Addiction and the Psychology of Deliberate Self-Harm and Suicide

Addiction science is at an impasse. Rates of addiction remain high. Translational results from decades of research conducted within the dominant brain disease paradigm are shockingly meager. Meanwhile, theories of addiction multiply and compete, fomenting disagreement about something as apparently simple as how addiction should be defined. Ultimately the cost of this impasse is borne by people with addiction themselves.

We need a new paradigm that puts psychology first.

Psychology is our most basic, powerful tool for understanding ourselves and each other. Humans are self-conscious and self-reflective beings. We understand ourselves to act for reasons, both good and bad. We take our actions to be explained by our thoughts and feelings, beliefs and desires, pleasures and pains, hopes and fears, plans and intentions. To understand human beings and explain their behavior, the first place to look is to their minds—that is, their psychological states. This is as true of a person in the grip of addiction as of anyone.

Shifting the Paradigm

My book What Would You Do Alone in a Cage with Nothing but Cocaine?: A Philosophy of Addiction argues for this paradigm shift. Addiction should not be defined as a brain disease but as a kind of behavior, namely a destructive pattern of drug use. A person is addicted if they continue to use drugs despite evident and severe costs, thereby acting profoundly against their own good.

The question this definition of addiction raises is why. Why do people use drugs self-destructively? Why don’t they quit for their own good?

Even if addiction is not defined as a brain disease, brain disease remains one possible answer to this question. The brain disease model hypothesizes that drugs have hijacked the brain, causing people to use compulsively. Simply put, the reason why they don’t quit is that they can’t.

Yet many people do quit—they recover. And many more could—if we were better placed to understand what is driving their use and offer individually and psychologically tailored care.

Psychology First

A psychology first approach to addiction does not deny that, in some cases, the answer to the question of why people use drugs self-destructively could be a diseased brain. Rather, it denies that addiction is the same for everyone and always and only about a diseased brain.

Human psychology is complicated. People—including people with addiction—are different. To help people recover from addiction, we need to recognize this basic truth.

The psychological factors that can explain self-destructive drug use are multiple and diverse. Some are cognitive, like denial and the array of biases we know to be part of ordinary human decision-making. Some are volitional, like cravings and the struggle for self-control that can beset any of us. Some are emotional, like the use of drugs to relieve suffering and the security-based attachment to drugs that can result. Some are based in a person’s social identity and sense of self as an “addict.” And then there is the profound importance of social, cultural, material, and economic circumstances to explaining addiction.

We don’t talk about any of this seriously and systematically enough when we talk about addiction. But we talk about something else even less: How the psychology of deliberate self-harm and suicide can answer the question of why people use drugs self-destructively.

How a Self-Harming or Suicidal Mindset Explains Addiction

The explanation is extremely simple. Some people use drugs self-destructively by design—not despite the evident and severe costs defining of addiction but because of them. These are people who struggle with a self-harming or suicidal mindset and use drugs as a means to self-harm or to die.

Of course, this is not true of everyone with addiction. But when it is true of a person, we need to acknowledge it to be in any position to help them overcome it—to change how they feel about themselves and their lives.

We can’t do this by pretending the problem is simply that they are compelled by a hijacked brain. We have to try to understand why people harbor desires to self-harm or to die. And we have to make space for people to give voice to what it is like to want to self-harm or commit suicide without shame or fear or judgment.

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First-Person Testimonials

People with addiction do give voice to these desires; we just have to listen.

Here is a what one of the subjects in a study conducted by philosopher and qualitative researcher Anke Snoek and her colleagues reports: “Part of my use was to punish myself and when I did use I would punish myself more by … because I would be regretful and thinking ‘oh why did I do that?’ and then it would become a prolonged punishment and ‘oh well you don’t deserve any better’.”

Here is the writer Cheryl Strayed, describing her addiction to heroin and her relationship with her boyfriend Joe, who was also addicted: “What I loved about Joe is that he didn’t love me, or himself. I loved that he would not only let me but help me destroy myself. I’d never shared that with another person. The dark glory of our united self-destruction had the force of something like love. I get to do this, I thought. I get to waste my life. I felt a terrible power within me. The power of controlling the uncontrollable. Oh, I thought, I get to be junk.”

And here is the philosopher Clancy Martin—who made numerous suicide attempts using methods such as hanging himself, cutting his wrists, and overdosing—writing about the connection between his drinking and his desire to die: “The tools were different, but the mission was the same … It doesn’t much matter whether it [takes] a person three years of worsening heroin addiction or three days of ferocious drinking or three terrible minutes with a handgun to end his or her life. The goal is death … Please, somehow, get me away from me.”

Notice how each of these people explains their addiction as deriving from a self-destructive drive. Notice also the presence of related themes that provide clues to their inner lives and psychologies: self-blame and the feeling of worthlessness; the allure of power and the need for control; the desire to escape not only from life but from the self.

Source: Princeton University Press

Lessons for Treatment

As a society, we are not good at talking about self-harm and suicide. It can be painful to contemplate let alone to witness, and we may be at a loss to understand these mindsets—or to know what to say to those who occupy them. But self-harming and suicidal mindsets are not uncommon. They are a natural if heartbreaking part of human life. We need to get better at talking about them.

Alongside collaborative efforts between clinicians and patients to identify risks and create viable safety plans, there are a suite of psychological treatments that can help to address the psychological foundations of deliberate self-harm and suicide, including cognitive behavioral therapy, dialectical behavior therapy, mentalization-based therapy, and therapeutic communities. When addiction is driven by a self-harming or suicidal mindset, these treatments offer potential help.

Better addiction research and treatment is desperately needed. Many obstacles stand in the way of both. But one is a failure to recognize the heterogeneity and psychology of addiction—including self-harming and suicidal mindsets.

To find a therapist, visit the Psychology Today Therapy Directory.