The Other

Over the past month, I have finished reading four autobiographical accounts written by people who suffer from mental illness. One suffered from schizophrenia, another bi-polar disorder, one from drug and alcohol addiction, and the last was a book written by the father of an addict. Technically, I suppose the last one is in a slightly different category, but the difference is merely one of perspective and in the end, that difference is trivial. The real theme here is suffering, the kind brought on by the alchemic transformation of biochemistry into madness.
Unlike what the world, (the untroubled world, the world of “normal”), defines as suffering, mental illness is a disease of one: one person, one demon, one battle. The individual at the eye of the storm is not living in a place where ebola, starvation, intestinal parasites, and bombs are the primary cause of death. (Here I must provide a rather banal disclaimer: yes, I know other cultures, including impoverished third world countries, have mentally ill populations, but that isn’t what this is about.) They live here. They live next door. They live, perhaps, in your house. They live, perhaps, in your own head.
We think of them as the “Other,” as in “Not Me.” Not Me is a place, as opposed to an actual person. Not Me is a country populated by your friends, family, and co-workers, all of whom are perfectly normal. Other is a place too, but it is populated by people who talk to themselves and smell funny and pick through the trash and have more cats than they do teeth. Other is a place populated by criminals, pimps, whores, drop-outs, the unemployed, and the unemployable. Obviously Uncle Bob doesn’t live in the land of Other – he just has “spells,” or is “sick again.” Obviously your beloved child doesn’t live there either – he is just going through a “phase.” And obviously your ‘til-death-do-us-part-teenage-sweetheart-made-for-T.V. spouse doesn’t live there either. He’s just having a “rough time” and is “under a lot of pressure.” Uncle Bob, your child, your spouse live in Not Me. Obviously.
Except…except when they don’t, but we don’t really talk about that, do we? Why? Well that’s pretty obvious too. Some people deceive themselves, true. Therapists love to talk about denial as if those of us who love someone who is broken have some sort of choice in the matter. We don’t talk about it because it is dangerous, and the danger is real. There is a danger that a person who has worked very hard to recover will lose a hard-won job if the word gets out. There is a danger that we will be kicked out of our home if our landlord finds we are caring for an adult alcoholic child. There is a danger that our neighbors will find out that we have a crazy person in our house and will try to force us to move. And that doesn’t even step into the emotional bullying pile of shit the good folks from Not Me will leave on our front stoop.
Now these books I read were brave and brilliant and raw and true, but the fact is that they were written by people with resources. Yes, I am sure they found more than one flaming pile of shit on their doorstep, but they had two things that most of us who deal with living in Other-world don’t have: access to treatment and environmental security. They had degrees, connections, families with money, someone in their life who could keep a roof over their head when they lost control. They had a physical safety net that your average, run-of-the-mill crazy person doesn’t have.
I do not begrudge them this and it takes nothing away from the immense courage it took to tell their stories. The fact that they had a safety net does not diminish, by a single iota, the suffering they experienced, and still do suffer, because mental illness may sleep, but it still dreams. My beef is not with these incredible authors who stood up and told their stories and in doing so, became advocates for all the inhabitants of Other, including – maybe, especially – those who are flying without a net, those who have been forced into hiding, and those whose symptoms are so conspicuous they cannot hide. No. My beef is not with them.
It is, instead, with a cultural norm propagated through the media, promulgated by politicians, and perpetuated by the inhabitants of Not Me. That cultural norm is unspoken because no one really has to say it. Everyone knows the mantra already. That mantra pretty much goes like this: Fuck ‘em. Fuck ‘em because they are criminals who drive drunk, sell dope, and steal shit so they can drive drunk and buy drugs more often. Fuck ‘em because they lay in bed all day complaining that they are depressed and not contributing to the motherfucking Gross National Product and what’s up with that? Fuck ‘em because they are on disability because they can’t control their weird behavior from 9-5, 5 days a week. Is that so damn hard? Oh yeah, and fuck ‘em times ten because they aren’t…well, you know…normal.
Screw the 5.7 million Americans who suffer from bi-polar disorder. Screw the 2.4 million schizophrenics and the 23.5 million addicts and those 14.8 million people who lay in bed all day whining about how sad they feel. To hell with the anorexics and bulimics and agoraphobics and the 33,000 people who commit suicide every year. Besides, don’t some of these staggering figures just represent the same people? Aren’t we counting the drunk schizophrenics twice? That’s cheating, exaggerating, a gross misrepresentation of the numbers! It’s alarmist propaganda, it’s pandering, it’s…it’s… bad form. And besides, aren’t half those people faking it anyway? If you listen to psychiatrists, everyone has a mental illness.
Thank you very much. I have already heard these arguments and I am, to say the least, nonplussed. The number of people in this country who suffer from a serious mental illness that even a child (not a precocious child who has memorized the entire DSM-IV, but just, you know, a regular kid) could diagnosis is somewhere in the millions. It’s a big number even adjusting by some arbitrary factor to account for dual diagnosis and flagrant malingering. If we had millions of people suffering from plague or leprosy, you’d see people marching in the street, demanding action, storming Capitol Hill. There would be a sense of urgency and something would have to be done about it.
It is an old saw, often used when discussing national priorities, but I’m going to bust out the rusted blade here and start cutting. Based on the response of pharmaceutical companies and lobbyists, I am absolutely certain we must have had an imminent erectile dysfunction crisis on our hands at some point in time, else there would not be such easy access to Viagra, which flows, yea verily, like water from the fountain pens of our health care providers. As a society, we act swiftly when our boners are at stake. Where, then, is a similar response to mental illness?
I leave you with a question that, as of today, has no answer. And as long as we continue to ignore the question, the suffering will continue in deep, immense, and immeasurable silence.

Of drugs, denial, and disappearing teaspoons

I have spent a lot of time lately thinking about drug addiction and stigma. I could go into an entire diatribe about how stigma impacts an addict’s ability to seek treatment and receive adequate treatment. After all, stigma informs our public policies and it is in the best interest of the bottom line for insurance companies and politicians to portray the addict as a leech, a moral reprobate, and a criminal. So the public takes the bait and we continue to let people suffer and die because of it. But aside from stigmatization of the addict, there is an equally as destrutive stigma associated with the addict’s family. There are many popular variations on this theme. If you are the parent of an addict, you’ve probably heard them all, or even used them to pummel yourself. Here are a few of my favorites:

“There must have been abuse in the home.”

“I’ll bet the parents are addicts too. The apple doesn’t fall too far from the tree, you know.”

“They were too permissive.”

“They were bad parents.”

“They didn’t engage in their child’s life.”

When used as a tool for self-flagellation, it takes the form of:

“What did we do wrong?”

“How could we have missed the signs?”

“Was it because of the divorce?”

“Was it because I was stressed when I was pregnant?”

“Should I have done more snooping in her room when she wasn’t home?”

O.K. Let’s can the condemnation right now. There is no one single path to addiction, and if you are the parent of an addict, the path your child chose may have absolutely nothing to do with you. Sure there are absolutely things that parents do or fail to do that may elevate a child’s risk factor for addiction, and if your child was raised like a lab rat with no other influences besides parental ones, we could say definitively whether or not it was your “fault.” But real life is not that simple, (and if it were, face it, it would be brutally boring).

If you review the literature on causality, you find that even the experts can’t agree. After years of playing nature-nurture tug-of-war, researchers in the field found they had to make up a word to account for why people become addicted. That word is biopsychosocial, and it is a word that no one who isn’t applying for a research grant would ever use. The rest of us call it “life.” From conception, a child is exposed to environmental stressors in the form of anxiety hormones, environmental toxins, and sometimes they just don’t luck out at the swim meet in the gene pool. If there is drug abuse, sexual abuse, or physical abuse in the home, sure, the kid is at risk for a whole bunch of psychological problems, but addiction may not be one of them. Conversely, parents of addicts may be Ward and June Cleaver, living in the suburbs with a white picket fence and tasteful furniture. Children of police officers may become addicts. Children of clergymen may become addicts. Children of psychologists may become addicts, for fuck’s sake. And now that heroin is hitting the suburbs – and it is – we now see soccer moms and Little League coaches with addiction issues. The point is, if you are the parent of an addict, don’t buy the stereotype and don’t own the stigma.

Now of all the dumb-ass excuses I’ve heard people use to beat themselves up for their child’s addiction, number one on my hit list is, “I guess I was in denial.” This is probably true for a small subset of parents, but let’s look at what denial really is. Denial is a state of utter refusal to believe the facts even when they are staring you in the face. In other words, you walk into your child’s bedroom, see him with a needle dangling out of his arm, and say, “Oh my. When did you become insulin-dependent?” That would be denial. Or your child has just been arrested and he’s carrying several grams of heroin, a syringe, and a prescription for pain killers that doesn’t belong to him, and you say, “I’m sure someone snuck that into his backpack when he wasn’t looking.” That’s denial. OK?

Denial is not missing the subtle cues that might alert you to the fact that something is wrong. After having watched several documentaries involving interviews with parents who had lost children to overdose, the one question they were always asked was, “Were there any red flags that your child was becoming addicted?” Most parents, presumably after innumerable therapy sessions, had learned to say, “Um…not really…well yes, there were a few. I guess I was in denial.” When pressed for these so-called clues, one mother said, “Well when Sean came home from college for the holidays he looked like a wreck.” She put it down to stress and assumed he wasn’t eating right. He also told her he had just come down with the flu. The woman’s whole family had also just come down with the flu. If your child said he had the flu and looked like hell, you would believe him. And you would believe him not because you were in denial, but because your brain has no frame of reference for dope sick. Unless you have seen it before and had other reasons to think of drugs – and bear in mind, this young man had been away at college for a semester – your brain doesn’t go there. Has he looked like this before? Yes, when he was sick. This is your experience as a mom. Thin, unshaven, a little green around the gills, a bit shakey? You’ve probably seen the same look a hundred times when you were raising him (except the unshaven part because frankly, on a two-year-old, that would be weird). This is the context your brain has for this particular look. When your brain hears hoofbeats, as the old saying goes, you think of horses, not zebras.

Another woman said she should of known because her teaspoons kept going missing.  This was a lovely, British, middle-class woman in her sixties. She did not strike me as the kind of person who had spent a lot of time watching people inject illegal drugs in their arms (among other places). What was her brain to make of missing teaspoons? Probably not much. Her brain had no context for connecting teaspoons with heroin, yet she too called this denial.

Another woman had packed her son off to college with a credit card which he was to use for text books and living expenses. At first activity on the card was normal, but then it started to escalate. Unless her child had addiction issues before going to college, what is mom going to think? She’s going to get pretty angry and give him a stern lecture about not using the card to take a girl out to dinner, or buy football tickets, or purchase a bitching stereo system for his car. Why? Because moms with kids in college expect that these are the kinds of things a not-quite-financially-responsible college freshman spends money on. Her brain has no context for thinking otherwise so she imagines what other financially irresponsible young people usually do when given a credit card. That’s not denial, but that’s what she called it.

These are examples of contextual thinking, which is, by the way, how our brains operate when dealing with missing teaspoons and maxed out credit cards. It is our default mode for thinking about the mundane things in our lives. Yes, we all have swell imaginations and use them when the context calls for it. If we were decorating a room, reading a novel, watching a movie, or visiting a museum, we’d let that bad-boy imagination machine have at it. If we are dealing with misplaced jewelry (that our addicted child has stolen, but we assume we’ve put down in one of those infamous “safe places” that we never remember later) or a scruffy kid who looks exactly like he did when he had the flu ten years ago, our brain dispatches with these things in terms of what it knows. It cannot do otherwise. Biologically our brain is still on the primordial savannah. If our primitive ancestors heard rustling in the bushes, they knew from experience it was probably a lion. They did not wait around to see if it was a neighbor bringing over Sunday brunch and a pot of tea. The subconscious conclusions at which we arrive when dealing with ordinary life frees up our much over-rated pre-frontal cortex to contemplate the meaning of life, to do complex long-range planning, and to determine what the fuck James Joyce could possibly have been thinking when he wrote Ulysses.

Most parents today hit adolescence in the sixties and seventies. Our experience of illicit drug and alcohol use was scraping together enough change to get our older siblings to buy us a bottle of Boonesfarm piss-poor wine. If we didn’t smoke pot ourselves, we knew people who did. We snuck cigarettes now and then. Some folks dabbled with hallucinogens and everyone knew at least one person who had. It was a phase, we outgrew it, we moved on with our lives and settled into spectacular, blissful normalcy. If we knew addicts at all, they were almost all aging alcoholics. Most of us know what someone smells like when they’ve been drinking. We know what cigarette smoke smells like. Many of us could identify a bong if we found one in our child’s room. That is the only context we have for illicit substance abuse. How on earth are we to connect missing teaspoons to heroin? How are we to recognize early signs of meth addiction or cocaine addiction?

An addicted child, they tell us, becomes withdrawn and isolated. So what? All teenagers do. You don’t ignore it certainly, but you don’t automatically make the leap to addiction until it is so deeply dug in that the child no longer cares about whether or not you know. That’s pretty far gone. You have to watch who your child hangs out with, they tell us. We do, and we make rules and set boundaries, but unless you are willing to spend your child’s teenage years sitting his room every night (that’s every night for six years) with a shotgun, you cannot know what he does in the middle of the night or who he does it with. Also, bear in mind that many young people do not become addicted until they go off to college. If your child is accepted to Stanford and you live in Milwaukee, you are not in any position to monitor his behavior unless you can afford a private detective doing 24/7 surveillance for the next four years. And even that’s no guarantee.

So what does this have to do with stigma? Simply this. A parent will self-stigmatize by using the word “denial.” If it’s true, by all means admit it and work on that, but merely missing the “red flags” is not the same thing at all. And the more time you waste smacking yourself over the head for something you could not possibly have seen coming, the more guilt you feel, the more you begin isolating yourself, the more likely you are to begin the blame and shame game. The end result of this game is that pretty soon the whole damn family is dysfunctional. Everyone is sitting in their own darkened corner, nursing their own shame, and blaming each other. It is now not only the addict who hates himself. It’s you, it’s your spouse, it’s siblings, it’s grandparents, it’s the kid down the block who unwittingly introduced your child to someone who knew someone who was a dealer. That’s a zero-sum game folks.

There are no positive outcome guarantees for an addicted individual, but there are definitely ways to ensure negative outcomes. Asking yourself “why” is a road with no outlet – unless of course you want to emulate addiction researchers and make up a new word for it. Personally, I wouldn’t worry about linguistic confabulations at this point in your life. Leave that to the experts. If you wait long enough, they’ll come up with something. You have more important things to do. Trust me, if the only commitment you have this week is to drive your addicted child to an NA meeting, you have more important things to do.

 

 

How we’ve totally fucked up addiction treatment

I debated a bit before using the word “fucked,” but face it. No one is going to read a scholarly dissertation on the subject. Instead, we need some straight talk (no pun intended) because there are too many people dying, too many families suffering, too many people are lost. Show of hands, folks. How many people know an addict, have lost someone to addiction, have struggled with it personally? If there is even one person on my list who doesn’t know someone for whom treatment has failed, and failed multiple times, they are either lying or dead.  I shall presume the former since the latter would be a bit unsettling.

Now most of you will not listen to William White’s youtube presentation on Recovery Oriented Systems of Care because it sounds dull and it takes about three days to listen to the entire series. But you should. If you are an addict, you should listen to it. If you are a family member, you should listen to it. If you are a certified professional, you damn straight should listen to it. Let me give you a quick synopsis of why addicts don’t recover and I can do it in one word: treatment.

Here’s what happens in today’s enlightened age of addiction treatment. Addict comes in. Addict is de-toxed. Addict has thirty days to get his shit together. Addict has graduation celebration. Addict is released from treatment. Addict goes back to old neighborhood and scores before he takes his first shit as a free man. Why?

We know that addiction is a chronic condition, but in our culture, addiction is treated as if it were an acute disease, sort of like the flu plus or minus a felony charge. White puts it like this. It is like taking a dying tree, uprooting it, planting it in good soil and nourishing it, and the minute it starts to bloom, we say, “Awesome. This tree has recovered.” And we dig it up, put it back where it came from, ignore it, and it dies.

Do we use this model with diabetics? Lupus? High blood pressure? Fuck no. How about cancer? Nope. HIV? Nope. Statistics show that alcoholics stand a good chance of remaining sober if they’ve reached their fifth year of sobriety. So how long should we provide follow up care (at minimum)? Hint: If you have to think about that one too long, you’ve got the wrong answer. Opiod addicts take even longer. Just like with any other chronic disease, addiction has a point where it is stable and the patient is able to manage it, for the most part, by themselves. And just like any other chronic disease, there are periods of remission and a potential for relapse. Notice I said “potential.” Not everyone does, but you don’t hear about them. Why? Because a large majority of people who recover don’t ever go into treatment. We can’t identify them, so we can’t study them.

And why can’t we identify them? Stigma. Who in their right mind is going to risk their job or their friendships or their family by telling a well-meaning researcher, “Oh hell yes. Man, I spent a whole year of my life pawning everything I owned, pawning stuff other people owned, crawling through the rose bushes at 3AM vomiting my guts out, and every once in a while, wetting the bed. I was just lucky I never got caught. And dude, that describes about half the guys in my college dorm.”  Even more salient, what former addict who never got caught is going to lead the civil rights movement against the stigmatization of addicts? If you can go public with your addiction it is because you are in one of two positions: either you’ve got nothing to lose because you’ve already lost it all, or you are Betty-freakin’-Ford. Either way, someone who is looking for hope is not finding a role model who looks like them.

If you’ve been in treatment, you’ve got yourself one serious case of stigma. You have to lie on job applications. You’ve got to sweep your former self under the carpet and pray to God that one of your old dealers or drinking buddies doesn’t recognize you when you are on a family outing with your kids. And you sure aren’t going to stand up at the Rotary club and be an advocate for the ones that didn’t make it lest someone sees the ex-addict in you and decides its time your membership expired.

But back to the acute treatment model. We’ve got other problems in our thirty day, instant recovery plan besides simply the duration of treatment. Here’s the biggie. Administrative discharge. If you’ve not been around people in a program, let me define this for you. The client enters treatment straight out of jail or off the street and we are SHOCKED – simply SHOCKED – that he does not even have rudimentary social skills. He breaks a rule, which may or may not involve using. What happens? He’s kicked out of the program. Now I’m going to paraphrase White again but “in what other chronic illness do we find patients kicked out when they become symptomatic?” He uses this as an example: You go into a hospital for a heart condition. On Day 2 of your stay, you have a heart attack. In other words, you have become symptomatic for the condition that brought you to the hospital. Does anyone come to your room and kick you out of the hospital for being “non-compliant?” No. They move you to ICU because you need more care, not less. Do you see the problem here? The guy that really needs the help, who is seriously a danger to himself or others, is kicked out of a program for exhibiting symptoms of his disease. If you are his counselor, you will see him again. And again. And again. That is provided that your facility allows him back in your program and many do not, thereby causing another problem in that the person who knows your case better than anyone can no longer treat you and you have to start over in a brand new environment with a brand new counselor.

But there’s more. Counselors who really care are actually leaving formal treatment facilities because they feel they can do more good as a volunteer. Why? First of all, they spend more time doing mandatory paperwork than treating clients. Second, there are “boundary issues.” Ethically, if your client walks out of treatment and disappears, you are not permitted to go looking for him. You can’t go to his house, his shelter, his street corner and say, “Hey what’s up? Let’s go have a cup of coffee and talk about what’s going on with you.” If you do that, you will be fired. You can’t interact with the client’s family and invite them over for one blessed afternoon of normalcy doing a backyard barbeque or having a picnic. In the facility, you can’t hug the client or pat him on the shoulder or have any contact whatsoever. Presumably this excludes CPR, but I am guessing that most counselors would even feel uncomfortable  about that. It is such a pervasive concept that I had one instructor at school who said she will not even offer a distraught client a tissue, although of course they are free to reach for one themselves – or use their sleeves.

In one class, we were given the hypothetical situation of running into a client in a shopping mall. The client is doing well and is happy to see you. Bubbling with enthusiasm and gratitude, he or she rushes over to give you a hug. The instructor’s advice? Extricate yourself from the client’s embrace and gracefully slide into a politically correct handshake. Play that scene out in real life and think about how it feels to be a client who has just been stiff-armed by their therapist. To make matters worse, you cannot disclose the identity of this person to your stunned family members. “Who is that?” your hubby asks, narrowing his eyes suspiciously. “Uh…just..ummm…you know…some guy.” This does not exactly model functional social interactions, ya know?

There will be a follow up to this post. It is just a beginning. I’ve caught White’s vision and I get it. And if you are addicted or love someone who is, I can only encourage you to read my meager offerings and then go subscribe to William White’s youtube channel. Here’s the link: https://www.youtube.com/channel/UCi6p8_KWZd2xWCYHg9cdGTw

You owe it to yourself, and to those you know who struggle with addiction, to understand the limitations of the current addiction treatment health care model in the United States. You need to understand why treatment is often a revolving door. You need to understand that there is a vision out there that could work and it needs advocates. Most of all, you need to know recovery is possible even for the most hard-core addict you know. Maybe that person is you. Don’t give up. Take action.

Understanding addiction – an open letter to non-addicts

First of all, I apologize for the title. I don’t know if one can properly say “non-addicts.” There must be a better term for it, but unfortunately, I don’t know what it is.

Second, I want to frame this post as a primer for parents, spouses, siblings, friends and all those whose lives have been touched by an addicted loved one. (Geez, I fucking hate the term “loved one,” but again I lack a better turn of phrase.) In short, it is for anyone who has ever asked, “Why?” or “How could they do this to me?” or “Why can’t they just stop?” It is for those who have ever said this to an addict: “You’ve been clean for 17 years, for fuck’s sake! And now you are at it again? Are you crazy?” It’s for parents who have done all they can and hit the end of the rope. It’s for those who tend to stick self-righteous labels on addicts – labels that infer that the addict has some sort of character flaw that makes them “bad” or “criminal” or “weak.” And I’m going to leave out a lot of the big words that scare people away from scientific explanations, because the best articles on the subject are way too intimidating for people who just want answers.

Sooooo – long story summarized in three points:

Fact: The one thing science can’t explain is why some people become addicted and others don’t. People from “good homes” with loving parents who are engaged and involved in their kid’s lives become addicted just as easily as people who have shitty parents. A person is a system – just like nature, just like computers, just like politics, just like academia. They are a combination of environment and genetics, nature and nurture. And it isn’t just the variables. It’s the interaction between them. No living organism, no matter how simple it is, functions in a single-variable lab where you can push button “x” and get result “y” every single time. That only happens in science experiments which are very tightly controlled and do not in any way resemble anything that looks like reality (Neuroscience of Need: Understanding the Addicted Mind, Standford University).

According to the NIH approximately half of a person’s vulnerability to addiction is genetic. Half. The rest comes from the environment and, (dare I say it?), random chance. Wrong place, wrong time, wrong influence. Any other explanation is simply garbage, not based on anything but someone’s own personal opinion. To think otherwise is to believe that if you love someone, you are able to control their every move simply through the influence of  your own stunningly superior will. You can’t. And if your kid or spouse or parent has been lucky enough to avoid this problem, count yourself just that – lucky  – and check your self-righteousness at the door. You passed on good genes and somewhere along the way, unbeknownst to you, your “loved one” narrowly avoided meeting someone who would lead them down the wrong path. One single chance encounter or event – just one – and it all could have turned out differently. One genetic oooops, and your perfect, squeaky clean life becomes unrecognizable.

Fact:  Almost anything is capable of causing addiction, including food. Unsurprisingly, (duh), drugs which influence the brain cause changes in the brain. Refer to the Stanford piece if you want the technical explanation, but to boil it down, studies have shown that brain-influencing drugs cause you to grow all sorts of new shit in your brain and eradicate some of the old shit. The new shit it grows is related to learning and memory. The parts of the brain that deal with survival – the oldest and most primitive parts – are affected the most. In essence, the brain eventually associates the drug of choice with survival and grows more receivers accordingly.

What is more important to an organism than survival? As it turns out, nothing. The substance of choice has basically trumped our much over-rated pre-frontal cortex because the survival instinct is hair-trigger and the pre-frontal cortex is slower. Before the pre-frontal cortex can even say “Hey wait a minute!” the mid-brain has reacted as if it was about to be eaten by a fucking tiger. The mid-brain has all sorts of awesome chemicals it can release in milliseconds to react to life-threatening situations. These chemicals pump up the heart rate and re-direct the blood flow to the parts of the body that are required to escape becoming human tiger chow. Simultaneously, chemicals are released that cut off all the non-essential stuff like digestion, reproductive hormones and deep, introspective thoughts.

Someone who struggles with addiction literally – read that word again slowly…literally – reacts to drug deprivation the same way they would react if they were about to be eaten by a tiger. So I ask you, if you were about to be eaten by a tiger, how much time would you spend dwelling on whether running away would impact the opinions of your friends and family? Would you, in fact, devote a few precious moments to thinking, “Hmmmm. You know my mother might disapprove of this?” Would you ask yourself, “Gosh. If I run now, will it look bad on my resume?” Or, “Good Lord! What will the neighbors think?” Fuck no.

So the old ways of learning go out the window and the news ways of learning are all about the drug. Pleasure circuits are hijacked and re-directed. Normal survival instincts that deal with food, water and sex are obliterated and re-formulated to accommodate this new model. Worse yet, the part of the brain that deals with memory is fucked up. (Again, refer to the Stanford piece – although there are many, many other sources, this one summarizes a whole lot of shit in one article). It is so fucked up, in fact, that the memory of the pleasure derived from taking the drug becomes sweeter than the actual experience of getting high.  This should be easily understood by anyone who has ever grown misty-eyed about some childhood memory. Wasn’t Christmas grand back in the day? Conveniently you’ve forgotten the bits about how your sister threw a tantrum and ran your new Christmas tricycle into a retention pond. Conveniently you’ve forgotten staying up all night to put together your daughter’s doll house which came complete with directions that appear to belong to a small nuclear reactor. You forget that Uncle Fred was drunk and that mom was taking Valium and burning the Christmas dinner. You forget that the cat mistook your new sandbox for kitty litter. You forget all that stuff and just remember the warm, fuzzy feeling you had on Christmas morning and the soft glow of the Christmas tree and the pile of unwrapped presents under it.

Yeah. So you understand how a memory can trump a fact, (or even a bunch of facts), yes?

Fact: Relapse happens in any chronic disease, including diseases of the brain. This is not to say that recovery can’t be permanent. It can, but it may take awhile. Don’t expect someone to come out of a 30 day program and just get on with things. The reason it is difficult goes back to the whole Fact #2 bit. And triggers. Triggers are anything that remind a person of an experience they had when they were high. Now recall that the memory of being high is better than the actual experience in the physically altered mind of an addict. And a trigger can be anything at all – a song, a smell, a place, a thing, a person. This is the way the human brain learns – by association.

It works like this. Once when I was about 21 and very stupid, I drank tequila on New Year’s Eve. Quite a bit of it, actually. Around midnight alarm bells started going off in the part of my brain that was still capable of having a coherent thought and that thought was, “Oh my God. I am going to feel like shit tomorrow.” And then I had an idea: “Maybe if I eat something, the room will stop spinning.” It was a really bad idea, but it was followed by an even worse one. My desperate eyes lit upon the one party snack in the room that was a) untouched and b) did not require eating implements. That one thing was fruit cake. To this day, my brain associates fruit cake with spending the rest of a perfectly good evening clutching a dubiously cleaned toilet in the home of a college friend who I fervently hope I will never run into again. To this day, I cannot stand to be in the same room with fruit cake. It’s not rational of course, but this is a perfect example of learning by association. And of course pleasurable memories are similarly learned. If your brain believes that good things happen when you do “x,” you will do “x” as often as you can because you have learned that “x” brings you great pleasure and deep satisfaction. Just the smell of baking bread, which you enjoyed at your grandmother’s house when you were a child, makes you want to return to that place and that time that made you so very, very happy.

In the case of addiction, the trigger works the same way. It fires and your brain reacts. It’s learned. And like the trigger of a real gun, once its been is pulled, you can’t stuff the bullet back in the gun.  This study, for example, showed triggering images to cocaine addicts. The images were tucked in between normal, every day pictures of non-triggering images. The triggering images displayed for 33 milliseconds – long enough for the image to register subconsciously, but not long enough for the brain to process what it had seen. The image was never consciously digested, never reached the executive functions in the brain, never even hit the reasoning circuits. Yet addicts who had viewed the pictures with the embedded trigger images reported stronger cravings for cocaine after the presentation than addicts who had viewed a presentation with no trigger images. The rational, reasoning part of the brain never stood a chance. It’s hard to “just say no” after the part of your brain that houses the survival instinct has already said “yes” without even being aware that it had done so.

This, ladies and gentlemen, is the perfect storm. Genetic predisposition plus random environmental events plus altered brain chemistry plus survival instincts plus altered patterns of learning plus altered memories plus subconscious triggers. If you’ve never struggled with addiction, you got lucky. If you know someone who does struggle with it, you owe it to them (and to yourself, in case you are predisposed to self-flagellation) to understand why it is so intractable and why it keeps coming back.

Can a person recover? Yes. Does it take a really long time? Yes. Do you have the right to judge? No.

Any other questions?