Addictions & Compulsions

How you see it is how you treat it!

The assessment lens through which we look at an individual’s issues will determine the set of possible diagnoses. The diagnosis given will dictate the treatment plan. The treatment plan will produce the outcome. It all begins with the assessment lens, which will always reflect the paradigm through which we look at a problem, define it and treat it. In other words, how you see it is how you treat it. If the assessment paradigm is either inaccurate or incomplete, then the diagnosis will be off, which means the treatment plan will be off, and unfortunately, the outcomes will not be what we had hoped.

Addictions are categorized into two different categories: chemical and process, or behavioral. Chemical addictions involve the abuse of drugs and/or alcohol. Process Addictions are behaviors that cause the same flooding of the receptor sites in the brain as substances do – unhealthy food consumption or the lack of consumption, pornography, sexual acting out or high-risk sex, compulsive video-gaming, gambling, etc. Crack cocaine and crystal meth cause an 1,100 percent increase in dopamine potentiation. These drugs have been considered some of the most powerful. When a male watches moving pornography, it causes an 1,100 percent increase in dopamine potentiation, equal to crack cocaine and crystal meth. Brains don’t care which avenue is used to get the flooding because by the time the experience gets to the brain, it is all about the activation of the receptor sites. These behaviors are as powerful as chemicals and, therefore, just as addictive.

People use the term addiction in different situations to mean different things. It is important for us to look at those differences and clarify the way we use it. When people say that they love doing an inherently healthy activity so much that they are addicted to it, it is an exaggeration used to express their strong fondness of the activity. Examples include golf, fishing, tennis, hunting, biking, skiing, chess, playing the guitar, running and many more. Is it possible that these types of activities could truly become an addiction? It is possible. You probably have heard about exercise addiction, where a person exercises to the point of self-harm and experiences many other negative consequences. For anything to be an addiction, there must be tolerance, dependence and withdrawal (which by themselves do not indicate an addiction), a boatload of long-term negative consequences, continued use despite many failed attempts to stop, failure to meet responsibilities, loss of significant relationships and more.

When people say that they had an addiction, as in had it in the past but no longer do, it usually means that they used to abuse substances and/or behaviors, and now they are not doing so. They may mean that they are clean – sober – or abstinent from doing the behaviors of their abuse, such as alcohol, drugs, porn or high-risk sex. Most people who actually had an addiction would not say, “I had an addiction,” as in past tense. They would say, “I’ve been clean and sober for 12 years,” or “I’ve been in recovery for 5 years,” meaning that they still have the “addiction condition” in their brains, but they have not partaken of the chemical or in the behavior in a certain amount of years. You could even generalize that anybody who used the words, “I had and addiction” probably didn’t have one; instead, he or she was probably compulsively abusing drugs and alcohol or behaviors.

In the treatment industry, and for the purposes of Capstone, addiction is defined as an irreversible condition of the brain that will always have the potential to be active again, even after years of abstinence. If you truly have an addiction, you cannot not have it. The mechanism for this neurobiological state could be a sort of “flipped-switch” condition. As people continue their escalation in abusive-compulsive-addictive behaviors, they can come to a point where they cross an invisible line from abuse, dependency and compulsion to addiction. This line is fluid, and there is no test to determine if it has been crossed. It is a process, not an event. I will discuss this further below at the link to A Deeper Look at Addiction.

The term addiction is used very frequently in a general sense to mean that a person is doing a self-destructive behavior to the point of absurdity. Saying a person is addicted to pot, cocaine, alcohol, porn, sex, food, gambling, video-gaming, etc., most often means he or she is out of control with behavior that is self-destructive with a continual and insatiable appetite to keep doing it, no matter the consequences. This is probably the most common use of the term addiction, but it is a mistake to think it always matches the addiction field’s definition in the previous paragraph. When it’s used this way, this definition is mostly accurate with fully matured adults but often inaccurate with young adults and adolescents. Let me explain.

It is not possible to accurately determine if a young adult or adolescent who is engaging in “self-destructive behavior to the point of absurdity” has an addiction, and it is vital to understand why. Young adults and adolescents are very different from fully matured adults in many ways but especially in their neurobiology. These differences demand that we adjust our treatment approaches to fit this age group.

I was at a luncheon at the annual NAATP (National Association of Addiction Treatment Providers) Conference in 2009 in which there was a panel of five people, each representing their treatment program. Top-notch people respected and knowledgeable, each representing top-notch programs. Collectively they had worked with thousands of teens and young adults over many years. The leader of the group would pull out a card, read the question, let the panel discuss it, and then open it up to the audience. One question was particularly significant to me. “Can we as an industry tell an adolescent or young adult that they are an addict?” I was expecting a yes from each person but got the opposite.

Every single member of the panel said no. All five. Their consensus was that we cannot accurately determine if any young adult or adolescent has an addiction because all of us have seen teens and young adults who were using so many drugs and/or alcohol that if they were older we would say that they were severe addicts, full-blown addiction, what I call the “body-rot” phase of addiction, Jelinek’s chronic phase. However, they abuse like this for a few years then something changes – they heal their trauma, get into a safe and supportive group of friends and family, finish high school or college, move to a new location, or are removed from an overwhelming situation of distress, and they stop abusing and instead, control use in a healthy way; a glass of wine at night or a beer at the barbecue on Saturday. (Not that I am for either, I’m a teetotaler by choice.) The maturing of the Pre-Frontal Cortex is often the neurobiological change that goes along with these positive changes. To find out more about the neurobiology of young adults and adolescents click here.

The neuroplasticity, or pliability of the young adult / adolescent brain is remarkable. It is sort of like a new can of Play-Doh that you’ve just opened; you can mold it and make it into any form that you want. These young brains imprint neuropathways quickly. They can also “unimprint, if you will, relatively quickly. Their Prefrontal Cortex (PFC), the executive function of the brain, is not fully developed until the late 20’s. A person that was considered a “mature adult” in the 60’s and 70’s was around the age of 20-21. Today that age is much later, due to the delayed maturation of the PFC.

Dr. Andrea Barthwell says that it is rare to find an 19-20-year-old who has a mature PFC and when we do, it is most often: a female; who is the oldest child; with younger siblings and; with absent, uninvolved, and/or non-nurturing parents; so, she has had to be responsible for food, shelter, clothing, safety and much more, since she was a small child. Our culture has changed dramatically in the last 2-3 generations and children are growing up without the responsibilities that build the “muscles” of the Prefrontal Cortex. Part of the function of the PFC is making decisions about choices and their consequences, navigating quality relationships, reading social situations and more. Take a minute to watch this 60-second video on YouTube and it will help you understand.

Caution! Not only can we not accurately determine who has an addiction, we also can NOT determine who DOESN’T have one, so trying to control-use after being a compulsive abuser of chemicals or behaviors is like playing Russian Roulette. Abstinence is always the best plan once a person has had an abuse problem that might be an addiction or might become an addiction, simply because it could. Please hear what I am saying, not what I am not saying. Pain, hurt, emptiness and consequences don’t just start once an official addiction or compulsion starts. They’ve been going on for some time; they sort of lie on a continuum. Both the hurt that the abuser is trying to medicate and the hurt the abusing causes to the individual abuser and their family and inner circle are in all these phases; abuse, dependency, compulsivity and addiction.
What does all this mean for your loved one?

You must be careful when thinking about diagnosing anyone with any diagnosis. As stated previously, the assessment lens through which you look at a problem takes you to the diagnosis, which usually is a label. When young adults and adolescents get officially labeled, they tend to live out a self-fulfilling prophecy, which is why we at Capstone don’t label them. That diagnosis determines the treatment plan which, in turn, determines the outcome. Using the wrong assessment lens means you made the wrong diagnosis which in turn means you developed the wrong treatment plan and that will produce failed outcomes.

Capstone does not just treat the compulsive / addictive behavior by itself because to do so means any gains will be short-lived because of the other two core systems; the core and the context. We must work on all three simultaneously because you don’t get lasting change in one without change in the other two. Thus, the Core-Systems Model.

How you see it is how you treat it.

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