While
interviewing hundreds of addicted clients over the years it became obvious to
me that addictions are what mental health experts call developmental disorders. That is, they develop over time as the
result experience, genetics and growth. Sometimes they appear quickly and
sometimes it takes years, but the stages of their development always seemed
similar between individuals and between addictions. I evolved a description of
the stages of addiction and recovery as a kind of theoretical structure, as a
teaching device when I worked at the Veterans
Administration Hospital
in Reno, Nevada.
Later, the stages were included in several published papers and eventually in a
treatment manual developed for use in treating problem gamblers in Las Vegas by a company
called Trimeridian.
It also
became clear to me that, although the separate addictions have been treated as
very different problems, they are manifestations of a single underlying
disorder that I’ve called the Addictive Response Pattern or simply, the
Addictive Response.
My desire
was not so much to build a formal theory as to describe as simply as possible a
general process many addicted individuals go through. The description includes common intellectual
and behavioral features that appear as people grow and change from an initial
addictive experience through the final stage of recovery and abstinence.
The
Stages of Addiction and Recovery Model (SARM) suggests a continuous development
and change process best viewed as an unfolding series of characteristics with
no abrupt change points such as hitting some sort of bottom or particular point
of desperation. Older theories viewed
the growth of addiction and recovery as opposite patterns while SARM attempts
to describe a continuous process of development.
The
developmental flow suggested by SARM is divided into six stages each of which
is a description of the thinking of an individual with respect to a particular
addictive at any given moment. The term addictive is used here as a noun to
indicate the substance or activity that holds addictive potential for
vulnerable individuals. It is the trigger needed for the addiction.
SARM does
not assume that the individual is in the same stage with different addictives.
That is, one could be in the advanced stages of alcoholism but a beginning
gambler. Knowing what stage of progression or development an individual is in
with respect to different addictives might be useful in predicting the need for
treatment, the level or intensity of treatment, and the possible outcome in
terms of quality of life and abstinence.
Developed
in the context of a program for different addictions—a program we called the
Addictive Disorders Treatment Program—we dealt with a broad range of addictions
including gambling, alcohol and substance abuse. SARM should be valid for all addictive
developments and could be applied to any addiction, even those not seen as a primary addiction for any given
client. Research shows that clients with
any specific addiction very often have other addictions that are usually not
addressed in specialized programs for alcoholism, problem gambling, overeating
or substance abuse.
The
tendency to substitute some other addiction for one that has become inactive is
nearly universal. Clients are, in fact, sometimes encouraged by advisors to
find substitutes to fill some supposed void
once they have undertaken abstinence from a primary addiction. Thus, without intending to develop any new
addiction, an alcoholic may find increasing problems with gambling or
overeating during periods of alcohol abstinence. Smoking and abuse of
prescription drugs are frequent in addictive disorder clients as are
non-substance dependencies such as compulsive spending and over-working on a
job.
There is
a risk of harming people with a single-minded, narrowly focused treatment of
one addiction at a time. Let’s suppose we have someone coming for help with a
gambling problem. She is a long time smoker, but smoking was not permitted
during treatment sessions, was not seen as relevant in treating the gambling
and was ignored. Other minor or sub-clinical potential addictions were
ignored while the gambling was suppressed by treatment. We learned, during the
initial interview, that there was some overeating, occasional misuse of
prescription drugs and unfaithfulness
to the spouse. Again, these were not the focus of treatment and were basically
ignored. They did not fit the diagnostic standards applied in treatment at the
time.
This
individual, to summarize, was a moderate drinker who occasionally over-used
cold remedies, engaged in casual sex from time to time and was somewhat
overweight. None of these were treated as problems as staff focused attention
on the gambling, and yet her other behaviors, although at the time moderate,
may have been more dangerous to health than the gambling. Had her treatment
focused on learning what are called coping skills—skills necessary for
self-managing emotions and behavior—it may have been of some general benefit.
Unfortunately, in most specialized treatment programs, other addictions are
seldom mentioned and discussions focus on the primary or identified addiction.
Was the
specialized gambling program successful? If we look only at the gambling, yes.
She went home, attended Gamblers Anonymous and all seemed well. Unfortunately,
compensatory addictions soon developed. She almost never gambled following
treatment, but drinking, promiscuous behavior and the use of barbiturates
escalated. She continued to expose herself to the health risks of tobacco use.
The woman was still looking for a solution to her lifelong dark feelings that were
not addressed by the program for gambling.
When a
primary addiction is suddenly stopped there is a very strong tendency to
develop a compensatory addiction that
is usually one the client already had at some milder level and which now grows
stronger and serves as a substitute preventing real emotional and intellectual
growth. Compensatory addictions soon undermine abstinence from the primary
addiction and are a major cause of relapse. This is why it is so important to
assess a person’s progression in all
likely addictions at the beginning of an intervention or treatment for a
specific addiction. Of what value is successful alcoholism treatment if the
client leaves with a stronger likelihood of gambling or prescription drug
abuse? Again, it is very likely that the different addictive progressions
within the same client sometimes move independently and mask the single
underlying disorder that I have called the generalized Addictive Response
Pattern
The
division of life into stages is arbitrary and artificial; it’s like calling
different parts of a river or a road by different names, and we do this
sometimes just to be able to talk about different parts of the same process.
The test of the usefulness is whether or not the addict can see how these parts
played out in life.
I
recognize six stages of development in the addict:
1.
Delight
and Discovery
2.
Protection
and Promotion
3.
Defense
and Denial
4.
Resentment
and Relapse
5.
Acceptance
and Abstinence
6.
Growth
and Gratitude
1. Delight and Discovery: In this first stage, a person samples a trigger, probably for the first time,
and may experience a rather immediate and strong emotional contrast effect.
Sometimes, of course, a first use causes fear or nausea, but with some
encouragement for continued use the user of the new trigger finds it will
produce a high or altered state that contrasts vividly to the customary
background of dark feelings, emotions that have never been confronted and dealt
with. Hyperphoria and sometimes great relaxation replace the normally painful
collection of depressing emotions and thoughts. Having had this delightful
experience, the new user of the addictive suddenly becomes a champion of its
use not only for self, but for others as well. The trigger is suddenly seen as
a kind of miracle drug or extremely important activity. The user is
self-medicating rather than solving emotional problems.
With some triggers such as smoking tobacco or
marijuana there is only an increase in general comfort level and ability to
relax, not an excited high. The user may not even notice this change in
feelings, but will easily become dependent upon it.
The
social isolation of the addict-to-be may begin when others not subject to the
same tensions, dark feelings and thoughts see little point in heavy use of the
addictive. Attempts to convert the wrong (invulnerable) people to use
eventually drive people away, and the individual is left to the company of
like-minded users
First use
is described by addicts in many ways:
It was
like coming home to a warm fire.
I felt
like a huge stone had been lifted from my shoulders.
I finally
felt normal and relaxed.
It
gave me such self-confidence like I’ve never known before.
Life
took a new, wonderful meaning for me.
I
never relaxed, even when I slept, until I found this.
I knew
then that I could do anything. It made me feel invincible.
It’s a
wonderful way to relax and take a break.
It’s
my one big treat, my one expensive luxury.
Some
beginning addicts do actually stay at this mild level without further obvious
progression, and they may stay there for long periods until some life reversal
or major transition increases vulnerability. Some are willing to give up use
because the loss of friends is too high a price to pay for fun. What is called natural recovery is possible at any
point depending on the individual’s level of vulnerability. Dark feelings come
and go; they can exist at all levels of intensity. Some others may find an
alternative addiction that fits better in their social circle.
2. Protecting and Promoting. The new addict continues to try
to promote use among others convinced he or she has discovered some great
truth. Enthusiastic evangelical crusading, of course, doesn’t pay off. The user
may find employment in a related industry, anything from street drug sales to a
return to college to study pharmacy. One fellow took a job selling wholesale to
taverns and spent his days visiting many bars giving out free bottles to bar
tenders and sample drinks to patrons. One new gambler recruited a group of
friends to help in a betting scheme he thought would beat the casino. (He’s
still in jail.)
The
addict may oppose any social or legal restrictions on use of their particular
addictive; all restrictions seem unduly harsh, the addict tends to view him or
herself as a rebel or enlightened reformer. The circle of real friends grows
smaller while the devotion of fellow users is mistaken as real friendship. At
this point the addict is protecting the trigger from blame, protecting use of
the trigger and still attempting to promote its use by others.
3. Defense and Denial. At this mid point in the
development of an addiction the social and financial costs become gradually
more obnoxious interfering constantly with the enjoyment of the trigger. The
addictive trigger, in fact, may now require increased use in amount and
frequency. Tolerance for the addictive increases, but the original refreshing
high gets harder to reach.
The
addict may hit physical or financial limits of consumption at this point
without reaching the old, desired level of euphoria or satisfaction. At the
same time, physical tolerance is gradually lowered as the years pass.
Family
arguments become increasingly bitter, problems on the job may develop and
possibly there are legal problems such as drunken driving charges, loan sharks
and even crime to support the addiction. Increasing pressure to stop or hide
the use of the addictive leads to resentment and an increase in background dark
feelings when not using. There may be ineffective and half-hearted efforts to
stop or moderate use. Rebound depression now demands a more immediate return to
elaborate anticipation and use. The addict may gradually become more secretive
attempting to hide use from family and co-workers.
4. Resentment and Relapse. Growing resentment at social
sanctions against use and at the damage being done by constant use lead to
outbursts of anger, impulsive acts and frequent periods of angry abstinence
followed by devastating periods of return to use. Attempts to abstain are
undermined by a refusal to change values and priorities. The addict has many
criticisms of any program or therapist that tries to help often blaming others
for a relapse. Abstinence at this stage is often similar to what has been
called a dry drunk. Dark feelings
that have been suppressed by the addictive may come to the surface during
periods of abstinence. The addict is particularly vulnerable at this point to
compensatory or substitute addictions. For some, resentment and constant
relapse become a way of life. By now, the addict may have lost everything worth
having and may become uncaring, isolated and even suicidal. It is extremely
difficult to talk about help with such an addict since, by now, he or she has
experienced a variety interventions none of which have worked. A sense of
hopeless surrender to the addiction may develop and we hear them saying, “I
know I was doing the wrong, stupid thing, but I just didn’t care anymore.”
5. Growth and Gratitude. A relatively few addicts reach
this final state that is the doorway or beginning of normal living. There may
come about a radical change in values and attitudes about life and about
addiction. Some, of course, have reported having a spiritual experience, an
epiphany or sudden insight. Most, however, discover a different way of thinking
and living more gradually through a self-help group, individual counseling,
study on their own or simply increasing age and life experience. They
gradually, in a hundred different ways, learn to manage dark feelings. People
can and do continue their psychological growth and can outgrow addictions
without substituting new ones. As they once blamed their addiction on other
people, places or events, they may now credit their newly found ability to
abstain to something going on in their lives at the time of this breakthrough.
It might be a twelve step group, a psychotherapy experience, religion, college,
etc. Any one of these experiences and many others can produce the new ideas and
the new ways of dealing with destructive feelings and impulses.
Hopefully,
the reader at this point may have some greater understanding of the bug that
bites the addict, and about yet other bugs still waiting to bite. But,
understanding and insight alone do not amount to a cure. Psychological growth
takes work, study, time and energy. In the next few articles, I take a more
detailed look at the attitudes, lifestyle changes and problems offered by most
so-called Twelve Step groups. So, at this point, we move away from describing
the development of addiction in order to look at the problems of what has been
called the recovery from addiction.
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