The Puzzle: why is recovery so hard?

A lasting recovery from a serious addiction is made much more likely by an accurate understanding of the nature of the addictive process and of the methods that have been found, by long experience, to be effective in overcoming it and keeping it in remission. In regard to addiction and recovery, as in most other challenging tasks, knowledge is truly power. For the more the addicted individual understands about what is actually going on with him and how to overcome it, the better are his chances of long as well as short term success at freeing himself from addiction.

But although the hard won experience of addicts and those who treat them is freely available from a variety of sources, e.g. books, 12 Step Meetings, treatment programs, friends or family members who have recovered &etc., the very same experience also shows that one of the principal obstacles to making use of this information is pre-existing misinformation about addiction that is usually remarkably resistant to change. The typical addict can therefore be said to be doubly ignorant, or negatively informed about his actual condition: for not only are his ideas about what is wrong and what needs to be done almost always incorrect, he is very likely to cling tenaciously to his false beliefs and to resist enlightenment and thereby relief from the experiences of others. It is as though a drowning man were deliberately to shove aside a life preserver and even to actively fight the rescuers who are struggling to pull him to safety.

The basic facts about addiction and recovery are neither complex nor difficult to understand. Why, then, do addicts have such difficulty in grasping and acting upon them? The answer to this question itself depends upon a correct understanding of addiction and its influence upon the thinking and judgment of the addicted individual.

Two Views of Addiction

Although there continue to be many people who believe that there is no such thing as addiction, i.e. that excessive or unhealthy involvement in a particular activity is merely a matter of unwise personal choice, those who have had direct experience of addiction either in themselves or in others are aware that matters are not quite so simple as the "personal choice" model suggests.

Personal Choice

The personal choice theory of addiction denies that the use of the term addiction adds anything useful to the understanding of behavior. Adherents of the personal choice model may even regard the concept of addiction as an unjustified evasion - an excuse for bad, unhealthy, or unfortunate personal choices, e.g. the choice to drink more alcohol than is good for one. According to such people there is nothing really different about alcoholics and other addicts besides the fact that they choose to indulge in certain behaviors to a degree considerably in excess of what is good for them and frequently those around them. Believers in the personal choice model envision a smooth continuum of behavior along which the entire population is distributed. In the case of alcohol consumption, some people choose to drink more, others choose to drink less. The only thing that differentiates them from one another is their choices. To a believer in the personal choice model, the introduction of the term "addiction" into the picture is both unjustified and unhelpful because it blurs and confuses what is thought to be at bottom a simple and straightforward question of choice.

Whether thought to result from personal choice alone or from a condition called addiction, the behavior that is of concern in such cases exhibits the following characteristics:

1. Excessive
2. Actually or potentially harmful
3. Repetitive
4. Stereotyped
5. Chronic
6. Highly resistant to change
7. Prone to relapse and recurrence when interrupted
8. Accompanied by denial and other psychological defense mechanisms

Although it is common to think of addiction only or mainly in connection with certain drugs, the characteristics of addiction listed above are actually manifested in a number of circumstances that need not involve drugs or alcohol. Pathological gambling, compulsive spending, certain forms of over- or under-eating and a number of other activities frequently display the very same characteristics and can in such instances be described as addictive behaviors. This broadening of the concept of addictive behavior is one of the things that disturbs adherents of the personal choice model, for they fear that if everything becomes a manifestation of a condition called addiction, no individual moral accountability for unwise and even immoral choices will remain.

Addictive process, illness, disorder or disease

The term "addiction" derives from the Latin addictere, one meaning of which is "to be bound to another." This refers to a process in Roman law in which a person, formerly free, was given over to another as a servant or slave. The modern understanding of addictive behavior is thus that the individual afflicted is not wholly free in his choices. To a greater degree than is the case with the non-addicted person, the choices of the addict –if they can even be called choices- are constrained or determined by factors at least partially outside his control. According to this view, the addict acts the way he does, not because he is unwise, stubborn, foolish or bad, but because he cannot help doing so. Whether it is called a disease in the strict sense of the word does not matter so much as does the conviction that in such cases there is something wrong with the addict that is not wrong with other, non-addicted people. In some fundamental way, according to this point of view, the addict is different from the non-addict.

Benjamin Rush (1745-1813), was a widely respected physician, signer of the Declaration of Independence, and chief medical officer during the Revolutionary War. Rush published An Inquiry into the Effects of Ardent Spirits on the Human Mind and Body in 1784. "‘Drunkenness is the result of a loss of willpower. Initially drinking is purely a matter of choice. It becomes a habit and then a necessity.' His view was that habitual drunkards suffered from an illness requiring medical rather than moral treatment.

Benjamin Rush's view differed from that of the famous preacher Jonathan Edwards, who in 1754 had published his Freedom of the Will in which he wrote:

"A man never, in any instance, wills any thing contrary to his desires, or desires any thing contrary to his Will.... His Will and Desire do not run counter at all: the thing which he wills, the very same he desires"

What Do Most Addicts Themselves Think?

Although "personal choice" advocates fear that if individuals who drink or drug or otherwise behave in a fashion that is called addictive are informed by experts that they suffer from a condition or disease which deprives them at least partially of the ability to control themselves, they will interpret this as a blank check to throw off whatever remains of their already diminished sense of moral responsibility for their choices, actual experience with alcoholics and other addicts shows that this is far from being the case. In fact, it is the very opposite of the way that active alcoholics and addicts think. And it is this seemingly paradoxical or counter-intuitive finding that gives a clue to the question raised above:

The basic facts about addiction and recovery are neither complex nor difficult to understand. Why, then, do addicts have such difficulty in grasping and acting upon them?

"The God that holds you over the pit of hell, much as one holds a spider, or some loathsome insect over the fire, abhors you, and is dreadfully provoked: his wrath towards you burns like fire; he looks upon you as worthy of nothing else, but to be cast into the fire; he is of purer eyes than to bear to have you in his sight; you are ten thousand times more abominable in his eyes, than the most hateful venomous serpent is in ours. You have offended him infinitely more than ever a stubborn rebel did his prince; and yet it is nothing but his hand that holds you from falling into the fire every moment."

For there are no more passionate and determined believers in the "personal choice" theory of addiction than practicing addicts themselves. Nor is the belief of addicts a merely impersonal or abstract one: they are prepared to risk, and do risk, their honor, their fortunes, and their very lives on their belief in the complete freedom of their will.

It has been said that an alcoholic is a fellow who can take it or leave it – so he takes it. And why not? For the majority if not the entirety of his drinking career, the typical alcoholic is completely convinced that he can stop drinking any time he truly desires to do so. In most cases, in fact, he has a private plan to stop drinking – when or if matters ever truly become bad enough to warrant his taking what seems to him such a drastic step.

Nor does the addict –of which the alcoholic is merely a convenient and familiar example- usually doubt his ability to control or moderate his substance use when he desires to do so. "Personal choice" advocates fear that telling alcoholics that they are "powerless over alcohol," that they cannot in fact drink responsibly no matter how hard they may try, will only make a bad situation worse as the "problem drinker" takes advantage of a false notion of powerlessness in order to drink even more and more irresponsibly than he did in the first place. But the reality of alcoholism and other addictions is that in the vast majority of instances the practicing addict retains a confidence in his ability to cease or moderate his substance intake that can only be described as baffling to observers who have watched him repeatedly try and fail to do so.

What is meant by "Denial" in Addiction?

The principal reason that the alcoholic or addict continues to believe something that is, at least in the eyes of those who have observed him over time, at times almost ludicrously untrue, is that his judgment and critical thinking are clouded by the psychological defense mechanism of denial. Thus the alcoholic who has never yet been able to control his drinking for any period of time, who has in fact repeatedly and quite predictably gotten into serious difficulties whenever he began to drink, believes in an almost unbelievable way and with a confidence that seems to others misplaced and bizarre, that "next time, it will be different." He shows a remarkable inability or unwillingness to learn from his own experience in regard to the consequences of his repeated unsuccessful attempts at normal drinking.

The concept of "denial" is complex and contains at least two distinct but overlapping notions, distinguished by the degree of conscious awareness involved in the denial of reality. In ordinary usage "denial" means the deliberate and manipulative disavowal by the denier of facts known by him to be true. Thus a criminal when caught by police will almost always deny having committed the crime with which he is to be charged. Used in this way the term "denial" is synonymous with lying.

The other usage of "denial" refers to an unconscious mental defense mechanism, one by no means limited to the phenomenon of addiction, in which the individual is said to deny some aspect of reality that is too distressing or painful for him to bear. The distinction here is that such denial does not involve conscious deception or lying but is more akin to a primitive form of wishful thinking. The mind in such cases holds fast to what it desperately desires to be the case and avoids that which it dreads and despises. Such denial is frequently found in the immediate aftermath of some sudden and unexpected catastrophe before the mind has had time to adjust to the new and unpleasant facts. It is called a "defense mechanism" because its evident function is to prevent the mind from being overwhelmed by intolerable negative emotion.

These two separate but still related usages of the term "denial" are further reflected in the grammar by means of which their meanings are expressed. The person who is thought to be more or less consciously and deliberately disavowing the truth of his addiction is said to be denying his problem – while the addict who is himself deceived by his denial is said to be "in denial" of his difficulties. But although these distinctions are useful and important, the fact is that both forms of denial are usually encountered. They may be present in the same person at the same time, making it all but impossible for therapists and others to distinguish how much useful insight the patient actually possesses versus how much he simply chooses not to use. And matters are made still more confusing by the well-known habit of addicts of all kinds to deceive others about their addictive activities, as when an alcoholic who has been drinking denies that he has done so.

Nevertheless, it is important for an understanding of addiction to bring into focus as sharply as possible the type of unconscious denial that deceives the addict himself about his problems – for it is this type of denial that poses the principal obstacle to recovery from addictive disorders.

Unconscious or involuntary denial is classified as a psychotic defense mechanism because it involves the denial or major distortion of reality itself. And a psychosis –state or condition of insanity- consists of being out of contact with reality, i.e. of believing something that is not true, or disbelieving something that is true.

Yet is it really that simple? Is psychosis nothing but believing something that is false or not believing something that is true? If this were the case many human disagreements might be considered forms of mental illness rather than rational differences of opinion. And the question naturally arises: who is to determine what is true and what is false in such matters?

These and other difficulties are responsible for the cumbersome definition that is usually given of a delusion(a false idea due to mental illness): a delusion is a false belief, not shared by the patient's peer group, that is not corrected by reason or contrary evidence. The qualifications are necessary to avoid labeling simple mistakes or religious, political or philosophical differences as indicators of mental illness.

In the case of the alcoholic the delusion usually involves the false belief that he will be able to manage his drinking without a recurrence of past problems, or that the problems involved are not as great as they appear to others. He is absolutely convinced of this to the point that no amount of contrary evidence or reasoning presented, sometimes beseechingly by others can change his belief or his behavior. In regard to alcohol, he thinks and acts like a crazy person.

Paranoid Projection of Blame: Another Psychotic Defense

Simple denial, whether conscious and voluntary or unconscious and involuntary, is seldom able to handle the progressive and relentless divergences from reality that the maintenance of a serious addiction usually requires. Other psychological defenses therefore are usually called into action as reinforcements to back up the primary defense of denial.

The other principal psychotic defense is called paranoid projection. This is considered a psychotic or reality-altering defense because of its massive distortion of reality. Like denial, paranoid projection actually revises the individual's perception of reality in a direction more acceptable to his desires – including the desire of his addiction.

Paranoid projection can be considered a kind of auxiliary or backup defense in the struggle to maintain an addiction. For while denial attempts to create the impression that there is no problem, or that the problem is not nearly as bad as other people claim, paranoid projection aims to dispose of any problems that cannot be altogether denied. Thus the alcoholic who gets his third citation for driving under the influence attempts to rationalize this away by blaming the police for unfair or corrupt enforcement policies. And addicts in general are prone to blame other people for their own actions – especially those relating to their use of mind altering substances. When confronted about their behavior by family or friends concerned about them, addicts typically become angry and defensive, believing that they are being unfairly accused or ganged-up upon by people with suspect motives. They find fault with those who question their behavior and convince themselves that it is the other people, not themselves who are to blame for what has happened.

Non-Psychotic Defenses: Rationalization; Justification; Minimization

Not all mental defense mechanisms that are invoked by an addiction to defend itself involve a total disregard or revision of reality. The defenses of rationalization, justification and minimization may be thought of as a form of non-psychotic "spin control" in which the best possible face or interpretation is put upon events which are acknowledged to have happened. By using these defenses the addict –actually, the addictive process itself- accepts those aspects of reality that cannot be completely denied or blamed on others, while at the same time "spinning" them in such a direction as to make them more palatable. The aim of all mental defense mechanisms is to reduce or eliminate conscious psychic conflict and dissonance with reality. The non-psychotic defenses function to smooth down or buff off the potential problem areas left untouched by the principal psychotic defenses, denial and paranoid projection.

Of course, not only alcoholics and other addicts make use of such mental defenses. When one strongly desires to believe something, the mind operates automatically to find reasons for such belief and to minimize or invalidate contradictory evidence. The problem for the alcoholic and addict is the powerful attachment they have to their addiction, hence the pressing need to construct a case that supports the continuance rather than the cessation of the addiction.

Addiction, Like Love, is Blind

There is more to addiction than simply the type or quantities of a substance consumed, or the frequency of a behavior such a gambling, spending or sex. Nor are the frequently encountered "negative consequences" of addictive behavior the essential element of addiction itself. For serious addiction may be present in the absence of any of the usual and customary external negative consequences such as adverse health effects, job difficulties, or marital or legal problems. Such external indicators are in fact relatively superficial and accidental. Their presence is useful in suggesting or confirming addiction, but their absence by no means rules out addiction. One of the commonest errors addicts and others make is to suppose that if such external complications are not present, neither can be a serious addictive disorder.

The addict's subjective mental state consists of an obsession and preoccupation with his addiction that has been likened by many observers to the state of being in love. It is this peculiar obsessive mental state that leads to the obvious and external behaviors that are commonly identified as addiction. But the real origin of addiction lies in the mind, and in the thinking, dwelling, planning and anticipating the addict engages in in regard to his specific addiction(s).

Like an ordinary lover, the addict is obsessed with the object of his love, misses it when separated from it, exaggerates its positive qualities and minimizes or ignores its negative qualities. It becomes the center around which his life revolves and the goal toward which he is constantly striving. Obstacles between the addict and his addiction only increase his desire and devotion – for "absence makes the heart grow fonder." And efforts by third parties to separate the addict from his beloved addiction invariably lead to renewed efforts by the addict to become reunited with what has become the most important thing in his life.

And also like the everyday lover, the love of the addict for his addiction does not always run smoothly nor lead to the blissful happiness that once seemed to be promised. In fact, the course of an addictive illness can closely resemble that of an unhappy, unhealthy love affair of the well known type in which the lover can neither live with nor without the beloved. There are repeated honeymoons, turbulent sequels, recurring breakups followed by grief and then by ecstatic reunion – and the whole cycle begins over again and repeats itself. Not without reason have some forms of love and infatuation been compared to an addictive process from which the lover is either unable or unwilling to free himself, and for which he appears almost insanely willing to suffer tribulations and pains – including at times, death itself.

The comparison of addiction to a love affair can assist the understanding of the addict's otherwise at times inexplicable behavior. If, for example, one merely substitutes "that woman" for "alcohol" in the typical pleas and lectures delivered to alcoholics by families, friends and therapists, it is easier to understand the actual predicament of the obsessed and "love struck" alcoholic who is being urged, for his own good and also for that of those who care about him, to break off a relationship which to him may mean more than life itself. He hears what is said to him by others, does not altogether deny that it has some truth to it, is perhaps even willing to concede that he is not acting as wisely and prudently as he otherwise might; but he nevertheless feels that no one but himself truly understands "that woman" and the real nature of his relationship with her, which he feels to be far richer and more worthwhile than mere outside onlookers could ever hope to know. And thus he resents criticisms and attempts to interfere with his relationship with his addiction, even as he may be willing to admit that there are some difficulties to be faced and that the fulfillment of his love does not necessarily come without a steep cost to him. But it is a cost that he considers himself willing, even honored to pay because of the intensity of his feelings for his beloved.

Another implication of the analogy of addiction-as-love is that when the attention and the emotional energies of the addict are captured by an overriding and dominant love for his addiction, there is less and less of him left over and available for other relationships. And in fact in all cases of even moderately advanced addiction, the primary relationship of the addict is in fact with his addiction, no matter how different matters may appear from a surface perspective. For in addiction, the Biblical observation that "no man can serve two masters" is truly confirmed. When push comes to shove it is the loyalty of the addict to his addiction that is likely to prevail over even the most intense and important of his other relationships and interests. Addiction is indeed a jealous mistress, and one that will brook no real competitors.

Still another similarity between a certain type of romantic love and addiction is the capacity of addiction, like love, to mobilize and capture the total resources of the self. Everyone knows that an individual "in love" is thinking, feeling and acting in a transformed and energized state that is not, in the ordinary sense of the terms, rational or logical. Therefore no one –or very few people, and those not for long- speaks to such a person in such terms. For it is understood that a person "in love" experiences himself, his life and his priorities in a different fashion altogether from the way he did before he "fell in love." The mythology of romantic love is replete with images and suggestions of affliction, illness, blindness, even madness – all conditions that radically alter the "victim's" sense of reality, and over which he is in the last resort powerless.

The Addicted Self

Addiction is -or becomes- a disturbance of the entire self. In its earliest stages it may appear localized and confined to a small sector of behavior – but even at this stage, a careful examination of the way the addict thinks and feels about the substance or process to which he is becoming bound demonstrates that there is a hidden and extensively ramifying root system just beneath the surface. Unfortunately, the chief source of this insight is retrospective: those addicts who have eventually, usually after much suffering and difficulty, gotten into recovery from addiction are frequently able to look back upon their own experiences and recognize that right from the start, something deeper, more subtle, and ultimately more sinister was beginning to happen to them than they realized or could have realized at the time. In fact, it was only in light of their subsequent experiences with the full development of the addictive process that they were able to spot the earliest signs of the addiction. Addiction, like life, must be lived forwards but can only be understood backwards, i.e. from the shores of recovery itself.

The natural history of an addictive process resembles the progression of an invasive malignancy. In the beginning the tumor is small, localized, and seemingly easy to remove. As time goes on and it spreads relentlessly to the remainder of the body it becomes difficult or, at times, impossible to remove. And it may prove fatal.

Addiction invades and destroys the self the way a malignant tumor invades and destroys the body. Time is required for this process to develop, just as time is required for a tumor to spread and infiltrate healthy tissue. In the case of addiction, as in the case of most cancers, the longer the process has been underway, the more difficult it is to halt or reverse it. And also like most cancers, addiction may recur and spread further even after initial efforts to treat it appeared successful.

As time goes on and addiction is continuously active, the self becomes progressively warped, distorted, and organized around the goals of the addiction rather than the normal and healthy goals of the free and growing personality. This resembles the shift from a pluralistic democratic society to a monolithic totalitarian dictatorship. At the extreme limit of the addictive process the individual has become an obvious and often pitiful slave of the addiction and has relinquished or subordinated every other interest and value in his life to his absolute ruler, addiction. But long before matters reach such an obvious stage, the personality has been under the spell of addiction and thus has been directed insidiously toward the goals of the addiction rather than the legitimate ends of the individual himself.

The addicted self is by definition an inflexible and unhappy self. Flexibility is impaired because everything is ultimately subordinate to the demands of the addiction; and happiness is undermined because the directing authority of the self is no longer the self but the addiction. These alterations in the orientation and operation of the self are often subtle and hence easily overlooked in the early stages of the addictive process by the addict himself as well as observers – but in the more advanced stages they are painfully obvious to onlookers and even, in some cases, to the addicted individual.

In addiction, the self steers and navigates according to a psychological false compass controlled by the addiction. The needle of the addictive compass always points in the direction of the addiction – and by so doing, it causes the self invariably to steer toward the addiction. The non-addicted self is flexible - and its compass is therefore free to find the psychological "North" by which it can navigate toward healthy waters.

The addicted self is an inflexible and at bottom unhappy self, no matter how carefree and spontaneous it may seem to others and even to itself. It is quite common for the earliest stages of addiction to be accompanied by a feeling of enhanced freedom and happiness. But as time goes on and the addiction acquires total mastery of the individual, the truth of Shakespeare's warning is all too often confirmed:

And oftentimes, to win us to our harm,
The instruments of darkness tell us truths,
Win us with honest trifles, to betray's
In deepest consequence.
Macbeth, I.iii

Once addiction is established the prime task for the self is to maintain itself at a level approximating normalcy. Like the character in "Alice in Wonderland," the addict must run as fast as he can just to stay in the same place. Long gone are the days, if they ever existed, of "highs" and special pleasures as a result of drug or alcohol consumption. Now the main thing is to avoid feeling bad. But because this cannot be done unless the addict is continuously "under the influence" of his addictive substance or process, much of his life is necessarily spent between drinks, drugs or other addictive behaviors. And when he is between such temporary remedies for bad feeling he is actually in withdrawal from them, hence feeling bad, thinking about getting relief, and unable to participate fully in whatever he happens to be doing at the time. His mind is always projected forward to the time when he will be able to obtain relief by engaging in his addictive behavior.

Thus the active addict is never normal: not when he is "using," and not when he is "not using." His mind and brain have fallen under the control of an artificial external mood-regulator(drugs, alcohol, gambling &etc.) and thus are no long free to respond spontaneously and normally to the ever-changing, subtle, and not easily recognizable demands of reality itself. Because of his artificial mood regulation the addict feels bad when, naturally speaking, he ought to be feeling good – and he feels good when, again naturally speaking, he ought to be feeling bad. His "hedonic (pleasure) compass" is no longer reliable and one of the basic functions of mood and feeling, that of supporting the survival of the individual, is under the control of the addictive process rather than the actual welfare of the person.

It is possible to view the powerful addictive drive as an extra instinct, equal in strength to those of hunger, sex and aggression but lacking their essentially self-preservative functions. In a sense, addiction is a case of the instinct to live or survive gone wildly astray: the same energies, the same urgency, and the same relentless determination found in the drive to survive and avoid harm are found in the addictive process. But in addiction the welfare of the individual is no longer a consideration, only the satisfaction of the addictive impulse itself. Thus addicts are known to risk their lives and well-being with apparent indifference, a mirror-image of the normal self-preservative instinct which under ordinary conditions steers individuals away from and not towards potentially harmful or lethal circumstances.

From this perspective "recovery" means, among other things, the recovery of the normal, flexible and healthy hedonic regulative functions of the self.

The concept of "recovery" implies restoration to a prior and presumably normal state. But evidence from a number of sources suggests that in many cases the future addict was in trouble, recognized or not, well before the emergence of his manifest addiction.

Alcoholics and other addicts in recovery frequently report that from the perspective of hindsight they now can see that they never actually felt quite right or like other people appeared to them to feel. When, therefore, they finally found their particular addictive substance or process, they experienced what might be called both a sense of relief and a "shock of recognition" at what it feels like to be "normal," i.e. free from negative or unpleasant affect, calm, relaxed, self-confident and secure. Naturally they commenced to repeat the behavior that at first brought them relief and good feelings. Over time the Faustian Bargain –selling of one's soul to the Devil for earthly satisfactions- began to come due, and less and less relief was obtained at higher and higher cost. Like cash advances on a high-interest credit card, addiction lures the addict deeper and deeper into "hedonic debt." Finally the bills can no longer be paid at all and bankruptcy –"hitting bottom"- occurs.

By combining the observations above, i.e. by understanding how the obsessive "romantic" relationship of the addict to his addiction is supported and defended by the mental defense mechanisms of denial, paranoid projection, rationalization, minimization and justification, an answer emerges in response to the question posed at the beginning of this paper:

The basic facts about addiction and recovery are neither complex nor difficult to understand. Why, then, do addicts have such difficulty in grasping and acting upon them?

The mental defense mechanisms described above function to smooth the path for the fulfillment of his desire. The addict's mind has been taken over by his addiction and becomes an instrument for the addiction to use to protect and advance itself and its interests. He has become a hostage in his own house, an unwitting victim of a secret kidnapping by which his very self has been hijacked by the addictive process and enslaved to its endless and irrational demands for gratification. This means, among other things, that what once was human has been subjected to the rule of the inhuman, i.e. of the blind, ruthless, unconscious, and utterly unethical force of the desire of addiction.

The process of recovery involves the recovery and restoration of the self. The human, i.e. the existing individual with all of his values and aspirations, displaces the inhuman force of the addictive desire that had insidiously taken over the personality of the addict and converted him into a mere puppet for the execution of the demands of the addiction.

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