By Frank Riessman and David Carroll
(From Social Policy Magazine Vol 27. No.2/ Winter 1996)
America’s war on drugs and our own personal battles to overcome addictions, ranging from compulsive eating to shooting up heroin, are severely hampered by the widely held view that addiction is merely one thing and that it varies only in degree. There are really two kinds of addiction–simple and complex–that are different in nature and require totally different approaches to overcome them. Consider the social and political atmosphere concerning drugs and addiction today. Enormous anxiety and media frenzy prevail regarding the dangers of becoming addicted to practically anything from drugs and alcohol to sugar and caffeine. Recovery from addiction is regarded as a tormenting process fraught with peril, a life sentence with no guarantee of success. Headlines tell us of cigarette manufacturers pouring nicotine into their products, adding greater addictive power and toxicity to a substance already contributing to the deaths of 400,000 Americans a year.
The message behind these warnings and a thousand others is that addiction is an irresistible and pitiless force waiting to pounce on the unwary American. Once hooked, the road back to normalcy is long, agonizing and, for some, impossible. Beware!
Yet we also know that, over the past 25 years, 50 million Americans have quit smoking and that 90 percent of them did it on their own. No professional help was required, no medication was taken, and no support group was joined. According to a 1990 Gallup poll, 70 percent of people who changed their drinking habits stated that they had done so on their own, without the help of doctors, therapists, or AA. And while there are approximately 10 million problem drinkers in the United States, there are also 90 non-problem drinkers. In addition, most people are able to handle potentially ruinous practices such as gambling or overeating without becoming addicted. There are, for example, confirmed gamblers who court their muse no more than two or three times a year on holidays in Las Vegas.
A sizable population use hard drugs in a controlled manner with no increase in tolerance–the “weekend bopper” syndrome. And data from ten separate studies of heroin addiction show that 30 percent of heroin addicts spontaneously reniit. In the case of those veterans who returned from the Vietnam War addicted to heroin and morphine, more than 90 percent were able to break the habit and return to normal life within a year.
If these findings were the only ones available, it would be difficult to understand what the addiction scare is all about, until we remember that the number of problem drinkers in this country is greater than the entire population of New York City; the money from worldwide drug profits is worth as much in trade as oil, an estimated $300 billion a year; 10 percent of the American labor force is said to work high or inebriated every day; 70 percent of smokers have tried to quit and failed; the Environmental Protection Agency classifies second-hand smoke as a group A carcinogen; the abuse of alcohol, cigarettes, and other drugs costs Americans $238 billion a year, $3.4 billion of which is spent on health care; every man, woman, and child in the United States pays approximately a thousand dollars a year to cover the costs of health care needed by substance abusers.
It is striking that while so many people are addicted to so many things, so many others are able to use these drugs and not become addicted. Is the power of addiction exaggerated or underplayed? That’s the wrong question. It may be necessary to rethink our basic view of addiction. We postulate that there are really two very different kinds of addiction–simple and complex.
The American Psychiatric Association’s diagnostic manual defines addiction as follows: “The symptoms include tolerance (a need to increase the dose to achieve the desired effect), using the drug to relieve withdrawal symptoms, unsuccessful efforts or a persistent unfulfilled desire to cut down on the drug or stop using it, and continued use of the drug despite knowing of its harm to yourself or others.”
Simple addiction is superficial dependence. It does involve physical craving and withdrawal symptoms when the substance is removed. But ample evidence exists to suggest that this form of addiction can be modified without resorting to in-depth long-run group approaches such as AA or professional rehabilitation programs. It is reversible by means of willpower and individual effort. Simple addiction touches only a part of the addict’s personality. Another, often larger part, either opposes the addiction, fights it and overcomes it, or makes it worse by building it up.
Some people, however, cannot overcome their addiction no matter how hard they try. For some people smoking, for, instance, has a psychological hold on them that is far more powerful than their physical need. In such cases, willpower or simple habit-breaking techniques don’t work. These smokers have a far more penetrating problem-a complex addiction that is considerably less manageable. When scholars attempt to define addiction, they usually describe the complex form. DuPont, in The Selfish Brain: Learning From Addiction (1997), states that addiction has four basic qualities.
- Good feelings. The addictive product generates profoundly pleasurable physical and/or mental sensations. It also eliminates unpleas- ant sensations. The substance makes the user “high.
- Loss of control over the addiction. Like Frankenstein and his monster, addiction over- powers its creator, causing addicts to lose control over use of the substance and other areas of their lives. An extreme example is cocaine or crack addiction where the drug erodes the ability to feel ordinary human emotions or to monitor behavior no matter how harmful or self-destructive it may be.
- Compulsion to continue despite the conse- quences. The addictive behavior persists despite the problems it produces for the user and others. A man may know his drinking is forcing his wife into divorce and his teenage children to leave home, yet he continues to drink and refuses to seek help.
- Denial. The addict, to varying degrees, denies that he or she. has a problem. Complex addiction is self-camouflaging and self-protecting.
Taken as a whole, this definition highlights the major features of current thinking on the way addiction works. We would add that in addition to pleasure, craving, and compulsion, the driving force behind complex addiction is an attempt to use the external addictive product as a means of enchaining, altering, or repressing an inner psychological mood. This reflects profound inner problems, though users are typically unaware of the connection between their problems and their addiction. Such behavior is highly resistant to rational intervention. It is part of a compulsive need to attain repeatedly a quick fix for a disturbing inner state.
Complex addiction requires long-term, intensive intervention such as AA, other 12-step programs, or professional recovery centers and therapeutic communities. Rational, self-administered habit-breaking methods such as self-hypnosis and willpower do not work for complex addicts.
Smoking and Depression
Addiction to nicotine is unique because even in its simple form it is one of the most difficult addictions to overcome. Heavy users of heroin and cocaine say it is easier to give up these drugs than to stop smoking. While over 50 million people have overcome addiction to nicotine it was not easy. Only 5 percent succeed on the first attempt, and only a third hold out for as long as two days on each try. If their addiction is complex, smokers find it impossible to stop, despite all their personal efforts to do so and their knowledge of the long-term, life-threatening danger if they continue.
In 1985, Alexander Glassman and his colleagues began an evaluation of a new drug designed to help subjects stop smoking (Glassman, 1993). In order to test this product accurately, Glassman’s team agreed that testing would be confined to smokers who were free of serious mental illness. No smokers suffering from schizophrenia or major depression were invited to be screened. Nonetheless, and much to the surprise of the researchers, 60 percent of habitual smokers who were chosen for the experiment and who wished to stop smoking turned out to have had a previous record of a major depressive disorder. Smokers who suffered major depression in the past were twice as likely to be unable to stop smoking than those who were depression-free.
Noting that psychiatry had paid little attention to the relationship between smoking and mental illness, Glassman began investigating those few studies that already existed. Waal-Manning and de Hamel (1978) had demonstrated that smokers rated higher on symptom measurement scales than non-smokers for both depression and anxiety. Pomerleau et al. (1978) showed that smokers who identified “negative effect” as a cause for their smoking were more apt to find stopping difficult than those who did not identify it. These studies pointed to the possible link between addiction and mental disorder, and that the pleasurable symptoms associated with smoking either disguised the depressed mood, altered it, or actually caused it.
Glassman found that seriously addicted smokers who were treated for depression tended to quit more easily than those who went untreated. Professionals will put smokers on Prozac for several weeks until a blood level is estab- lished, then slowly wean them off tobacco.
Since Glassman’s pioneering work, many studies confirm the relationship between smoking, depression, and other mental disorders, especially schizophrenia. Studies reported by Breslau et al. (1992), for example, show that among young people major depression is related to nicotine-dependent smoking. A community-based study of 750 people in Los Angeles showed a significant relationship between depression and smoking rates among women. A CDC survey, among high school students, demonstrated that students who smoked were up to 18 times more likely to say they had attempted suicide than nonsmoking students.
Nicotine produces a mild euphoria in many users and tends to increase alertness and concentration. A number of tests show that subjects register a small but measurable improvement in memory and attention when tobacco is inhaled. Some smokers claim that cigarettes have a relaxing effect and reduce stress.
Grenhoff et al. (1986) have shown that nicotine helps release the neuro-transmitter dopamine, similar to the mechanism at work in the euphoria-producing chemistry of opiates, amphetamines and cocaine.
For those who can quit without severe difficulty, the habit is casual and physical. It is a simple addiction in its clearest form. However, for those who have tried to quit for many years or, conversely, who continue their habit despite full knowledge that it shortens their life span, smoking has a far deeper and more enduring psychological grip. It may be masking an underlying pathology such as depression. Their cigarettes take on an almost totemistic meaning and they refer to them as their “friend,” their “last pleasure,” or their “anchor in the storm.”
Alcoholism
A percentage, albeit a small percentage, of reformed problem drinkers are capable of social drinking at a moderate level. Such persons are simple addicts. For them, drinking is just a social uninhibitor and a pleasant high.
Alcoholics who are complex addicts, on the other hand, drink not just for the taste or the kick or the company, but because alcohol gives them, for a variety of chemical, physiological, and genetically-based reasons, benefits that they desperately need.
James Milam, the indefatigable proponent of the biologic theory of alcohol addiction, holds a view that an inborn physiologic weakness lies at the root of alcoholism rather than a psychological need, namely that an alcoholic’s body cannot process alcohol normally.
He divides drinkers into two groups: those who are born with an irresistible physical propensity for alcoholism and those who are not. “Alcohol is a selectively addictive drug,” he writes. “it is addictive for only a minority of its users, namely, alcoholics. Most people can drink occasionally, daily, even heavily, without becoming addicted to alcohol. Other (alcoholics) will become addicted no matter how little they drink” (Milam and Ketcham, 1981, p. 34).
Stopping is always an option for nonalcoholic drinkers, Milam claims, and they usually can wean themselves on their own. Such persons are free to choose their own drinking destiny. Those born with a biologic weakness for alcohol represent a highly vulnerable alcoholic target. If they drink, their genetic tendency will inescapably addict them.
Suppose that a biologic alcoholic begins drinking whiskey on a regular social basis. Like many people, she likes it, so she continues to drink, believing that the feelings the alcohol arouses in her are entirely normal and are experienced by other people as well. Soon, however, her biological urge kicks in, and she craves the whiskey more intensely than her drinking friends do. The secondary need stems from her biological makeup rather than her personality.
The rhythm and intensity of the growth in power of addiction differs in relation to each person’s biological makeup. The part of the drinker’s personality that might oppose the addiction is overcome by the part that biologically (or in our model, psychologically) craves the alcohol. There is, as a result, no resistance after a certain point. His or her addiction is complex.
When and if such biologically based alcoholism is controlled, the ex-drinker is obliged to remain sober, as organizations such as AA insist. Unlike the simply addicted person, light social drinking is not an option. “Alcoholics can never safely return to drinking,” writes Milam, “because drinking in any amount will sooner or later reactivate their addiction.”
We can now see that the apparently contradictory attitudes toward addiction–that it is self-curable, that it is not self-curable; that it is a disease, that it is not a disease; that its power over people is exaggerated, that its power is supreme—each possess a kernel of the truth. The ultimate power of addiction depends on whether it is a simple or complex addiction.
Food Addiction
Take sugar. Some people eat large amounts of sugar-based foods every day, yet never develop an addiction. The sweets carry no charged symbolic value, The taste alone is the attraction. Such people have a simple addiction. In complex addiction, people not only derive taste pleasure from sugar but cathect to it as well, finding in a candy bar or bowl of ice cream a deep psychological comfort, a sense of security or self-reward that developed in childhood.
An example of complex addiction comes from one of the authors’ own experience. A confirmed drinker for many years, Riessman enjoyed two or three martinis every night before dinner. He found that the alcohol relaxed him and induced a pleasant sensation, but friends and family began to believe that he had become an alcoholic.
In 1990, diagnosed with diabetes, his physician told him that he would have to control all sugar, and he must stop or control his drinking. That very day, he completely stopped drinking: without withdrawal symptoms, without craving, and without regret. But he found himself entirely incapable of breaking his addiction to sweets, specifically to the half-pint of ice cream he enjoyed each night before bed. Well aware of how dangerous it can be for a diabetic to eat so much sugar at a single sitting, he nonetheless could not forgo this nightly treat no matter how hard he tried.
Why, it might be asked, could someone stop a lifelong habit of drinking gin, a substance renowned for its addictive qualities, in a single day, yet find it so difficult to stop eating something as innocuous as ice cream? For Riessman, the alcohol was a source of relaxation and enjoyment only, and his attraction to it was, at most, simple addiction. The icy dessert, on the other hand, harkens him back to happy and secure past times. Like Proust and his madelaine, the sweet taste of the ice cream triggered unconscious associations of highly charged positive emotional experiences-birthday parties, parental rewards, family gatherings, warm summer nights, home, friends, fun, the lost joy of being a child. This effect was far more significant than the physical relaxation produced by the alcohol; and so, with all its embedded psychic symbolism, the ice cream became the drug of choice, a complex addiction.
Methods of Intervention
What are the implications of the simple/complex addiction model for treatment? One explanation for the high failure rate among interventions is the fact that efforts are often made to treat complex addiction by simple means. And conversely, the application of in-depth interventions for relatively mild and self-treatable addictions may be one reason that critics insist that the “myth’ of addiction has been oversold to the public. Successful intervention depends on accurate diagnosis.
We thus recommend the following approach to intervention:
- For simple addiction, relatively modest methods of recovery are appropriate such as willpower and self-hypnosis, which can be self-applied.
- For complex addiction, in-depth, long-term treatment methods should be utilized with an emphasis on total abstinence, personality change, self-help group participation, and prolonged rehabilitation.
This process, of course, presumes that these two addictive modalities can be clearly distinguished. Sometimes, this may not be possible in a therapeutic setting; as with most aspects of human behavior, gray areas exist. For example, is someone’s cigarette smoking or alcohol use a problem or just a bad habit? The boundaries are not always clear and tend to change over time and in different social settings. When do we call a repetitive, pleasure-driven behavior a simple addiction, when a serious problem? Though the answers to these questions require considerably more study and observation, we would suggest that complex addiction is often indicated along with the need for a more serious form of intervention when one or more of the following conditions are met:
- Users find it impossible to stop their addictive behavior;
- Users are in a state of extreme denial about their addiction;
- The addiction causes serious personal problems for the addict on the job and for the addict’s friends and/or family;
- Physical illness related to addiction does not lead to stopping.
Once diagnosed, what type of intervention, is appropriate for each?
For simple addiction, intervention is oriented toward rapid recovery. Persons suffering from physical dependence or from an intermediate dependence between simple and complex may require stronger medicine than willpower, but not always. It may be true that only the simply addicted person is capable of breaking a dependency on his or her own. Complex addiction, by definition, is out of control and “curable” only with the help of others.
There are a number of possible types of treatment and habit-breaking techniques for the simply addicted person.
Willpower. Due to physical discomfort, illness, lack of money, personal problems or any number of other reasons, users decide it is time to stop. This is an ambitious undertaking but, statistically speaking, a majority of people who overcome simple addiction do so without outside help. Many people suffering from alcohol dependencies are classified as alcoholics although they may be experiencing a simple addiction that is relatively easy to reverse. When Peele (1989) and others observed just how easily such persons break their addiction, they identified the entire 12-step movement as a superfluous program when, in fact, it is superfluous only for one type of addict. It may be that the intervention groups that Peele points to as being statistically more successful than AA actually cater to a higher portion of simple addicts than to complex addicts. Some “simple” alcoholics, for example, may select AA because it’s the only game in town, then leave soon afterwards because its level of intensity and demand is not needed.
Meditation and religious practice. Many mildly addicted persons find that prolonged periods of quiet sitting, either of the religious kind (Zen, yoga, prayer) or secular concentration exercises, help center the mind and reduce the addictive urge. A number of religious, centers around the country offer do-it-yourself “spiritual detox” programs for drug and alcohol abusers.
Exercise. Exercise is widely used to promote and expedite physical detoxification. Jogging, calisthenics, aerobics, and other regular exercise serve as a natural antidepressant or tranquilizer and take the edge off the addictive need.
Nutrition. Theories abound concerning the relationship between nutrition, vitamin deficiency, and addiction. Lack of B-complex vitamins, especially BI and B6, is sometimes suggested as a cause of alcoholism. Alcohol is known to destroy calcium, iron, and magnesium, so supplements may help. Glutamic acid has been shown to be of some value. Improper balance of food groups has been targeted by some nutritionists as a reason for chronic overeating. Some users claim success following certain diets or self-cleaning juice fasts. As yet we are not certain if the positive results gained from such regimens derive from science or from suggestion. We don’t know if the gains people make from improved nutrition and increased vitamin intake come from some unknown anti-addictive chemical in the food or from the natural benefits that a decent diet bestows.
Herbs. A small number of simple addicts prepare herbal potions to help reduce addictive desire. Angelica root tea is recommeded for recovering alcoholics. Bugle weed is prescribed for treating people with DTs. The Chinese herbal materia medica includes a number of patent medications especially blended for drug craving, overeating, and cigarette urge. Commercial anti-addictive herbal mixtures can now be purchased at health food stores and even in a few supermarkets.
Anti-stress techniques. A combination of travel, change of scene, time off, socializing, massage, hot and cold baths, and participation in sports and games can be part of a self-recovery plan.
Hypnosis. Professional hypnosis has long been used as a method for helping addicts stop overindulging in smoking, drinking, eating and sex. The ultimate effectiveness of this method is in debate.
Self-hypnosis and self-suggestion. Self-hypnosis is easily learned, easily applied, and is a popular self-help method for overcoming almost any addiction. Its most commonly used form is guided imagery to help stop smoking.
Acupuncture and acupressure. Auricular acupuncture of the ear is used to help stop smoking. Many acupuncturists, acupressurists, and practitioners of oriental massage advertise anti-addiction treatment for alcohol, drug, and eating disorders. Some entrepreneurs have developed special ear clips and bracelets, said to stimulate anti-addiction acupoints or reduce appetite. Self-applied acupressure techniques for reducing the urge for cigarettes or alcohol are in wide use, and a number of books feature chapters on self-applied addiction control.
General alternative medicines. Homeopathy, chiropractic, radionics, rolfing, massage, light and heat therapy, energy healing, and other non-orthodox therapies are used by an increasing number of persons for tension control and relief from physical dependencies.
Complexly addicted persons, on the other hand, require stronger medicine, usually an intensive program such as AA or a professional rehabilitative treatment.
Complex addiction is deeply rooted in the person’s psyche and/or biological makeup. In such cases, what is required is an overall physical, emotional, and spiritual program of recovery plus a well-developed support system. The goal is not temporary abstinence, but permanent and uncompromising sobriety.
One of the important implications of the simple-complex analysis relates to the issue of pain reduction. There is a tremendous fear that the larger configuration that we term complex addiction may result from prescribing morphine for severe pain. However, in these cases, the addiction is simple and is overcome fairly easily. U.S. News and World Report (March 17, 1997) reports a study that found only seven cases of serious addiction in a population of 250,000 that received morphine in large doses.
The conceptual framework of simple and complex enables us to understand why different approaches are effective for different people, to use our resources more efficiently, to help addicts understand the nature of their addictions, and ‘to cure a far greater percent- age than current approaches permit.
Conclusion
The two types of addiction clearly call for different interventions. We need to develop distinguishing characteristics of the two types prior to intervention. A complex addiction always includes an intervening variable such as depression with regard to smoking and the physiological dimension in the alcoholic (the belief that the alcoholic metabolizes alcohol differently is one of the physiological hypotheses). At present, the difference between two types–simple and complex-is only determined after the treatment intervention, e.g., the drug addict responding to acupuncture would be classified as a simple addict. The drug addict who does not respond to this methodology would be seen as a complex addict particularly if he or she is relatively responsive to Narcotics Anonymous. The real challenge is to predict these different types prior to treatment. For example, the construction of questionnaires, interviews, life histories, and behavioral indicators could make a treatment prediction, which would then be tested over time. What, for example, are the intervening variables for compulsive gamblers, compulsive overeaters, cocaine users, workaholics, and so on?
If psychological factors such as depression are critical features in complex addiction, why all the fuss? Why not see the psychological underpinning as the essence? The answer lies largely in the special power of addictive behavior. A depressed individual is one thing, a depressed smoker is quite another. The addictive elements, withdrawal symptoms, and increased tolerance have powers of their own. In combination with psychological or physiological factors, in the case of alcoholism, a complex addiction emerges, resulting in a problem that is much more difficult to treat. Above all, the proper form of intervention must be appropriately matched to the individual’s type of addiction. It is also key that intervention be designed as nearly as possible to address the whole person and not simply the physical craving. When the whole person is addicted, the whole person must be treated.
References
Breslau, N. et al., ‘Nicotine Withdrawal Symptoms and Psychiatric Disorders: Findings from an Epidemiologic Study of Young Adults,’ American Jotirnal of Psychiatry, 149, 1992: 464-469.
Dupont, R., The Selfish Brain: Learning from Addiction (Washington, DC: American Psychiatric Press, 1997).
Glassman, Alexander, H., “Cigarette Smoking: Implication for Psychiatric Illness,” American Journal of Psychiatry, 150, 1993: 220-237.
Grenhoff, G. et al., ‘The Nicotine Effects on the Firing Pattern of Midbrain Dopamine Neurons,” Acta Physiol Scandinavian, 128,1986:351-358.
Milam, J. and Ketcham, K., Under the Influence (New York: Bantam Books, 1981).
Peele, S., The Diseasing of Ameyica.- Addiction Treatment Out of Control (Lexington: Lexington Books, 1989).
Pomerlau, O. et al., ‘Predictors of Outcome and Recidivism in Smoking Cessation Treatment,” Addictive Bebavior, 3,1978: 65-70.
Waal-Manning, H. and Dehamel, F., “Smoking Habit and Psychometric Scores: A Community Study,” New Zealand Medical Journal, 88,1978:188-191.