Tools, and Treatment Options. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-022-00974-z

Ross CA (2000). The trauma model: A solution to the problem of comorbidity in psychiatry. Richardson, TX, US: Manitou Communications.

Sang J, Patton RA, and Park I (2022). Comparing Perceptions of Addiction Treatment between Professionals and Individuals in Recovery. Substance Use & Misuse 57:6, 983-994. https://doi.org/10.1080/10826084.2022.2058706

Schick MR, Trinh CD, Todi AA et al. (2023). All Positive Constructs are Not Equal: Positive Affect, Happiness, and Life Satisfaction in Relation to Alcohol and Mental Health Outcomes. International Journal of Applied Positive Psychology. https://doi.org/10.1007/s41042-023-00103-8

Scroggs LB, Goodwin Jr LR, and Wright McDougal JJ (2022). Co-Occurring Substance Use Disorders and Grief during Recovery. Substance Use & Misuse 57:3, 418-424. https://doi.org/10.1080/10826084.2021.2019771

Williams DM (2023). A meta-theoretical framework for organizing and integrating theory and research on motivation for health-related behavior. Frontiers in Psychology 14:1130813. https://doi.org/10.3389/fpsyg.2023.1130813 ?

Zarate D, Dorman G, Prokofieva M, et al. (2023). Online Behavioral Addictions: Longitudinal Network Analysis and Invariance Across Men and Women. Technology, Mind, and Behavior 4. https://doi.org/10.1037/tmb0000105 ?

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