Addiction: Disease, Choice, or Both

In this post I discuss how addiction is both a disease and a choice. I also describe a meditation exercise for dealing with cravings, which are a symptom of the disease. The description includes the transcript from a session with a patient.

I see frequent arguments about whether addiction is a disease or a choice. The issue seems quite polarizing with adherents of each point of view tending to disparage their opponents. But what if both are correct? What if addiction is both a disease and a choice, with each reinforcing the other? I find this approach helps me sort through complex clinical cases and come up with effective interventions. So let’s look at it more closely.

Addicts usually describe an intense craving for the substance. This craving is different from wanting the substance or having thoughts about obtaining or using the substance. The craving is much more intense and impossible to ignore. The craving is a symptom of the disease and is very different from discomfort.

Imagine you have hundreds of large ants under your clothing. The ants bite you constantly, all over your body. The only thing that gives you relief from the ants is using a substance or a behavior. But the relief is short-lived and the ants return until you use that substance or behavior again. This is discomfort and the decision to use a drug to relieve it is a choice.

What is craving? Hold your breath. In a very short time you will feel an irresistible need for oxygen because you are suffocating. This is craving, and the decision to start breathing again is not a choice. The disease of addiction is what hijacks a person’s mind causing the person to experience the need for a substance or a behavior with the same intensity as the need for oxygen.The choice of addiction is the decision to engage in behaviors that relieve discomfort. There are people who develop a bad habit of using a drug or a behavior, but do not develop the disease of addiction. Those are the people who can stop when they put their mind to it. Their mind is their own and has not been hijacked.

An example that illustrates the way the disease and choices interact is when  someone addicted to opioids receives Suboxone. Suboxone treats the disease of opioid addiction. It binds to receptors in the brain in a manner that reduces the overwhelming craving. However, the choices associated with opioid addiction remain, and these are not treated by Suboxone. Habits of thinking, of relating to others, of responding to stress, of choosing friends all need to be changed for the person to break free of the addiction.  The Suboxone makes it much more possible for the person to make healthy choices, and in that respect it is a miracle treatment. But unless the person changes the choices that drive their addiction they will not succeed in staying clean. Using the metaphors above, when someone is using Suboxone opioids are no longer experienced as if they are as necessary as oxygen. However the person still needs to be able to experience the biting ants without relieving that discomfort by using drugs.

Most of the treatments for addiction do not treat the disease directly. Instead they address the choices that influence the strength of the disease. Recovery programs, therapy, healthy relationships, 12-step groups, and medications all help a person make choices that help them avoid using the substance or behavior. Over time these healthy choices will reduce the strength of the disease. However, especially in the first year or so of recovery, the person’s mind may still be hijacked and even while they are making healthy choices they are having cravings. That is one reason why people who are recovering from an addiction can need support for such a long time.

Cravings are different from thoughts in that they are more visceral. They seem to come more from the core of the body, or involve sensations like a taste. Techniques that work to reduce thoughts about using will not work to reduce cravings. The following meditation technique is powerful enough to reduce the strength of a craving quickly, within minutes or even less.

If you are going to use this technique you should practice with it before you actually experience a craving. However, practicing the technique has some risk in that the practice requires you to experience some degree of craving. That means that you should not practice unless you are in an environment where you have enough support so that if you experience craving you will not be at risk for using. The best option would be to work with a therapist who is either familiar with this method, or who can use this material to learn the technique.

If you are a therapist or counselor and want to use this method I suggest you practice with it on yourself first. If you have no cravings to work with you can use it to change the experience of any uncomfortable visceral sensation, pain for example. If you have no uncomfortable physical sensations that occur spontaneously you can create some to work with by waiting till you have to pee very badly and using this technique to reduce the discomfort.

Technique for reducing the physical intensity of a craving:

  1. Remember a time when you felt a craving for the substance or the behavior.
  2. Focus your attention on the craving so you feel it strongly.
  3. Allow your imagination to create a representation of that craving.
  4. Shift your attention to that imagined representation and pay less attention to your physical body.
  5. Imagine changing the imagined representation in ways that reduce the intensity of the craving.
  6. When you find a imagined representation that is associated with a low level of craving fix that imagined representation in your mind.
  7. Shift your attention to the first imagined representation briefly and feel the craving increase for a few seconds.
  8. Shift your attention to the representation in step 6 and feel the craving decrease.
  9. Repeat steps 7 and 8 several times so that you can experience the craving increase and decrease.
  10. Conclude by focusing on the representation in step 6 and imagining that representation is accessible any time you want it.

The following transcript is from me talking someone through the technique. I have added in comments which are set off by brackets in bold text ].


Me: So you were using the healthy thoughts you had been taught and they weren’t working.

Patient: Uh-huh. And I kept telling myself those thoughts over and over and nothing made any difference. I felt really hopeless.

Me: Right. And you were probably blaming yourself for not doing it right too. That must have really sucked. [ When patients blame themselves for a technique not working the resulting guilt/shame makes them worse. So I wanted to stop that. ]

Patient: Yes.

Me: OK. The reason the healthy thoughts didn’t work is because the craving was in your body, not in your head. The healthy thoughts were in your head and those healthy thoughts couldn’t get into your body and change what was going on there. Does that make sense?

Patient: Yes.

Me: So a craving is more physical. Its in your body and because a craving is different from thoughts of using the techniques to deal with using thoughts often don’t work for cravings. So it wasn’t that your fault that the healthy thoughts didn’t work. That was the wrong technique to deal with the cravings. [ It wasn’t the person’s fault that the healthy thoughts didn’t help. They are simply not that effective for dealing with cravings. ]

Patient: Oh. That makes me feel better.

Me: Yes, I imagine so. Would you be interested in learning a technique to deal with cravings? [ Making sure the person is interested is respectful. ]

Patient: (Nods)

Me: There is some risk because you will have to remember your craving to learn the technique that makes the craving decrease. This is scary for anyone who has really experienced cravings so I need to make sure they are ready for that. ]

Patient: That sounds scary.

Me: But you are willing to try?

Patient: I trust you. When asking someone to willingly experience something that distressing we need to have a strong relationship with them. ]

Me: OK. Before we start let’s set up a rough scale to rate the strength of a craving. 0 is no craving, and 10 means the craving is so strong that I would have to tackle you to stop you from running out of here to go use. [ The scale is important as it lets us know if the technique is working. A little light-hearted wording helps reduce the tension. ]

Patient: All right. (Laughter)

Me: So here we go. Take a couple of comfortable breaths and relax so that you can feel your body. If it is easier for you to remember and imagine with your eyes closed you can close them. [Pause, closes eyes] Now remember the situation where you felt that craving you were telling me about. Just let your attention go back to that time and place and let the craving return. If the situation was recent this can happen in seconds and usually takes only a minute or so at most. ]

Patient: (Nods)

Me: Remember the craving is in your body so feel that and let me know how strong it is.

Patient: About a 5.

Me: That’s pretty strong. Since this is a safe environment let’s see if we can make it stronger so we can really test out this technique. Allow yourself to really feel that craving, to remember whatever you need to so that you can get that craving up to an 8 or a 9. The stronger the craving is at the beginning the more they and you can trust the technique. ]

Patient: (Some nervous movements. Breathing more shallow.) Its there. If the person is really feeling a strong craving they usually show some signs of anxiety or distress. ]

Me: 8 or 9?

Patient: Yes. There’s a kind of a taste I can feel when I want to use real bad.

Me: OK. Now let your imagination give some form to this craving. If this craving had a color or shape or temperature what would those be? This step is the key to the technique. The imagined form is a representation of the craving. It does not have look like the neural activity of a craving. It is like using letters to represent an object. The letters “d o g” do not look anything like a dog. And if I reverse those letters to “G o d” I am not referring to a dog facing in the other direction. The imagined object that will represent the craving is an abstraction and we allow it to be that. We will then work with the abstraction. Somehow that evokes changes in the physiology, but we don’t have to make the imagined object look like the physiology. ]

Patient: Red  [This is a common color for a high level of craving, but that varies among individuals. I have had people report all sorts of colors as a representation of a high level of craving. ]

Me: OK its a red object, and what temperature is it? Once the person starts responding the pace goes fairly quickly. ]

Patient: Hot

Me: Shape?

Patient: A kind of spikey thing.

Me: A red, hot, spikey kind of thing. Size? [ Repeating the characteristics help both of you to remember them. I also write these down so I can keep track. ]

Patient: Big.

Me: How big?

Patient: Just big. We already have some details to work with so precisely how big is not necessary. On to the next characteristic. ]

Me: Texture?

Patient: Not sure  [ No need to ask for more if its not immediately forthcoming. ]

Me: OK red, hot, kind of spikey, and big. Hard, soft?

Patient: Not sure.

Me: That’s fine. So we have a red, hot, big, spikey kind of thing. Repeat the major details to help them keep those in mind. ]

Me: Now let’s start changing that. Ask your imagination to see if it can change the color. Maybe to yellow. [ If the imagined object has a color I will start with that. I usually suggest a color that is relatively close on the color wheel to where we started. If it did not have a color or the person could not change the color then I would start with a different characteristic. ]

Patient: That’s a little better. Any change indicates the technique is having an effect. If the craving gets worse with a color change simply go back to the last color. ]

Me: A little better. OK, what about white? [ I take notes on the changes and the effects in order to keep track. ]

Patient: Oh, that’s worse.

Me: OK. Let’s go back to yellow. Going back to the color before it got worse. ]

Patient: That’s better.

Me: Good. Ask your imagination to keep playing around with the color. Maybe green.

Patient: Oh. That’s better.

Me: Nice. What number?

Patient: 5.

Me: Cool. What about blue?

Patient: Oh that’s really good.

Me: Nice. What number?

Patient: Maybe a 2.

Me: That’s good. Try some other colors. Now that the person is having success I am letting them do more exploration on their own. ]

Patient: Purple didn’t work. Black is no good either.

Me: Blue sounds the best?

Patient: Yes.

Me: OK. We’ll stick with blue. What has happened to the temperature? We are already at a low level of craving. Even a reduction to 5 is quite helpful. So now we will play with the other characteristics of the image. I first ask about those as they may have already started changing spontaneously. ]

Patient: Its cooler.

Me: Cooler. And the shape?

Patient: Its smoother, like a circle. And smaller.

Me: OK, so we have a cooler, smaller, blue circle. Can you shrink it down a little, make it a little cooler. See if the person’s imagination will continue changing the object in the same direction as the spontaneous changes. ]

Patient: That’s really nice. Its a small blue circle and its cool and I can hold it in my hand.

Me: What number of craving?

Patient: About a 1.

Me: Can you live with a 1? Making sure that the person is OK with this and not expecting a 0 level which is often impossible. ]

Patient: Oh my God! (Laughs) Yes!!

Me: OK. Now we need to practice a bit. We need to go back to a high level of craving and practice making it lower. Are you with me? In order for the person to really trust the technique we need to repeat it. Otherwise they can think it was just a fluke. ]

Patient: Uh-huh.

Me: So remember the craving and let that red, hot, big spikey kind of thing come back. And feel the craving increase. It may not get as strong, but that’s OK.

Patient: OK. Its there and I feel the craving again.

Me: All right, now shift that object back the blue, cool, small circle. Your imagination may not need to go through all the steps we did the first time. Just let me know if you need help. [ The less help they need to repeat the process the more likely they are to be able to use it on their own. So simply offer to help but don’t give it if they do not need it. ]

Patient: (Pause) OK. Its there again. The small blue circle.

Me: Craving?

Patient: Maybe a 1. [ Now that the person has repeated the technique once I ask them to repeat it several times without guidance. This gives their imagination more freedom to continue modifying the object, and gives them the confidence they need to use it on their own. ]

Me: Excellent. Now practice a couple more times having the craving return and lowering it by imagining the blue, cool, small, circle or whatever your imagination creates to keep the craving low. Finish by remembering the imagined object associated with the low craving so you can call it to mind easily. Let me know if you need help or when you are done.

Patient: (Long pause. Opens eyes.) Wow. That was amazing! It is always amazing no matter how many people I use this with. ]

Me: What did you end up with?

Patient: It was like a little blue pebble that was smooth and I could put it in my pocket and it wouldn’t bother me.

Me: Nice. So remember that little blue pebble and connect with it and what it helped you do today. The person needs to recall that imagined object to reinforce the experience of being able to decrease the strength of a craving. They are not connecting with a low level of craving but the process of reducing the intensity of the craving. ]

Me: Notice too that we did not use thoughts to deal with the physical sensations of craving. We used your imagination. So if you are having using thoughts, counter those with healthy thoughts. If you are having cravings, use this method. This method will not work for changing thoughts. So I want the person to use the appropriate technique for the difficulty they happen to be dealing with. ]

Patient: OK.

Let’s review this technique. We started with a very uncomfortable physical experience. We used imagination to create an imagined object that represented the physical experience. We then played around with changing the imagined object looking for changes that made the physical experience more comfortable. The object that we ended with, the little blue pebble can now work as a rapid way of evoking the more comfortable physical experience. You also can use this method to help reduce other uncomfortable physical experiences, such as pain. The imagined objects will vary, but the process is the same.


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