The word 'addiction' is poorly chosen, as it suggests that addiction is an 'illness'. This mistake is made because we describe a process or certain behaviors and choices with a noun. Language-wise we thus make a mistake, because this way we make a dynamic process into a static and unchangeable given.
What are the results of this wrongful choice of word?
In diverse branches of medicine, we handle the same strategy. For example, we refer to the process of the breaking of a bone with 'fracture' or 'bone breaking'. In this example, this is a useful manner of describing the process, as we are speaking of an irreversible process. Without a technical action, like a cast or a surgery to immobilize the leg, the chance is smaller that the bone will grow back together or heal. The advantage of a static word is in this case that both the patient and the doctor know what needs to happen. There is one standard way of treating the problem, a manner which you can write down into a schedule or manual in a step-by-step fashion. When we describe the process of rampant cancer cells, we do the same thing by using the word 'cancer' as a noun. With this, doctors and scientists also developed standard procedures per type of cancer and then tested this on thousands of people to see which way they could statistically save most lives. This approach stays useful here, because science keeps improving and each year we can save more human lives with this approach. As opposed to the previous example, this process could be seen as reversible. As science has not advanced far enough to be able to understand all aspects of this process, the treatment remains in categorizing large groups of people - with one specific noun - remains the most useful method at the moment. The past few years, more and more researchers are also starting to look at cancer as a dynamic process with happenings, and in the coming decades we can expect spectacular advances in the treatment by therapies which are tailored per patient. The goal is to take action during the specific steps in the process in which the cancer cells are found at that time. However, this is not the same case with the nouns 'addiction', 'alcoholism', or even worse: 'addict' or 'alcoholic'. In these cases we are speaking of behavioral patterns upon which people act themselves. These, too, we try to describe with the help of a noun. This approach, however, has led to poor results, as there are no magic pills or medical treatments which make it so that certain nerve cells make specific different decisions. Choices are made by a person themselves. We can, at most, partially influence the stimulus effect which indirectly influences the choice. Blinded by the successes of the medical model which had spectacular successes in the previous century, researchers lost sight of several important aspects. Namely the role of choice and the role of habit formation.
(Lack of) Freedom of choice
Traditionally, doctors assumed that we need to treat addiction or alcoholism mainly as a physical illness. In the 80s, psychiatrist Luc Isebaert started to wonder if this assumption really led to the most useful theory when it comes to helping addicted patients. Without denying that physical and genetic factors play a role, he focused on the question of addiction should not instead be seen as a 'learned inability to choose'. For example, whether or not one chooses to drink another glass. If this way of seeing the situation is correct, the patient will be able to re-learn the ability to learn and thereby gain self-control over their addiction and thus become enabled to live more happily. Therapy is now re-defined as helping to recover the ability to choose.
Who do I want to be?
The Viennese psychiatrist Viktor Frankl explained in his well-known book 'Man's search for meaning' (1946) the basic idea that a happier life means 'living your life the way you want to live it'. WIth other words: happiness develops when you are able to organize your life in such a way that it is in accordance with who you want to be. When a person develops the feeling that they cannot change their life in such a way that it is in accordance with their deeper life wish, it causes frustrations, stress, anxiety, depression, or behavior which tries to 'numb' these hurtful feelings. This series of behaviors is what we call 'addiction'. Viktor Frankl was strengthened in this theory by the observation that only some of his fellow sufferers in the concentration camps managed to survive. According to him, the survivors had in common that they had a clear 'existential calling', or meaning in their lives. Their motivation and energy to survive came from this meaningfulness.
The real motivation to heal
The reasoning which can lead to a feeling of inability to fulfill one's deeper existential life wish and thus to addicted behavior, also delivers the key to therapy: deep inside, the patient is motivated to once again live the way they want to live, namely as a good father, a good mother, son or daughter, a good professional, a trustworthy friend, and so on. Most often, addicts are hardly motivated to break out of their addiction, as it is the key to numbing their painful experience which is caused by believing to have lost one's existential mission in life. From that perspective, it is logical that there is no motivation to let go of their last-mentioned tool. As a therapist however, you find miracles to take place when you ask the patient the question as to who they really want to be. By starting off with that motivation, many seemingly non-motivated patients suddenly are able to flourish and to regain control over themselves. Unfortunately, our culture rarely asks us about our inner wishes. In the west, we have little experience with this.
Habit formation
We already described how you can motivate an 'addict' to make new choices in order to live the life they want to live. However, they will have the feeling that they are unable to do so. Why= Because an undesirable 'habit' has been developed throughout the years.
What is a habit?
In his ‘Rethorica’, Aristotle describes the structure of each habit. It consists of three standard building stones each time. A 'thought' which is combined with a 'feeling' and linked to an action or 'behavior', and all of this in a certain 'situation' or context. These three elements are linked to each other. They are set in our memory, or have been learned. Each time we end up in a certain situation, we will remember and repeat this 'triad'. Why does out life consist of 90% habits? If we would have to think of every detail in our lives, we would literally go insane. Our brains would be over capacitaty! To prevent this, nature provides us with habits. An example: to learn to read or write, we first need to 'practise' for a few weeks with separate letters of the alphabet. Only after our brain has automated the writing of each separate letter, we will learn to write words. And not before this can be done automatically and subconsciously, we would learn to write sentences, and only years later we would write entire dissertations. Imagine that you would have to think, each time you write a text, about which muscles in your fingers you need to actively relax or tense in order to write the letter a or the letter b? You could never write an entire letter or text without becoming exhausted after just a few words. Automating of most of our behaviors is needed in order to be able to function at a higher level! Only when most of our actions are regulated by learned habits, we can realize new things in a creative manner. That explains why illnesses like autism, where automating behavior is difficult, often lead to rigid, repetitive behavior. These people put so much energy into the learning of habits that they find it difficult to be creative or flexible when it comes to unexpected situations in life. What is an undesired habit? And undesired habit is a habit which leads us away from our deeper existential life goal. Many stress-bound habits such as addictions, anxieties, and depression are learned undesired habits. They bring us into a negative vicious cycle, where the habit itself causes us to move further away from our desires. This leads to even more frustration and stress, and hereby to the confirmation of our undesired habit. What is a desired habit? A desired habit is a habit which makes it easier for us to - automatically - do the things which bring us closer to realizing our wishes and dreams. Just like the habit to brush one's teeth each morning keeps one's teeth clean, the habit of going through your agenda each morning or cleaning up your workspace will make it so that you can do your work more effectively, for example as part of a deeper goal of being a good professional. Freedom of choice in the development of desired habits You notice that we need to learn several desired habits in order to realize your goals, while an addiction only requires one undesired habit. The world of possible useful habits is much more creative and rich than the rigid, cramped-up world of addictive habits. This has one major positive effect. When the addict, later on, practises to replace undesired habits with desired ones, there are tens of choices to make. And as long as each desired habit partially affects our learning process and helps us to let go of the addicted habit, we are able to let the patient have many choices in therapy, and even encourage them in the making of choices.
Choosing which habits we want to learn
This sounds like defeatism: 'We can choose, but are steered by our habits?' This is the paradox in which the thinking about addiction often gets stuck. However, the solution is logical. Humans namely have the ability to 'choose' to learn 'desired habits'. The cerebral cortex in humans has reached a level of development which makes it possible to make this choice, even if genetic factors or emotional factors from lower parts of the brain, the limbic system, make this more difficult. This freedom of choice is something mainly given to us by our prefrontal cortex, which differentiates humans from animals. Humans can choose which desired habits they wish to develop. In the clinical-medical practice we do notice differences: some patients easily learn the desired habit of controlled drinking, while others find this choice difficult and decide to, instead, stop drinking completely. What is essential, is that the patient themself makes this decision instead of a caregiver getting in the way of this free choice: we want the patient to learn to choose by themself, without becoming dependent on the advice given to them by a therapist. That last thing would mean that one addiction is replaced by another, which is impossible to be the goal of therapy. The caregivers can, at most, provide scientific information tot the patient, so that they can make an informed decision. There is definitely not a problem either if a patient chooses to practise the habit of controlled drinking today, and comes back the next week, saying that stopping completely might be a better choice. We believe that genetic factors do have a choice in how difficult or easy it is for someone to learn to choose controlled drinking versus complete abstinence. Still, the patient needs to find out about this themselves.
Focusing on solutions
Okay, now we know that people can learn habits. But how does one do this? The American Steve De Shazer developed, together with his wife Insoo Kim Berg, the model of solution focused therapy in the seventies. This theory assumes that a patient finds it easiest to learn habits and solutions by solely answering solution focused questions and never (or hardly ever) problem focused ones. The experience with the online self-help program 15Minutes4Me confirms that people indeed change a habit more quickly when daily answering questions about what they are already doing correctly and what they are doing to move into a desired direction. We notice that they learn to think in a solution focused manner after just a few weeks, and that new, more desired habits start to appear spontaneously. By focusing attention on solutions, these newly discovered habits become easier and more attractive. By repeating this for thirty days or so, a solution is practised until it becomes a automated habit. The participant is more and more likely to choose these habits, which bring them closer to their life goals.
Learning to permanently choose between desired and undesired habits.
Relapse prevention Life is difficult and we are regularly exposed to unexpected downfalls, whether these are large or small. In moments of adversity, we are attracted to remembering our undesired habits and if we do not act, there is a risk of relapse. It is namely so that learning a desired habit does not remove the undesired habit. both now exist, and humans must learn to choose the habit they desire. Preventing relapse At times where relapse is lurking, the participant needs to learn to acknowledge what it is that is going on. It is an invitation of once again consciously choosing for the desired habit. What happens is of essential importance to long-term success: the ex-addict learns to choose for the desired habit again and again, even under difficult circumstances. That has the result that a higher-level learning process is developed. They namely do not only learn to develop a new habit, but also learn to choose between the two learned habits: the undesirable and the desirable one. When they then practise this for six months or so, even relapse prevention becomes a long-standing habit, unless dramatic happenings, such as the passing of a loved one or another extreme loss take place. In these cases a new boost can be useful, in the form of a therapeutic conversation or another few weeks of self-help.
Decision
In this article we described how the treatment of addiction has improved a lot by changing the paradigm. From the observation that the word 'addiction' points at a medical model which has few useful insights when it comes to the treatment of 'undesired habits', we looked for a theory which helps people to learn to develop desired habits by themselves. The motivation and power to do so is found in people's desire to live a good and useful life for themselves and for others. Humans are social creatures. From that perspective, there are better prospects than there are when constantly trying to use the unattractive motivation of giving up a habit in order to forget that you do not 'live like you want to live'. With proper motivation, a person can once again choose to develop desired habits, in order to move toward their dream life. This practise process usually takes a few weeks. Then, they will have to learn to prevent relapse in difficult times by constantly choosing for the desired habit, each time when stress activates the undesired habit in the memory. After a few months of practising, most people become relapse-free. Only after heavy life happenings, like the passing of a loved one, it can be useful to get some help in the form of help-providing conversations or an online self-help program. Read and download the full Dutch article: (pdf) Free from addiction through new habits Share this article with your friends on Facebook, Twitter, or Linked-In, and then do our free self-test.
Paul Koeck, MD
