Avoidance, Sobriety and Reality: The Psychology of Addiction
The antidote to addiction is learning to tolerate reality.
Posted February 28, 2010
Despite their limitations, preconceptions, and borderline exploitation, recent reality television shows about addiction do shine a bright and dramatic light on two dark, secretive, debilitating, and very destructive mental disorders: substance abuse and substance dependence. Like many, but especially as a clinical and forensic psychologist with almost 35 years of dealing with such tragic tales, I still find it simultaneously fascinating and painful to watch shows like Intervention and Celebrity Rehab with "Dr. Drew" Pinsky. I suspect I am not unlike other ambivalent viewers, who stop channel surfing long enough to gawk at the emotional equivalent of a human car wreck. Despite being disturbed, horrified, and racked with voyeuristic guilt, we just can't quit watching. Still, part of what makes such programming so compelling is our compassion for the suffering souls we see literally struggling for their lives. And our conscious or unconscious identification with their struggle. In some ways, addiction is an extreme example of an existential challenge that we all wrestle with every day: accepting reality as it is. One obvious dynamic of addictive behavior (be it alcohol, licit or illicit drugs, sex, food, internet, or television) that I hope viewers are made more aware of by such so-called reality programs is the powerful connection between addiction and the compulsive desire to alter, avoid, deny, and escape reality. In this sense, these "reality" shows are, at their best, indeed about learning to confront, rather than retreat from, reality.
For those who haven't seen or heard of these shows, Intervention dramatically depicts what happens to addicts prior to entering treatment and demonstrates what it takes to get them there. Denial and other chronic behaviors designed to avoid or escape reality are starkly revealed in the addicts' predictable and powerful resistance to entering treatment. Celebrity Rehab documents the goings-on in an in-patient addiction treatment program catering to so-called celebrities, including the likes of Mackenzie Philips (daughter of musician John Philips), basketball star Dennis Rodman, former Guns 'n Roses drummer Steven Adler, actor Tom Sizemore, and other lesser-known or infamous individuals, like ex-madam Heidi Fleiss, Rodney King, former teen beauty queen Kari Ann Peniche, and porno performer Mary Carey. The program is supervised by television personality and now celebrity physician "Dr. Drew" Pinsky, M.D., a board-certified internist specializing in "addiction medicine" — a medical specialty (not unlike AA) tending to conceptualize and treat addictive behavior as a "disease." Dr. Pinsky is a physician, but, to my knowledge, not a psychiatrist, psychologist, or trained psychotherapist. And it shows. Still, Dr. Pinsky's heart is clearly in the right place. He is a caring and compassionate physician committed to helping his patients heal. But his lack of psychological sophistication leads to making sometimes cringe-worthy, laughable, dubious, and even dangerous decisions in his treatment of his difficult and demanding celebrity clientele. Unfortunately, Dr. Drew's compassion and caring often overcome his ability to be paternally firm and consistent when setting limits for his patients, some of whom act like (and, indeed, emotionally are) spoiled, petulant children who won't be told no. Or angry adolescents rebelling against external discipline and authority. Frequently, Dr. Drew and his staff make excuses for the residents' bad behavior, blaming it on withdrawal, medication, or, more generally, their "disease." This is a serious mistake. It tends to permissively collude in the patient's chronic denial of reality and responsibility. Personal responsibility, a fundamental part of accepting reality and adulthood, is habitually avoided by addicts. And this bad habit must be broken if recovery and sobriety is to succeed.
Of course, chronic intoxication and withdrawal from drugs influence one's feelings, perceptions, judgment, and actions. But does that make the person not responsible or accountable for his or her conduct? Under California law, for example, the courts specifically exclude intoxication and addiction in and of itself from the legal criteria for a plea of "Not Guilty by Reason of Insanity," which would stipulate that the defendant was not legally responsible for his or her actions due to their state of mind at the time the crime (or crimes) were committed. There is considerable wisdom in this statute. Existentially speaking, there are always choices available to someone, even in the throes of addiction, whether it be alcohol, drug, or sex addiction. And it is crucial to his or her psychotherapeutic treatment that full responsibility be taken for those typically self-destructive choices. Such choices start with the self-defeating decision to either continue to feed the addiction or, more constructively, to seek assistance of the sort offered by 12-step groups or Dr. Pinsky's Pasadena Recovery Center, and so many others like it. The addict may not have the power to say "no" to the substance or behavior yet. But they do have the power to say "yes" to getting help, a point made quite clear by Intervention.
The fact is that addiction, by definition, is a psychiatric, psychological, or mental disorder first, and a biological or physiological illness second. The recovery movement and Dr. Drew's own dogmatic conceptualization of addiction as a primarily biologically based disease is a significant part of the problem that he and others have in effectively treating such patients. Addiction, be it to alcohol, cannabis, sex, or porn, is not a biological disease like diabetes or leukemia. Patients may, in some cases, inherit a genetic, temperamental predisposition to the tendencies that make one susceptible to addiction. But that is not what makes them an addict. More than anything else, addiction is about denial of reality. It is, like depression, nonetheless a debilitating and potentially deadly psychiatric syndrome. People do suffer and die from addiction. And that these patients are severely ill, especially in the advanced stages of addiction and during withdrawal, cannot be denied. But that does not make addiction a biological "disease" per se. For, as AA has long rightly recognized, thanks to psychiatrist Carl Jung's influence on its founder, alcoholism and other addictions are at least as much sicknesses of the soul, psyche, or spirit as of the physical body and brain.
Psychologically speaking, addiction is all about escapism. Avoidance. Denial. Addicts run from reality, and in some cases have been running all their lives. The addict cannot tolerate reality and its vicissitudes. Neither internal reality nor external reality. They find reality repugnant, uncomfortable, and overwhelming, and prefer, like the psychotic, withdrawal into fantasy, bliss, or oblivion over reality. They seek constantly to alter subjective and objective reality to their own liking. For one thing, reality — the existential facts of life — can be both painful and anxiety-provoking. Like all of us, addicts don't like confronting pain or feeling anxiety. That's human nature and comports with Freud's "pleasure principle": We all tend, whenever possible, to avoid pain and seek pleasure. Addicts prefer the pleasure of intoxication, the bliss of oblivion, to the suffering, banality, ordinariness, and difficulty of mundane day-to-day reality. Of course. Reality inevitably includes suffering, pain, loss. Reality entails consciously acknowledging, not just intellectually but emotionally, both what was hurtfully done to us in the past (by parents, peers, or others) and what we have hurtfully done to others. Who wants to experience (or re-experience) that? But the problem is that to avoid this reality, the addict has to keep getting high, because these "demons" never go away. They're always there, lurking, waiting to bite them in the ass as soon as they start coming down. And what goes up must always come down. So this is the psychological problem of addiction. And when it (consciousness) comes crashing back to Earth, reality and withdrawal from fantasy painfully set in. The psychological and emotional demons and demands of reality return with a vengeance. Reality cannot be run from indefinitely. A major part of addiction treatment entails acknowledging, confronting, and experiencing reality. In most cases, the addiction has permitted the patient to keep outer reality and his or her inner demons at bay. Sobriety forces the addict to face reality, motivating the addict to want to find some way to avoid or alter it again. Breaking this vicious, sometimes fatal, cycle of avoidance of inner and outer reality is the key to treatment. This holds true not only for the addicted patient, but, to some extent, for all psychotherapy patients.
So many addicts (likely including some of Dr. Pinsky's patients) suffer from undiagnosed major mental disorders and serious personality disorders. Their chronic substance abuse and addictive behavior is symptomatic of these masked mental health issues — while at the same time obviously contributing to and exacerbating them. The majority of such patients belong in and could probably benefit from what is called a "dual diagnosis" program, which is specially designed to address both their serious mental health issues and the co-occurring substance abuse or dependence simultaneously. To his credit, Dr. Pinsky seems to acknowledge this fact, often focusing in his televised sessions with patients on any history of trauma, especially physical, emotional, and sexual abuse during childhood. And he occasionally brings in psychiatrists, psychologists, and other mental health professionals to work with his patients. While it is clinically true in general that, in most cases, the severe substance abuse itself must first be addressed, detoxification completed, and sobriety established before meaningful psychotherapy for such childhood or other trauma can proceed in earnest, the reality is that without the proper therapeutic structure and support, this simply won't happen. As soon as the patient starts feeling stressed, sad, lonely, angry, or anxious, they will simply return to the only way they know to cope and comfort themselves: by doing drugs or engaging in compulsive, self-destructive "acting-out" behavior designed to avoid becoming more conscious of reality. Unconsciousness is the primary culprit in addiction. This is why intensive, ongoing, real psychotherapy needs to be an integral part of any effective treatment process for addiction.
The antidote to addiction is learning to tolerate reality. Little by little. That is what sobriety really is. This is what the recovering addict needs the most assistance with: soberly dealing with inner and outer reality. And part of existential reality involves personal responsibility. We are responsible for consciously facing and dealing with our inner demons as constructively as possible. And we are responsible for dealing maturely with the outer world. It is clear that, especially for so-called celebrities sheltered from reality by fame and money, sobriety (be it from alcohol or other substance abuse or compulsive sexual behavior) demands accepting the same reality we all deal with every day: being responsible for ourselves; making choices that are in our own best interest; and tolerating tedium, frustration, anxiety, and life's inevitable physical and emotional suffering. Addiction is the habitual avoidance of reality. What the addict needs to discover is that reality is bigger than we are. A devastating blow to one's narcissistic grandiosity, to be sure. But the beginning of healing wisdom and a willingness to accept and embrace reality — including both its negative and positive aspects — on its own terms.