As National Recovery Month comes to a close, I wanted to reflect on an issue that is probably the one family members of addicted people most frequently raise in our groups. It relates to the misdeeds of addicted people. So often, they ask, “Why don’t they just stop drinking and using drugs?” Much of the stigma of and pessimism about recovery from addictive disorders is rooted in addicted people’s repetition of damaging behaviors.
“Continued use despite adverse consequences” is one of the clearest brief definitions of addiction. Non-addicts are often puzzled and exasperated by the failure of these people to learn from their negative experiences. Clinicians who do not specialize in working with addictions sometimes think in terms of sociopathic or addictive personalities, oral fixation, or passive dependent traits. The defense mechanism of “denial” is often invoked to explain the dysfunctional behavior. Each of these ideas has a certain plausibility, but they tend to be pejorative, and none are supported by substantial evidence. Furthermore, these approaches have not proved to be particularly useful in helping people overcome their addictions.
Based on listening to my patients and tracking the current research findings in neurobiology, this is the way that I currently understand what is going on with the misdeeds of addicted people. The addictive use of substances changes the way the brain works in a number of important ways. One is that the balance between the influence of the limbic lobe and prefrontal cortex is shifted in favor of the limbic lobe. This means that even when the person is not under the direct acute effect of substances, thought processes that are more primitive, impulsive, and reward-focused will be more dominant. Rationalizations will be more convincing and more likely to guide decisions relating to abstinence. “Higher-level” thinking, such as critical judgment that restrains dangerous behaviors, will be suppressed.
I frequently hear my patients talk with genuine pain about the suffering that their behavior secondary to their addiction has caused themselves and others. What is startling is the “disconnect” between these regretful memories and subsequent primitive thinking that leads to more addictive behaviors. The word “forgot” is sometimes used in this context, but using this word in this context is misleading. The dynamic of unconscious defenses is sometimes invoked to explain this but does not seem apt to me. Moreover, many of these people had previously demonstrated excellent thinking and decision making, and as they progress into recovery, this ability returns. The rapidity of these improvements does not seem to me to fit with the developmental or personality-based theories.
A better explanation would be that sustained abstinence from the substances allows for the brain to heal so that the dominance of the prefrontal cortex over the limbic system is restored.
Educating patients, as well as their families and friends, about the brain component of this complicated bio-psycho-social-spiritual disease is important. Many have difficulty accepting this concept, misunderstanding it as a “cop-out” of responsibility. I find that adopting this point of view reduces shame in the patient and increases compassion in family members and friends in a way that can improve the likelihood of recovery.