Addiction – why is it hard to change?
At the end of this blog is a link to the YouTube video which is the audio version of this discussion of addiction. Sometimes it can be helpful to read the words on the page and hear them being spoken at the same time.
From a psychology and counselling viewpoint, it is commonly agreed there are around ten signs of addiction:
1) The behaviour is uncontrollable despite attempts at control.
2) There are negative and self-destructive consequences to varying and escalating degrees as a result of the behaviour.
3) Despite these negative consequences, the person experiences extreme difficulty when trying to change behaviour.
4) The behaviour continues in spite of the person’s persistent desire to stop.
5) The person can become secretive and make attempts to hide the addictive behaviour from others.
6) The behaviour is a dysfunctional method of coping with life and/or dealing with negative emotions.
7) The addictive behaviour generally escalates overtime.
8) The person experiences large mood fluctuations and ambivalence or conflicted feelings concerning the behaviour.
9) An excessive amount of time is spent either thinking about, engaging in or recovering from engaging in the addictive behaviour.
10) And there is a significant reduction in time spent on other and more productive activities.
The key features are that the behaviour is persistent, uncontrollable and has clearly self-destructive consequences.
The saying “once an addict, always an addict”, has arisen from both lay and professional observations that people engaging in addictive behaviours often have difficulty stopping permanently. Studies show relapse rates after treatment are around 80% and this is regardless of the treatment method. My own view is that the fact that even one person who was previously in the grip of an addiction has given up permanently is evidence that the saying “once an addict, always an addict” is not true.
Still, a lot of people really do struggle to change, what follows is some of the reasons why:
Reward/Delayed Gratification - One of the reasons people continue with self-destructive addiction behaviours is the immediate consequences (or rewards) from the behaviour are positive. They temporarily bring pleasure and/or remove pain and the negative consequences of engaging in the behaviour are temporarily delayed.
The reverse occurs when people try to abstain, where the immediate consequences of stopping will be negative (withdrawal, craving, difficult-to-manage negative feelings) and the positive consequences of recovery from the addiction are a longer-term goal that is delayed.
The most immediate consequences have the strongest impact on our behaviour, and this partly explains the difficulty of breaking an addictive behavioural cycle. This is known as instant gratification and is contrasted with delayed gratification which is the ability to endure discomfort and wait for a reward.
Before psychotherapy or counselling treatment is likely to be effective it is essential that, in the mind of the person with the addiction, the negative consequences of engaging in the addictive behaviour must outweigh the positive consequences, and they need to have developed the ability to delay gratification - endure discomfort whilst waiting for a delayed reward.
Disease/Genetic Concept – How professionals talk about addiction can influence peoples understanding of their problems. For example, believing they have the addiction gene or viewing alcohol addiction as a disease, can be seen as meaning the individual is not responsible for their problems. In overcoming addition, factors such as motivation, commitment to change and willpower are instrumental in making lasting changes. A person who views their addiction as biologically determined, either as a disease or genetic, may view the problem as outside their control and they may be less likely to believe they have the power to change as a result. Although the disease/genetic concept may be factors in why some people develop certain addictions and why some people may find it hard to change, it cannot account for those who successfully change their addictive behaviour. Additionally, it is not always a helpful concept in terms of recovery as it can become a self-fulfilling prophecy, fostering feelings of helplessness and lack of personal responsibility that make it much more likely people will struggle to change.
Motivation & Readiness for Change - A high degree of personal motivation is required to successfully change addictive behaviour. Being ready for change and having the motivation means the negative consequences of the addiction must outweigh any perceived benefits in the person’s mind. And, they need to also believe they are capable of changing.
Expectations - The expected effects of the addictive behaviour are thought to be influential in determining whether an individual engages or not. This ties in with the difficulty in delaying gratification, where people with higher positive expectations of the results of engaging in the addictive behaviour will engage more often and struggle to abstain. When someone focuses more on the positive aspects of their addiction, we say that they are not yet ready to change, either because they do not recognise they have a problem yet or they fluctuate in and out of denial.
Recognition of the problem is the foundation for developing enough motivation to change. Having negative expectations, of both the short and long term effects of the addictive behaviour, indicate the person has reached problem recognition and are likely to be ready for change.
Co-occurring Psychological Issues - Some theorists suggest that underlying psychological problems can precede and even cause the development of problematic addiction behaviours. Having psychological problems as well as an addiction issue can make it even more difficult to change. People can get drawn to addictive behaviours as a way of managing underlying psychological or mood management problems, but the addiction will make any pre-existing mental health problems worse. This is illustrated by the fact that people who do not already have underlying mental health problems, can and do often go on to develop them as a result of their addiction. And, it can sometimes be difficult to know which came first, the addiction or the mental health problem. In those cases where someone has both a mental health issue and an addiction problem, recovery will be extremely unlikely unless the underlying psychological issues can be identified and treated successfully with psychotherapy or counselling, in addition to the addiction issue. A stumbling block for many is that the addiction behaviour, particularly if it involves substance use, will need to be tackled first. The reason for this is that destructive addiction behaviours are patterns that tend to contribute to, reinforce and exacerbate emotional and psychological difficulties. If the addictive behaviours are not addressed first, psychotherapy or counselling treatment is unlikely to succeed because it will be undermined by the addictive behaviour. When substances are involved, this is especially the case because they change how the brain processes information and psychotherapy and counselling require participants to be able to access their difficult emotional material and substance use is often engaged in precisely to keep this difficult emotional material out of awareness.
The self-medication hypothesis - this assumes, specifically for users of drugs or alcohol, that they self-administer to treat their underlying psychological or emotional disturbance. The self-medication hypothesis can also apply to other non-substance addictions because of the way engaging in an addictive behaviour temporarily changes brain chemistry. Individuals who find it difficult to deal with their negative emotions or struggle to have positive feelings and positive relationships, can self-medicate through their addiction as a way of coping. However, as mood and psychological disturbances develop as a result of engaging in addictive behaviours, particularly substance use, any pre-existing mental health problems are often made a lot worse, not better.
Psychological Factors - although the biology of addiction is important, particularly with regard to substances that produce physical dependence, psychological factors are more important when it comes to changing. The reason for this is because people generally have a high degree of emotional and motivational investment in continuing with addictive behaviour. Combine this with beliefs concerning responsibility for and ability to control personal behaviour and it is easy to see why psychological factors will dominate whether a person can successfully change or not. It is not just the withdrawal symptoms, which are of limited duration, that make change difficult, detoxification is only the first stage, after which the psychological factors that kept the addiction behaviour going must be dealt with and it is these that most often stop people from being able to change their addiction behaviour. The ability to delay gratification and to endure discomfort without turning back to the addictive behaviour is often missing.
Social Factors - Studies have highlighted the importance of social factors, particularly supportive relationships as influential in helping people change addiction behaviour. Other significant social factors are the negative health, legal and/or financial consequences of not changing. Relapses are thought to result from an interaction of social, psychological, situational and physiological factors that interact with each other so that it is not possible to specify a single factor as being predominantly responsible either for managing to change or not managing to change.
Motivation - plays such a key part at all levels of addiction, from starting the behaviour in the first place, to deciding to stop and then relapsing only to attempt stopping again. We tend to think of motivation as an internal state, something people either have or don’t have. But motivation is influenced by many internal and external factors, such as social context, beliefs about responsibility and control mentioned earlier. Motivation is prone to fluctuation depending on what is going on externally around the person, it is not a fixed attribute that is either present or not in unchanging quantity. Another key feature of motivation is that it must be the individual who has established their own arguments for behaviour change rather than going along with what someone else has suggested they do. Crucial for success is the individuals commitment to stopping, their belief in the reasons why stopping the addictive behaviour is a good idea and also that they believe they can succeed.
Independence - Some people with addiction issues have not achieved sufficient independence from their families/partners and the family/partner can inadvertently function in a co-dependent way that makes it more difficult for the person to change. Sometimes, focusing on the member of the family or partner who has the addiction problem can actually be a distraction away from more serious underlying dysfunction within the family or the relationship. The family or partner may inadvertently undermine the person’s attempts to abstain as they may have a vested interest in keeping the addicted person with them in co-dependency. When there is a danger that the person will succeed in changing, this can be destabilising and cause the family or partner to feel threatened with the loss of their role. These dysfunctional family or relationship patterns have been called “enmeshed” and in such cases the family or partner may need to be involved in the psychotherapy or counselling treatment to look at their own issues. Additionally, the addicted person may need encouragement to detach and become more autonomous and independent and less “enmeshed”.
Meaning/Alternative Sources of Reward - To successfully stop an addictive behaviour, it is essential to find new sources of reward to replace the addiction, for example, finding new sources of human acceptance and affection, and establishing new interests, new goals and meaning in life. Giving up an addiction can leave a large void in an individual’s life and if it is not filled with functionally rewarding activities and rewarding relationships then relapse is more likely. This can be one of the biggest obstacles for successful change, and the less the individual has sources of pleasure, reward and interest outside their addiction the more difficult it will be for them to change their behaviour permanently. Sometimes people may have to change their environment and let go of some relationships if they are to succeed in changing. This includes giving up associations with people who continue to engage in the addictive behaviour, avoiding situations or learning new responses to situations that trigger urges to engage and, as stated already, finding alternative sources of reward in social, vocational and leisure activities.
Misunderstanding Relapses - A major problem that many people have when trying to stop an addictive behaviour is rather than seeing transitions in and out of addiction as part of the process that eventually leads to recovery, the first occasion of relapse can often be misconstrued in their mind as the final outcome of trying to change and they don’t make further attempts as they conclude they are not capable of change. It is unrealistic to expect people who habitually engage in addictive behaviours to be able to stop completely and permanently at the first attempt. Lifelong and total abstinence is an unrealistic and potentially demotivating goal. People often need to go round the cycle of change and in and out of abstinence several or even many times before they get to where they want to be and can maintain permanent behaviour change.
Psychotherapy or Counselling Focus - Instead of seeing addiction as a discrete all-or-nothing entity that people either suffer from or do not suffer from, it may be more realistic and beneficial to concentrate on, and expect, the transitions between active engagement and periods of abstinence that lead to eventual recovery. Periods of relapse after commencement of psychotherapy or counselling are a valid focus of attention. This enables people to learn valuable insight into the dynamics of their behavioural choices and will increase their chances of remaining abstinent for longer the next time around. It is essential not to see success as all (abstinence) or nothing (use). Concentration should also be on the periods of successful abstinence, however short, not just on the relapses, so more positive and motivating messages are fostered and the prospects of increasing abstinence are improved. Any relapses should not be seen as inevitable or due to personal deficiency but as a decision they made and the person is encourage to fully understand what led up to each decision to re-engage in the addiction and figure out what they need to do differently next time. This way of taking responsibility helps the person believe in themselves and start to get more control over their behaviour.
Summary - Each person will have their own particular hierarchy and configuration of what they need to do and to change before they can successfully maintain abstinence from their addictive behaviour. However, the commonalities are that each person must first recognise their addictive behaviour is problematic, accept that they are responsible for their behaviour, believe they are capable of changing it and have developed their own arguments and motivation for doing so. Abstinence will leave a void that must be filled with new sources of reward and recreation and if supportive and warm social relationships do not exist for the person already, they must be established perhaps along with social skills training, if required. Engagement with the environments and people associated with the addictive behaviour should be limited or avoided where possible. Additionally, new responses to deal with potentially triggering situations and people must be learned. Any psychological problems must additionally be addressed, whether they preceded the addiction or developed as a result of the addiction is not always a relevant factor in psychotherapy and counselling.
Getting out of the cycle of addiction will be more difficult the more environmental, psychological and social changes a person has to make. Formal treatment in psychotherapy and counselling can help the if the person seeking to change and therapist are mutually honest with each other. The therapist additionally needs to make sure that each area discussed above is tackled and the person is treated holistically and with respect, compassion and empathy.
I suppose this has been more like an essay than a blog, it is such a complicated area but if you know anyone who is struggling with addiction, or maybe you are yourself, I hope this has reassured you that there is always help at hand.
I hope you enjoy the video and please do let me know what you think. If you have a YouTube account and are signed in, you can leave a comment on YouTube. Alternatively, just send me an email to info@louhillier.co.uk to let me know your thoughts or if you would like more information on how to access psychotherapy or counselling for yourself or for a family member or friend.
Don't forget, help is always just a click away ...
Namasté
Lou