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The ultimate risk of addiction treatment


In the field of addictions work, so-called, it is common for practitioners and later patients who integrate ideas to cast addiction as a problem of emotion.

The addictive personality is one who is pleasure and novelty seeking, and risk taking, it is said. Risk-taking except in the area of intimacy, wherein he/she is likely avoidant. Psychoanalytic theory, attachment theory, and a host of techniques derived from either, are supported by neurobiological research, which affirms that unconscious process, communication that occurs implicitly, via eye contact, body language, and voice prosody, is mediated via the prefrontal orbital areas of the brain, and nurtured (or not) in human beings during early childhood development. The role of the therapist in our society, not unlike that of the early caregiver in some respects, is to serve as an auxiliary ego, using words, reflection, tone and physicality: to connect.

Addicts and trauma survivors would appear to have something in common: a penchant for disconnection, or dissociation, as trauma researchers indicate. John Bowlby, the founder of attachment theory in the latter half of the twentieth century, offered that psychoneurosis derives from protracted separation anxiety: that children deprived of maternal care first protest, then despair, and then finally exhibit detachment, which is characterized by dissociation, a state of disembodied escapism. What latter day research indicates is that infants and toddlers’ levels of the steroid hormone cortisol maintain elevated levels when a caregiver is either absent or insensitive. If such a child is deprived of all caregiving, cortisol levels stay chronically high and therefore children will develop passive parasympathetic strategies of dissociation. Habituation of the brain to the opioid-releasing state of dissociation thus becomes a “default mode” of affect regulation. The result: a predisposition to addictive behaviors, and insecure attachment in the form of an unresponsive, intimacy-avoidant personality.

This perspective is a paradigm shift for many seeking treatment for problems of substance abuse, sexual acting out, food addiction, and such, because society’s inclination is to externalize the problem of addiction: it is the substances that are addictive, for example—not so much that a predisposition within an individual exists. Meanwhile, sex addiction is a term used by some to exert an alternative, moralistic argument against sexual promiscuity, or alternative sexual lifestyles, rather than an assessment term that draws attention to a mood or mind-altering use of behavior. Food addiction is a label that is likewise criticized for being a thinly veiled attack upon the obese, especially obese women. The problem with labels is that they elicit persecutory anxiety, especially in those prone to what Melanie Klein once termed the paranoid-schizoid position, a primitive stage of childhood development. The benefit is that labels, like any succinct form of communication, draws quick and urgent attention to problems that merit just that.

The reason why the paradigm shift is important is so that preventive measures can flourish. Education is of course important, but education in the cognitive, Socratic sense is only the beginning, not the end of the intervention. We can, as we have for decades as a mental health community, provide appropriate medical care for those whose dependencies (to opioids and alcohol, for example) merit such monitoring and focus; we can concurrently and thereafter dogmatize that the consequences of addiction (jails, institutions, and death, to quote 12-step programs) are prohibitive; we can gingerly (or not) shame addicts into realizing that their behaviors are self-centered and immature, and we can impose various consequences based upon the premise that imposing limits will alter behavior (actually, limits are a good idea, but are mostly beneficial for friends and family—not as an agent of change in treating addiction). But for real change, the following is necessary.

Consciousness. Structure. Honesty. Time. Consciousness comes first. Not consciousness of the problems outlined in the last paragraph. There’s plenty of consciousness-raising about that already. Consciousness of feeling states, beginning perhaps with bodily sensations, as mirrored, amplified, and sometimes spoken to by an observant other, perhaps a therapist: someone who will monitor the moment-to-moment reactions of the patient; modulate closeness, sensitive to the fears that may manifest as withdrawal, whether the person is aware of their defenses or not. Structure comes in the form of routines: go to therapy, 12-step meetings, work and family obligations, etcetera—those necessary things to do to support growth and recovery. Time: the re-building of this afflicted self takes time, patience, and ongoing consciousness, about things like bodily sensations, feeling states that are felt and not—about that which has been driven underground, into the unconscious, and otherwise discharged via behavior.

This recovery process is another kind of risk. The biggest risk of all: to re-attach.


Graeme Daniels, MFT

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