Sex, Drugs, Gambling, & Chocolate:
A Workbook for Overcoming Addictions
What is addiction?
What Causes Addiction?
What Is the Scientific Support for This Book?
What Does “Overcoming Addiction” Really Mean?
How To Use This Workbook
For Whom Is This Book Intended?
Why Am I Qualified to Write This Workbook?
But What If You Really Are an Addict (or Alcoholic)?
|Every man has business and desire, such as it is.|
|– William Shakespeare (1564-1616) |
Hamlet, Act I, Scene v
|Every man put himself into triumph; some to dance, some to make bonfires, each man to what sport and revels his addiction leads him.|
|– William Shakespeare (1564-1616)|
Othello, Act II, Scene ii
Did you read the list on the opposite page [a list of 115 addictions]? Isn’t the variety of addictive substances and activities amazing? Once you have read a few chapters of this workbook, I hope you will agree that nearly everyone has an “addiction” of some type. If you have one, large or small, and want to do something about it, keep reading! This workbook presents a “common sense” approach to overcoming addiction, one that is also supported by research.
We begin with the idea that addiction in its varying degrees is an extreme version of habit, and overcoming addiction occurs using the same processes we use to change other habits. To be sure, severe addiction can result in horrendous consequences, but even severe addiction can be changed using normal human change processes.
Although some individuals become more addicted than others, everyone slips from habit into addiction (broadly defined) at times. Both are normal, part of being human.
The ordinary processes that change either habits or addictions include, among others:
- increasing self-awareness
- identifying and resolving conflict
- discovering and developing alternative behaviors
- experiencing support from others
- not acting on temptation
- being persistent
Habit change is a psychological problem, and addiction also can be viewed as a psychological problem requiring a psychological solution.
In the traditional approach to addiction, used by almost all addiction treatment and support groups in the United States, addiction is viewed as a medical and spiritual problem — a disease — and attending Alcoholics Anonymous (AA) or other “12-step” groups is necessary for recovery. AA’s 12 steps describe how recovery occurs by turning over one’s will and one’s life to the care of a “higher power” (or God, as understood by each individual).
This workbook was written to provide an alternative approach for those who might prefer one. In the remainder of this Introduction I present an overview and brief justification of this alternative.
“To addict” is derived from a Latin root meaning to assign to, or to surrender. There is no definitive contemporary definition of addiction. We will use a “working definition” which is consistent with what is known about addiction treatment and with common sense.
Addiction is repeated involvement with anything, despite excessive costs, because of craving.
The three central concepts here are “anything,” “excessive,” and “craving.” Let’s work backwards.
Craving. Craving can be a complete experience: feelings, thoughts, sensations, images. When craving occurs, you strongly desire a specific substance or activity. You have an urge for it, get jumpy and twitchy, feel you can’t go on without it, start losing interest in everything else, recall a previous “high” and look forward to the next one. Craving is a kind of tunnel vision. As it gets stronger, you perceive less and less of everything else, and become increasingly focused on getting back to your addiction. If nothing significant stops you, that’s what you do. Chapters 8 through 10 will focus on how to cope with craving.
Excessive. All involvements have a cost. If the cost is in proportion to the benefits received, we are satisfied. If the cost is relatively low, it’s a bargain. In addiction, the cost is relatively high. Although there are still benefits in addiction (we’ll elaborate on this in Chapters 3 and 4), addiction is the opposite of a bargain. In addiction, repeated involvement occurs because the tunnel vision of craving momentarily hinders us from recognizing the discrepancy between cost and benefits. In mild addiction, cost clearly but slightly exceeds the benefits. In severe addiction, the difference between costs and benefits is dramatic. A habit is repeated involvement when costs and benefits are about equal.
Anything. Although addiction has usually meant substance addiction, in recent years there is recognition of addictions involving gambling, sex, spending, relationships, and other activities. It now appears that any substance or activity (i.e., anything) could lead to addiction, because addiction is a type of relationship between an individual and the substance or activity. If you need suggestions about substances or activities to consider, look at the list of addictions opposite page 1. This does not present a definitive list (that would be impossible), but many common addictions are listed. The individual is an active contributor to the addictive relationship, and not a passive victim of a substance or activity. If we were at the mercy of certain substances or activities, everyone sufficiently exposed to them would become addicted, but this does not happen.
Consider phobias. Most of us are exposed to elevators, freeway driving, heights, insects, and other aspects of daily life. Only a few of us develop phobias (excessive fears) to these objects. Although it is possible to develop a phobia to anything, in practice most phobias occur to predictable objects and situations. These phobias are predictable because their objects or situations are fearsome in at least some degree to most people, because of the possible (even if unlikely) connection to survival. If elevator cables break, an auto accident occurs, a fall occurs, or you get bitten by a disease carrying insect, death may result. We get phobic about these kinds of objects. We typically don’t get phobic about desks, books, sidewalks, or other almost-always-benign objects.
Similarly, addictions tend to develop to substances or activities that strongly influence emotions. Substances that influence emotion via physiological (physical) actions are called psychoactive. But even substances which are not physiologically psychoactive can become “psychologically psychoactive” because of learned associations to them. The same process could occur for activities. I have observed (a few) addictions to non-psychoactive substances, the negative consequences of which were substantial.
If addiction is a relationship then there is no one “most addictive” substance or activity. Heroin or crack cocaine are often suggested to be the most addictive substances. Although more individuals might seek a second experience with these substances than might with some other substances (although no one has ever proven this), it also is beyond doubt that many individuals do not seek a first experience, and many other individuals, after one or several experiences with heroin or crack cocaine, do not seek more. Furthermore, those who have quit heroin and cigarettes, or crack cocaine and cigarettes, state that even though they enjoyed heroin or cocaine more, the cigarettes were harder to stop. Like all relationships, addictive relationships have many components.
For a particular individual there may be a “most addictive” relationship. This is often called the “drug of choice.” Why this drug (or activity) is most favored is undoubtedly a complicated interweaving of biology, personal history, personality and circumstance that is well beyond our current ability to explain. We are also not able to explain how individuals with a drug of choice and possibly several additional addictions may also have a mild or non-existent positive response to other “addictive” substances or activities. Although we might be addicted to almost anything, we are usually very far from being addicted to everything.
In summary, an addiction can develop to any substance or activity, but addictions tend to develop only in those which under normal circumstances influence emotion. Even though an individual may have several addictions, he or she does not have all addictions.
There are many behaviors that at first glance appear to fit this working definition of addiction. A college freshman who ends up in the emergency room after his first alcohol binge may not have been repeatedly involved with alcohol (although he may soon be). A medical patient on opiates for pain control probably does not crave the next injection for the high, but simply wants a reduction in pain. An occasional low stakes poker player may incur a minor expense when she loses, but the pleasure of gambling in this manner, for this individual, outweighs the cost, so it is not excessive. This last example illustrates how addiction is highly dependent on the context in which it occurs. What is a minor expense for one individual might not be for another.
The working definition of addiction is similar in some respects to the traditional definition of addiction (or alcoholism) as a disease. The “three C’s” of the traditional definition are craving, consequences and (loss of) control. However, the traditional definition is all-or-none (you either are an addict/alcoholic or not), craving is often suggested to be uncontrollable, and moderate involvement with the addiction is considered impossible.
The facts contradict this disease model of addiction. There is a range (actually multiple ranges) of addictive behavior. There is no clear dividing line where addiction begins. Craving is fully controllable (otherwise addiction is a hopeless situation–but it’s not!). Moderate involvement is possible and worth considering.
The working definition of addiction also suggests the possibility of a positive addiction (or good habit). Positive addiction is regular involvement with a substance or activity, accompanied by a minor degree of craving, with the benefits of involvement outweighing the costs. Habit is repeated involvement when costs and benefits are about equal. Ironically, the resolution of (harmful) addiction involves the development of positive addictions.
Consider toothbrushing. If you brush regularly (and I hope you do!), but miss a brushing, do you begin to crave the opportunity to brush? I do, and I believe many others do. The craving is not strong, but there is a sense of having missed something. As severe addictions develop, positive addictions drop out of the individual’s life (including toothbrushing!), and the restoration of these behaviors (and the development of new ones) is a crucial aspect of overcoming the addiction.
To summarize, there is a continuum of repetitive behaviors. At one end lies harmful addiction (costs exceeding benefits), at the other lies positive addiction (benefits exceeding costs). In the middle is plain habit. All involve craving to some degree. We might also describe the continuum as consisting of bad habits, plain habits, and good habits. When I refer to addiction I will mean a harmful one, in accordance with the working definition above. I will indicate positive addiction or good habit when that is meant.
The same repeated behavior could be a positive addiction, a harmful one, or a habit. Exercise or wine-drinking are two common examples. Cocaine use is another example, if we consider the coca-leaf chewing of millions of South Americans, which is akin to coffee drinking. Possibly any addictive involvement that lies at the severe end of the continuum, for some individuals, could also be found at the other end, in other individuals (although the behaviors associated with these involvements would be dramatically different). Some involvements may in practice tend toward only one end of the continuum (e.g., toothbrushing), but what happens normally can also happen in unusual circumstances or contexts. A cost-benefit analysis of any behavior must take into account its frequency, intensity, context, and other factors.
In short, to understand your addiction you need to understand your life. This workbook attempts to help you do that.
This workbook is about overcoming addiction, and about a broader issue: the management of desire. Addiction develops when desire goes unchecked. Desire is a fundamental aspect of human life, and learning to manage desire is part of normal human development. Overcoming addiction is a special case of managing desire. Overcoming addiction is managing desire writ large.
I leave out of this discussion some Eastern approaches to living, in which the goal of proper living is the elimination of desire. In the Western tradition life is about satisfying desire.
Some desires have their own names: hunger, thirst, greed, lust. Otherwise, we speak of desiring (seeking, wanting, wishing for) various objects and situations in our lives. We feel these desires with varying degrees of intensity. We spend our time identifying, sorting and acting on our desires. We attempt to satisfy those reasonably within our reach. We feel lucky when we get something we weren’t sure we could, obtain, and disappointed when we miss out on something we thought was within easy reach.
The stuff of daily life is effort expended to satisfy desire. We work or go to school, possibly because we are satisfied by these activities in themselves, but also because we earn or hope to earn money to purchase items and experiences, to satisfy our desires. We seek satisfaction (we might also call it pleasure). What money buys will bring us satisfaction directly, or position us to obtain satisfaction. Besides money making, we engage in many other activities that are means to other ends. Those ends ultimately can be described as satisfaction, or as happiness. There are vast differences in what individuals find satisfying. There are also vast differences in their capacity to accept new satisfactions in place of old. Changing one’s satisfactions is central to overcoming addiction.
Conflict is also the stuff of daily life. Conflict occurs when one person desires this, and another desires that (she wants to go to the beach; he wants to go to the mountains), or the same person desires both this and that (two incompatible things). In addiction, for instance, a conflict can occur between a desire for substance-induced euphoria, and a desire for health. Recognizing and examining this conflict are the first steps to managing addiction, just as they are for managing other conflicts. Both sides need to “sit at the negotiating table” and air their agendas before resolution can be found. Chapters 3 through 5 describe how to do this for addiction. As I will amplify in Chapter 5, if there is no conflict there is no addiction. Under certain circumstances what might look like addiction is not addiction, because the conflict does not exist. “Morphine addiction” in the terminal patient is a clear example.
Unlike the aforementioned Eastern approaches, this book focuses on advancing or maturing desire and satisfaction. We can outgrow earlier, or excessive pursuits (and the desires that prompt them), by developing equally (even if somewhat differently) satisfying pursuits. At age five my favorite food was popsicles. I still enjoy an occasional popsicle, but my tastes have matured. Freud called the process of reaching higher satisfactions “sublimation.” Socrates called it ascending the “ladder of love.” In Chapter 11 we discuss higher satisfactions. One goal of this workbook is to transform desire itself. Otherwise we are, in varying degrees, slaves to it.
As a drive state (such as hunger), desire prompts us to do what we need to do to survive. As a craving or want, it motivates us to pursue experiences that lead to pleasure, satisfaction, and at times, euphoria. Without desire we would not survive, nor pursue activities. We would have no reason to. However, desire can be unmanaged or mismanaged. Addiction is one form of this mismanagement. You may judge for yourself the extent to which mismanaged desire, particularly by those in power, has brought suffering upon humankind.
In severe addiction the desires related to satisfaction appear to become confused with the desires related to survival. Over time our satisfactions actually decrease, but we pursue our addictions as if our survival depended on them. Fortunately it is possible to overcome this situation, as described in Chapter 9.
There is substantial scientific literature on the treatment of addiction. I have not provided references in the text because they are of little immediate value to the individual desiring to overcome addiction. In the annotated bibliography (Appendix B) are several works which can provide a gateway to the scientific and popular addiction literature.
The treatment of activity addictions is largely unstudied, and the treatment of addiction to substances other than alcohol firmly supports at present only one treatment — methadone maintenance for heroin addiction. More than being a treatment itself, receiving methadone in place of heroin sets the stage for making other improvements.
This leaves treatment for alcohol problems, which fortunately has been well studied. Over 200 randomized controlled clinical trials of various alcohol treatments are now published in the scientific literature. Several treatments have emerged as effective: the community reinforcement approach, behavioral marital therapy, moderation training, brief motivational counseling, social and coping skills training, and aversive conditioning. Some medications and stress management training are also effective. These treatments are neither well-known nor widely available. American addiction treatment is almost entirely traditional (disease model and 12-step oriented). This lack of alternatives is one of the reasons this workbook is needed.
This workbook presents an integration of ideas that appear in various forms across all or many of these alcohol treatments: a generic empirically supported treatment for addiction. Fortunately this generic approach appears likely to apply well to activity addictions and other substance addictions. Clinical judgement is certainly involved in the integration proposed here, and other clinicians might have integrated these treatments differently. Nevertheless, I am confident that most empirically oriented addiction clinicians will agree with the main ideas of this workbook.
Although you can’t really judge a book by its cover, with the multitude of books in contemporary society, the cover of a book may be all that most individuals read of it. Because “addiction” is often a negative concept, I was initially concerned that many people would pass this book by, thinking “I’m not addicted.” How would they discover that the workbook assumes that everyone has had some degree of addiction, probably to multiple substances and activities? How would they discover that the book is potentially beneficial even to someone who is not an “addict” or “alcoholic”? That’s where the list of addictions opposite page 1 comes in. My hope is that listing many types of addiction, which cover a wide range of typical severity, helped you realize this book is about everybody.
On the other hand, individuals who have experienced substantial addiction problems may feel that the notion of everyone being addicted trivializes their problems. The daily heroin user and someone who watches too much TV or who eats too much chocolate may not think of themselves as having much in common.
My middle course is to recognize the vast differences between individuals in the consequences they have experienced because of addiction (as well as how they are perceived by society), but to suggest that there are common elements in overcoming addiction. The workbook presents these common elements. For those with less severe addictions the workbook by itself may be sufficient for completing desired changes. If those with severe addictions are not completely helped, then with luck they have made progress.
“Addictive behavior” has replaced addiction in the last two decades for many psychologists, and it is the term I typically use day to day. It seems to fit better with the idea of a continuum of addictive problems, the possibility of either substance or activity addictive behaviors, and the active role of the individual involved. I chose “addiction” as less cumbersome for the printed page. “Habit” is another option. It avoids the immediate negative connotations of addiction. However, the sense of “habit” for most readers may not include the severe addictions, which are definitely a focus of this workbook.
“Overcoming” is part of the title in order to emphasize the possibility of getting completely past addiction. You can so fully overcome addiction that there is nothing special you need to do to stay free of it. You can be finished with it!
To have thoroughly concluded that “I can live without it” is, for the severely addicted, a critical accomplishment. With luck, individuals at any level of addiction can go beyond this discovery, to accomplish the ultimate purpose of overcoming addiction: to live even better without it.
I have attempted to write a brief but comprehensive workbook for overcoming addiction. For some individuals only a relatively brief effort to overcome addiction is needed, and the brevity of this work is appropriate for them. Nevertheless, I have attempted to cover the major issues typically involved. Even if some of these issues are not pertinent for you now, it will be good to be aware of them. They could come up later in your life — possibly with another addiction.
This workbook covers addiction in general because overcoming addiction is one process, and you will probably need that process several times in your life. Most individuals actually have many addictions, of varying degrees of severity, not just one. Even if only one is a significant problem for you now, the others may still be in need of changing later. Changing one large negative behavior usually involves changing many smaller negative behaviors, as well as developing many positive behaviors. If you learn general principles of behavior change, you can apply them as many times as you need to — for the “big ones,” and the not-so-big ones.
Each chapter begins with an Overview. The Overviews are also collected together in the Summary at the end of the workbook (Appendix A). By reading this Summary you can identify the chapters of most use to you.
The Questions and Projects at the end of each chapter help you consider how to apply what you have just read. There is lots of space to make notes. Record the ideas and techniques that are most relevant for you.
If you make enough notes, you’ll make it your book, because it will cover what you need. Even if you are not writing answers to the Questions and Projects, you may want to read them, because some ideas from the main chapter text are not fully elaborated until then. If you are progressing through the chapters as part of psychotherapy, the Questions are also intended to provide springboards for discussion for you and your therapist.
The process of overcoming addiction is typically not neat or organized. The individual’s journey often does not make sense until nearly the end. Although there is in the abstract one process of overcoming addiction, there are as many expressions of this process as there are individuals. The workbook attempts to allow for this variability. In the final section of each chapter you are encouraged to record the ideas of the chapter that are most useful for you at that particular moment. On later readings, which are encouraged, other ideas may be recorded instead. Your notes will become a log of your journey of discovery, a log that will help you make full sense of the journey when it’s complete.
Any changes you make in your life are ultimately your own responsibility. They will be made in your own way, and you will deserve full credit for them. There are as many ways to change as there are individuals. Keep trying until you find what works for you. I hope that many of the ideas in this workbook will be helpful to you. If they are not, remember that you can also look elsewhere for guidance. The Bibliography and Resources at the end of the workbook, and the support groups listed in Chapter 6, provide places to start. You might also consider (or re-consider) traditional treatment and support groups.
Most individuals who overcome addiction will do so with minimal outside assistance. In the professional literature this recovery without professional treatment or support group attendance is called “natural recovery.” If you doubt that this is possible, consider smoking. Almost everyone who quits smoking does so without attending treatment or a support group. Perhaps we should not be surprised by this. Everyone knows it’s easy to quit smoking, right? Wrong! Studies also document natural recovery from alcohol and heroin use.
Treatment for addiction is an adjunct to a naturally occurring process, rather than an essential component of recovery. In medical treatment it is assumed that the patient has a natural capacity for healing. Medical intervention aims to get the patient over one or a few specific obstacles to health, but not all of them.
Many will overcome addiction without the assistance of a workbook. If natural recovery is not occurring, buying and reading a workbook is a smaller step than entering treatment. This workbook may also be a useful adjunct for someone who has sought treatment, especially individual or couples psychotherapy or counseling. The therapist and the client might progress through the workbook together. As noted below, the workbook may not serve well as an adjunct to traditional treatment.
For individuals with severe addictions this workbook can be an introduction to change — an overview of it. However, the workbook may need to be supplemented with additional readings and professional services. Individuals with severe addictions also typically have multiple and often severe additional problems — poor health, relationship problems, financial problems, work dysfunction, inadequate social support, depression, anxiety disorder (phobia, panic, PTSD, generalized anxiety), attention deficit disorder or developmental disorders, major psychiatric or personality disorders, or other problems. Overcoming this set of problems usually involves making improvement on all of them, and significant help is often needed.
There is a range of beliefs about the traditional approach to treatment. If you view it as the only route for your recovery, this workbook probably will not be helpful to you. The differences in approach would probably require so much “translating” as not to be worth the effort.
However, you may view the traditional approach and this alternative as different but equally valuable, at least given what you know about them. If you are not committed to one approach, this workbook may help you make a decision. Most individuals will fare best if they select one approach or the other, because many (although not all) of their ideas are opposites of one another. However, I also believe that there are as many roads to recovery as there are individuals. Regardless of your other choices, I would be pleased if this workbook is useful to you.
Although the underlying ideas in this workbook are also applicable to adolescents, the presentation of these ideas has been done herein with adults in mind. A separate workbook would be needed to present these ideas adequately to adolescents.
I am a clinical psychologist who started practice in 1984 in San Diego, California. Since 1985, I have specialized in providing “alternative treatment” for addiction. Prior to 1985 I had been aware of the lack of options in American addiction treatment. I have a personal passion for “reason” and the development of reasonable solutions to problems. The 12-step idea that addiction could be resolved only by reliance on a “higher power” made no sense to me. I do not doubt that a spiritual awakening can resolve addiction and many other problems, but I do not believe that it is the only method that will work. The idea that addiction could be resolved only by speaking with others who are “recovering” from addiction also seemed unreasonable.
If I take my broken arm to the emergency room of a Catholic hospital, they treat it using entirely non-spiritual methods. If I ask to see a priest they willingly send one, but they probably don’t suggest I see one either. The hospital’s view is: God exists, but we don’t need to go that high to repair a broken arm.
Whether the physician setting the arm had previously also had a broken arm is not relevant to his or her ability to set mine. We know enough now about overcoming addiction that a well-trained mental health professional can help someone regardless of the professional’s personal history. If you accept the ideas in this workbook, you will also realize that we all have in common some level of personal experience with addiction.
I believe that there might be many different types of spiritual awakenings, not just the type suggested by AA. Addiction treatment needs to be able to accommodate all types of spiritual awakening. I hope that for many readers the exercises suggested by this workbook, particularly those in Chapters 11 and 12, will lead to a type of spiritual awakening, or support other spiritual awakenings of the reader’s choosing.
In graduate school, I took one course on “alcoholism,” but it exclusively focused on 12-step based treatment. Later I discovered that there was a substantial scientific literature on the treatment of addiction, but treatment based on this literature was not widely available. By 1985 I decided that I wanted to make these treatments available for those who preferred them. This workbook summarizes what I have learned by study of addiction and its treatment, and by listening and learning from clients as we work together to apply the sometimes abstract principles of change in their very specific lives.
Although for many of my colleagues working with addiction is decidedly not appealing, I have found it very satisfying. There are significant prejudices against individuals with addiction: “How can you tell when an addict is lying? When his lips are moving.” “When an alcoholic tells you how much he drinks, double or triple it if you want the truth.” Although there are certainly times when addicted individuals deceive professionals (and sometimes, even more importantly, themselves), deception and self-deception are not unique to addiction. Professionals with negative attitudes toward the addiction need to consider the role their own non-empathic, antagonistic or controlling behavior might play in eliciting the behavior they object to. Most individuals with addiction respond well to empathic listening, sincere concern and a flexible perspective. In time most of them make major changes.
If your perspective on addiction includes labeling yourself as an “addict” or “alcoholic” who has a disease, then this workbook probably is not for you. AA and other 12-step groups are easy to find because they are listed in every American phonebook. There are over 96,000 AA meetings around the world each week, and additional thousands of other 12-step groups. Many individuals report that their success in overcoming addiction occurred because of the insights and support they received in 12-step groups.
However, if you are not sure that this is your perspective, you may be interested in knowing the following facts. Although many individuals seek out AA (and I recommend attending a meeting if you have never done so), most do not follow through for any significant length of time. As noted above, the majority of individuals who recover “naturally” do so without attending AA, other 12-step groups, or treatment. Although there is a very large body of professional writing on AA, it has been infrequently studied with scientific controls, and scientific judgement on its effectiveness cannot yet be made. 12-step based treatment, which helps someone make good use of attending 12-step groups, has only recently been supported by research as possibly being as effective as the proven treatments I mentioned earlier. None of the proven treatments is based on understanding addiction as a disease, nor are they based on a belief in a “higher power” (which is the cornerstone of the AA approach). In the proven treatments addiction is understood as lying on a continuum, and clients are given a range of options about how to participate in treatment and what treatment goals to have.
The traditional approach is the most widespread (if you doubt that just call a few treatment centers listed in your local yellow pages), but there is no need to be embarrassed about pursuing an alternative approach if you desire to do so. You have substantial scientific justification for this choice.
One final note by way of introduction. I suggest that you not use the labels “addict” or “alcoholic.” They are examples of all-or-none thinking, and may be unhelpful because you can waste effort on wondering whether the label applies to you. You can think of yourself as having had problems (plural) because of the substance or activity, and as now wanting to change your relationship with it. To say you have “a problem” is just to re-word addict and alcoholic. This re-wording may be some improvement, but you are still thinking in all-or-none terms (some have a problem, some don’t). Even the term “addiction” is a convenience for the sake of writing this book. You could use “habit” or any other term you prefer. If you believe that you have had some problems from one or more substances or activities, and if you desire to reduce or eliminate these problems, the pages that follow will show you what to do.