Addiction is generally poorly understood. People often think of it in terms of moral dysfunction (poor choices), instant chemical dependency, trauma management or blatant hedonism (joy seeking). While there is an element of truth to each of these, mostly none of these are accurate. There is also contention about how to define addiction, and from that what should be included and what shouldn’t be. We are going to take a brief look at some history to understand how we got to this confusing space, then we will look at a useful model of addiction, and finally what you can actually do about “addiction”.

Formal Addiction Diagnosis

Diagnosing Addiction is challenging in a few ways.

First is the debate about whether addiction has to be direct chemically related (a substance of dependency) or if addiction like behaviour around an activity that triggers a neurotransmitter that is similar to what you may be taking a substance to trigger is also considered an addiction.

Second is how each country considered fair use versus over use. For example, in some countries, a standard drink of alcohol with dinner and another later in the evening is considered culturally appropriate, while other countries consider any alcohol use a problem.

Even if you gain a diagnosis, the treatment plan unfortunately relies on many outdated models for understanding addiction, which we will cover below.

Substance Use Disorder (DSM)

Therapists, doctors and psychiatrists define addiction primarily in terms of Substance Use Disorder (SUD) as defined by the DSM 5. SUD is considered to be a pattern of symptoms caused by substance, that a person continues to take despite recognising its negative effects. We can consider these 11 criteria in four main categories:

• Impaired control
• Physical Dependence
• Social Problems
• Risky Use

Non-Substance Addiction

Currently Gaming Addiction and Gambling Disorder are the only non-substance related addictions currently recognised in the DSM. Gaming Addiction is still in discussion and some criteria have been proposed for it. Porn addiction is not a formally recognised diagnosis, however the behaviours can be very similar to that of Gaming Addiction, Gambling Disorder or other Substance Use Disorders.

Gambling Disorder Criteria

Misleading Ideas about Addiction

There are many errors in understanding what addiction means, and therefore what it is. We’ll explore the most common errors here, so that we can get them out of the way of truly understanding what addiction actually is.

Moral Disorder is Victim Blaming

Often people think of addiction actions as choices – to do it, or not to do it.

We humans pride ourselves on our ability to make choices – to have Free Will. We have the Free Will to choose whatever we want to do, and we use our moral compass to help us to chose to do “the right thing”, and thus those who are doing “the wrong thing” are making poor moral choices. There are a few old mental conditions that were originally considered to be some kind of Moral Disorder, and Addiction is one of them.

Let us examine this idea of “choice” a bit closer.

To exercise your Free Will, you need to have to know what your choices are, have better choices available to make, have the resources to implement those choices and have enough conscious awareness to be able to choose.

Often in addiction, most of these are missing.

Here is a thought experiment. About 1 hour after you have fallen asleep, I want you to wake up and write down whatever it was you were dreaming about. You can’t use an alarm to wake you, or someone else to wake you – you have to decide right now to wake up 1 hours after you fall asleep, and then keep to that decision and just wake up.

Obviously, this is not likely to happen. You can, with all good intent, decide right now to do this task, and truly and absolutely mean to do it. However, once you have fallen asleep, your conscious volition to wake up is now gone – you are in an altered state of being (sleep) where your prior conscious choices are no longer effective.

People who are attempting to cease their addiction, but find that they are doing that addiction action anyway, are no longer in conscious volition of their choices as they are also in an altered state of mind.

What I’m trying to say here is, it isn’t about making a choice and sticking to it. Those who are able to do so – good on you, your addiction is mild and you don’t enter into an altered state of mind. More on why you have an altered state of mind later.

New thought experiment: I want you to choose to flap your arms and fly.

This should be easy, since you are just making a choice and acting on it, right? Hopefully, this is obviously not going to work as you aren’t a creature that can fly by flapping your wings. With enough gadgets and gizmos, this may be possible, and without them, it is not. Choosing to do something is nice, but useless if you don’t have the ability to enact the choice.

New thought experiment: I have a number of buttons in front of me on this box. Which colour should I press for you to win? You need to make the correct choice, or you lose.

I hope that this is also obviously a faulty request. I haven’t told you how many buttons I have, what colours they are, and as I type this, you can’t see the box. You would be making a random choice and hoping it works, but you don’t even know what your choice options are.

When someone is repetitively doing something that is not good, rather than blaming them for making “bad” choices (a moral judgement), we should be investigating to see if they have the knowledge of better choices, resources to enact those better choices, and the conscious will power to persist with those better choices.

If we do not, we are merely indulging in judgemental victim blaming.

Addiction is not about Will Power, but it also kind of is

Similar to the above fallacy about Moral Disorder, people often think that addiction is about sticking to a choice.

Will power is not what most people think it is about.

Will power is about having a chemically well balanced brain, with good information, to have good reasoning about what you are doing, why you are doing it, and no serious conflict in persisting doing it.

Thought experiment: Predict how long you can keep your hand in the water for in terms of minutes.

Most people who think they have strong will power fail the Cold Pressor Test. This is a frequent pain test in psychology research, where you put a hand (or other appendage) in ice cold water for as long as you can. Unless you are already struggling with hypothermia, there is no serious risk to your health to have your hand in the bucket of ice cold water for quite a while, however your body is going to start to inform you fairly rapidly that this is bad. Most people cannot handle doing this for even two minutes before removing their hand because the sensation of pain is too high. Was your answer longer than this? Isn’t it a matter of will power to keep your hand in?

We have Will Power so long as it is convenient to do so. The longer we push against an obstacle, such as pain, the more frequently we find a reason to justify why that was a stupid decision and therefore we can change it and make a new choice not to do the bad thing. Our body will override us.

The neurotransmitter most commonly attributed to Will Power is Dopamine. Sometimes we can focus Adrenaline into sustaining our Will Power too. Keep this in mind when we get to the Medical Model section.

The Abstinence Model is Cruel and Wrong

For many people who have a repetitive habit, the cost of stopping seems worse than the cost of continuing, so you will continue the addiction. At some point, you may decide that the cost of continuing the addiction is more costly than stopping and so you will make a decision to cease. So long as the cost of ceasing and abstaining from the addiction is not too expensive to your brain chemistry, finances, social group or other health factors, then you are likely to be able to just stop. If this is you, you are privileged to have only a mild addiction that was mostly just convenient to you.

Most people who struggle with addiction do not have this experience. Ceasing some forms of addiction, such as significant levels of alcohol or heroin, can be deadly. These are examples of where you will likely need medical support to cease. Direct health risk is not the only cost you may have. Most substance use is a form of self medication, where the absence of the chemical will cause you to decompensate (an inability to compensate for the loss of the agent) leading to poor mental and or physical health. Social harm can also occur, if ceasing the addiction leads to social isolation, which can then lead to higher risks of suicide and long term self esteem issues.

The basic idea of Abstinence leans on the idea of a Moral Choice and Willpower, which we’ve already covered is erroneous.

Unfortunately, the Abstinence Model gets worse.

Alcoholics Anonymous (AA) was founded in the USA during the 1935 Prohibition, where the government made alcohol illegal. Prohibitionists, mostly led by Pietistic Protestants, aimed to heal what they saw as “an ill society beset by alcohol-related problems”. Fundamentally, this was the birthplace of the Moral aspect of our current views of addiction. In response to this law, the jails and prisons filled up as people persisted in drinking. The judges were looking for an alternative method of managing those who broke this law, and they turned to a new system, Alcoholics Anonymous, developed by Bill Wilson and Dr Bob Smith in collaboration with the Christian Revivalist Oxford Group. People ordered to attend this program attended anonymous meetings where they could talk about their experience, and a sponsor to try to help them stay on the path of AA. The path was defined by the Twelve Steps of drug rehabilitation and self-improvement. A key component of these Twelve Steps is seeking alignment with a personally defined concept of “God as we understood Him”. Every second step in the Twelve Step program is religiously based. Religious ideology is not a solution to addiction, as addiction is mostly biological.

It is technically illegal for USA Judges to order someone to attend AA or their sister program Narcotics Anonymous (NA), because that infringes on people’s religious freedoms as outlined by their First Amendment of the USA Constitution, and yet Judges have and continue to do so. The AA and NA programs have spread around the globe, becoming the de facto standard step people think of when they want to stop a substance addiction. The religious and moral connotations of these models informs most people’s erroneous conceptions of addiction.

Above, the graphic shows the actual 12 Steps of the Alcoholics Anonymous Model – Steps 2, 3, 5, 6, 7, 11 and 12 are putting the solution to addiction into gods hands, abdicating your own ability to affect change – that is 7/12 steps, over half of them. Steps 4, 8, 9 and 10 are using the Moral Disorder ideology – 4/12, or a third of the steps are stating that it is all your fault. This sets up a contradiction in messaging – it is your fault you are an addict, yet somehow the only power to cure you is that of god. Logically, if your moral compass is in error, you can fix it, so you don’t need god; OR if god is the only one who can save you, then it is gods fault that you are an addict. The AA model somehow works it so that it is both your fault and that you are powerless to affect change. This makes it impossible for you to be in charge of your life.

Due to the nature of the AA / NA program being anonymous, it is hard to get good data about how effective it is. People who relapse and begin using again are encouraged to just try and try again, told that they need to get more right with god or make better moral choices. This means that the AA / NA program has not “failed” so long as the relapsing person hasn’t left. Often the people that participate in studies are those who have “succeeded”, which automatically biases the results. Meta analyses of AA show that studies on how effective AA is are generally biased to the point of uselessness or contradict each other so much that it brings into question whether or not AA works (1) (2). In science, when you can’t find an unbiased study, or various studies mostly balance each other out (of same quality), then it implies the studied thing is not effective. Effective treatments and interventions are not plagued with effectiveness doubt, contradiction or poor quality studies.

We will cover that biological aspect next.

The Useful Medical Model

We humans are a strange collection of cells working together to create a person. No cell understands the whole, they only understand their local part – much like no brick is the house, but a collection of bricks and other parts in the right configuration make a house. We are all different to each other, not two humans are alike – just like there are no two identical houses. Even twins are different to each other, much like houses built off the same plans are subtly different.

With all of this in mind, it is astounding that humans can do what we do. We are able to communicate with each other, learn a great deal of the same kinds of information and manage to live a good human life. Most of us.

Consider that two people of different heights can walk together down the street talking to each other. To do this, they need to compensate for different leg lengths and stride speeds to keep close enough to each other that they can speak to each other. The bigger the difference between them, the harder it becomes to compensate for that difference. Perhaps the shortest one will use a mobility aid like a scooter to compensate for short slow legs, or the larger one will stop occasionally to let the shorter one catch up.

We humans have so many compensation mechanisms in our biology so that we can achieve similar things. Sometimes, though, we can’t manually compensate and we need some assistance.

Most humans are similar enough to each other that adjustments are small and easily achievable. We call these people Neurotypical (common brain) and often they have typical body biology. Then we have those who diverge from the typical.

Neurodivergence

Not all brains are created equal. In fact, no brains are the same, but often brains cluster around various versions of similar. The biggest single group has been named “typical”, as it is the most common representation of “human” found. When we refer specifically to the functional ability and defaults of this typical group, we refer to the brain category by calling them “neurotypical” (common brain). This is what we measure “being human” from. It isn’t a brilliant model, but it is a good enough one for most things. The biggest problem with the way this is perceived is that anyone who diverges from this default is considered anomalous, atypical, broken and wrong. They aren’t, they are just different.

Some other clusters of brain types have quite a different way of being human. Two of the larger clusters of neurology are Autism and ADHD. We cover the how and why in more detail in our Neurodivergence page.

There aren’t good tests for Neurodivergence. That is, the tests we do have is checking to see how poorly you manage in a neurotypical world – that is they are measuring distress based on the assumptions of neuronormative expectations, rather than “is this person in the group we call X”, eg “does this person have an Autistic brain?” If you have managed to learn some kind of compensation for your difference to the expected norm, or you successfully mask your discomfort and or exhaustion, then the tests for neurodivergence will fail. We discuss this in further depth in Understanding Autism, the Medical Model.

The majority of people who come to see me for addiction are neurodivergent, and the common reason why they have addictive behaviours is to cope, compensate and self-medicate.

The Neurology of Addiction

Our brains work primarily on neurons communicating with each other in various networks to sort information and make decisions. Between the neurons are a kind of on / off switch called a synapse which relies on particular neurotransmitters to turn the normally off switch on in specific ways. If you have an insufficient quantity of a neurotransmitter to close the switch, your brain will struggle to think well (cognition), feel okay (mood) or behave as you aught or want to (reaction and response).

When we learn, actions that we perceive as good for us are rewarded with the release of a neurotransmitter called Dopamine. Dopamine is part of the Dopaminergic System, which both reinforces the behaviour, so that we will do it again, and helps us think better (Dopamine), feel good (Noradrenaline, made from Dopamine) and have energy to do actions (Adrenaline, made from Noradrenaline). This is great when we are trying to learn something.

Sometimes it is not a skill or knowledge that we are learning, but rather forming a habit, discipline, system or routine. The same reward pathway exists to form any of these.

If we are low on Dopamine (such as ADHD), or wanting more Dopamine / Noradrenaline to feel better (Depression / Grief), or feel like we need to do more but can’t (Noradrenaline / Adrenaline), then we may use a substance to boost our chemistry to achieve these, or stumble upon a behaviour that triggers the release of these in our body. With the biological need met, we feel better, which is rewarding, which then releases a bit of the reinforcement Dopamine. Hopefully you can see how this now plugs into our learning reward system, which either satisfies a biological need, or begins to form a pattern of behaviour.

There is another pattern that is important to consider, which is on a spectrum of habituation to acquired dependency. The more that we do a particular set of actions, the more those actions seem right and are easy to do. We may not like certain aspects of those actions, but the comfort of doing them and the satisfaction of completing them can initially outweigh the aspects that we don’t like. Breaking that habit can be hard. If there is a chemical component to this, we can begin to become dependent on it. Behaviours do have an inherent chemical component, but it is relatively weak compared to a substance that you may take. For people with existing conditions, such as ADHD, Bipolar, Anxiety, Depression, OCD etc, even a small biochemical boost can be enough to bring relief.

Substances such as opioids, cannabis and nicotine mimic naturally occurring chemicals in our bodies that have soothing qualities for our neurology. Our bodies are efficient at using the least resource to get the job done, so if you are adding a substance that you normally make enough of, you body will begin to make less of it since it is cheaper (for your body) to push you to acquire the external chemical rather than make it from basic ingredients. This leads to an acquired chemical dependency, which is what most people think of when they hear “addiction”.

This is not the same as treating an existing condition with medication. If you have ADHD, for example, you are born with this condition which may become diagnosable later in life when you pass certain developmental milestones and find that your struggling production or management of Dopamine is insufficient for you to function. When you take medication for ADHD, you are not giving your body a substance that it is making adequately on its own, you are helping your body to make and supply enough because it can’t do it on its own.

The problem comes in when you don’t know you have this condition. You are struggling and don’t know why you are experiencing frequent systemic discomfort. You may stumble upon a commonly available substance, or use a reasonable recreation and find you feel better. Your body now knows you have access to a means of getting that necessary biochemical and will push you to go and get it whenever you are low. Often the times you are low will lead to compromised thinking (cognition) and mood disorder (anxiety, aggression, acting only on urges). This form of addiction is accidental self-medication.

In my experience, most addiction is self-medication and only rarely is it an acquired dependency. When a client comes to me for assistance with their substance or behaviour addiction, the first step is to properly assess whether this is the accidental self-medication addiction, or if it is an acquired dependency addiction.

Understanding Craving

Most craving is biological, primarily to do with neurology. Some is to do with unthinking automatic habits.

Biological Craving

What is craving? Craving is a powerful desire for the substance or action. Not fulfilling the desire causes discomfort or distress. Or perhaps, the substance or action relieves the discomfort you are feeling. That is, your discomfort comes first, and almost OCD like, you take a substance or do an action to relieve that discomfort.

Where does the discomfort exist? Pain is perceived in the brain. If you block the pathways that an injury can signal to the brain, you are unaware of the damage, and thus the pain. Pain exists in the brain. Discomfort exists in the brain. What neurotransmitters and synapses are involved in discomfort?

Most craving comes from our biology. It is a signal from your brain that you are low on a substance that your brain needs to function correctly. When self medicating, this is usually because you have a neurological condition such as ADHD, where you are struggling to make one and or use of the Dopaminergic neurotransmitters, Dopamine, Noradrenaline or Adrenaline, or you have too much of one of these and are seeking to try to manage the over supply in some way. For example, you may be feeling high levels of anxiety if your Noradrenaline is too high, so to compensate for this you crave alcohol or opioids for their sedating and anesthetising properties. When we identify what neurotransmitter is causing the discomfort and treat that, by either addressing the synthesis bottle neck, increasing the production, improving the efficiency or dampening the production, the craving for the substance or action that would normally be used to relieve the discomfort diminishes and generally evaporates.

One doesn’t have to be born with the condition of neurotransmitter / synapse / neuro receptor discomfort. In theory, this can be acquired. Animal studies have shown that when force fed opioids, alcohol, nicotine and cannabis, their own natural synthesis for the neurotransmitters these substances mimic in the animal system diminishes, or the threshold of quantity before triggering a needed action shifts, requiring that external acquisition of the mimic substance to maintain a functional level. In theory, this is possible, but you will note that the animals had to be forced to have the substance. On their own, the animals do not seek the substances. It is true that elephants may go quite out of their way to consume alcohol, and monkey’s may consume caffeine via the base plant, mostly the animals do not consume to excess for long enough to acquire a dependency. This begs the question, why do humans? Most people experiment with various substances in their youth, yet most don’t acquire a substance misuse disorder. If these substances were so addictive, wouldn’t all humans be abusing the substances?

Instead, I argue that an acquired dependency is often a false step in self medication. That is, in the need to manage the discomfort of a condition, a substance that was available to diminish or offset the discomfort was found, and in the over use of that to poorly manage the discomfort, you accidentally acquired a dependency on something else as well.

A different case needs to be made for Chronic Pain. Pain is awful. Endorphins and Adrenaline are used to manage pain perception. Endorphins are also used to feel joy, and Adrenaline is also used to energise actions. When Endorphins are channeled to managing pain, you feel a lot less joy, for some to the point of Anhedonia (absence of joy including things you used to enjoy), and for the Adrenaline that is repurposed for managing pain decreases your ability and desire to do tasks, for some to the point of Depression (a lack of desire to act, an absence of energy to get things done). Trying to manage pain poorly can quickly lead to alcohol and opioid dependency. There is a vast difference between scripted opioides of an appropriate dose to find the balancing point of pain management and enjoying life, and acquired opioid dependency. What we have discovered over time is that over use of opioids can lead to shifting the needed threshold of endorphins / blood opioid for pain management and joy, which leads to the acquired substance dependency without a pre-existing condition prior to the pain. This is why your doctor keeps questioning if they can reduce the medication and get a similar result – they are trying to avoid the old problem of the opioid epidemic.

There is one more biologically driven category that must be noted. PMDD (PreMenstrual Dysphoric Disorder) can but extreme enough to drive substance misuse during the PMT phase and the Mid Cycle Crash phase of menstruation. PMDD is almost always connected to ADHD and can be treated with a combination of ADHD medication and hormone treatments. Read the PMDD page for more specific details. If you have active ovaries and a substance use disorder, then track when you misuse the substance the most and see if it connects to your menstrual cycle.

Psychological Craving

When we learn skills, we reach a point mastery where we no longer have to think about all of the details of how we do the thing, we just do it. Some of our skills are reactive skills. That is, we don’t think to catch our balance before we fall, we reactively catch our balance as we are falling. This level of autonomy is far more efficient to do than to be in manual control of everything all of the time.

This is a wonderful and cheap system of living, so long as these autonomous skills are good for us. When they aren’t good for us, they can lead us to doing actions, aka behaviours, that are not desirable, with outcomes that are bad for us. That is, bad habits.

If our routine is to do certain things in a certain order, and we do this kind of routine unthinkingly, then it is cheap to get those things done for us, but fixed in how we do them. That is, it is hard to change just a part in the middle. For example, it is easy to change the order of how you make your favourite hot beverage, so long as you think about it before you do it, but to do so takes more effort and being specifically cognitively aware of your actions as you do them. When you mindlessness make your beverage, you’ll revert to your common practice method of doing so, even though yesterday you wanted to change it today. This is a key component to why we need to shift from minlesslessness or thoughtlessness to mindful. We need to become deliberate in our actions around specific situations and times so that we can manually change our behaviour to what we want to do, instead of what we habitually do. We talk later about various methods such as Disrupting the Behaviour, Deliberate Action and Different Satisfactions.

Frequently, when we take substances or actions of addiction, we are not thinking clearly. We generally have an impaired cognitive function, which can include poor ability to think logically, impaired insight, compromised judgement and feeling that are dysregulated. This is all to do with the Biological Craving we covered above. Due to this impairment, we need to set up and practice our prefered behaviours ahead of time, not rely on us making a wise choice in the middle of the behaviour of addiction – because we can’t choose at that point with impaired cognition.

Many neurodivergent people are uncomfortable with change. We can find it quite uncomfortable to change a process, a way that makes us feel comfort even if the consequence is uncomfortable. It is much harder to make changes when we are unmedicated, fatigued, hungry, or experiencing problems with our hormones (menstruation, adrenaline, cortisol or thyroid).

When our cognition is impaired enough, our survival system kicks in and pushes us to do the automatic behaviour that brings our cognition and comfort back on line. Without a replacement analogue solution, in our compromised state, we do the tried and tested addiction behaviour that has worked in the past. This is why it is important to understand the biology and psychology of addiction behaviour so that while you have the cognitive ability to make changes, you set this up with Disrupting the Autonomous Behaviour, take Deliberate Actions prior to the time you are likely to struggle to make good choices and have already found Different ways to Satisfy the reason why you take the substance or do the behaviour. We need to understand how to recognise when our cognition begins to become impaired and have a pathway back to full capability prior to losing all of our choices.

If we do not recognise that the current behaviours are problematic, we will see no reason to change them. We need to have sufficient cognitive function to have insight into how what we do now affects us and others later; judgement about what is fair, unfair and what else we can do; and the ability to set up the above Disruption, Deliberation and Different solutions.

In recognising that what is happening now is bad, we need to believe that tomorrow can be better. We need to have some hopes and dreams of better, and that we can get there. Sometimes it is hard for a person struggling with addictions to see a way out, especially you have tried and tried and failed. This is where a competent therapist can help you, because we do know it can be done with a combination of addressing the biology and changing the chosen behaviours. We can hold your hope and faith for you when you can’t, if you can trust in us. Unfortunately, if you have dealt with an incompetent therapist, this can be very hard to do.

Each person is unique, so there is no generic answer that is good for everyone. I have laid out a fairly comprehensive system here for what should work for most people, with quite a few variants depending on your specific situations. However, not all of this will apply to you specifically and being able to tell what will and what won’t requires testing. That is, try some things and see if they work. If they do, make adjustments to see what works better. If they don’t, consider why it may have failed and either make adjustments or don’t use that method, depending. This is the scientific method of discovery. A good therapist can help you keep accuracy in the trials and outcomes.

Sometimes, to help us maintain our addiction recovery going, we may need to make promises directly to others, or to ourselves on behalf of others, that we care about. You may have made promises before, but without the proper understanding about addiction, you weren’t able to succeed. I invite you to make those promises to yourself on their behalf, and this time, with this guide, and hopefully a good therapist and doctor, you will succeed.

It is important to recognise that we will always miss the old, simple solutions. We stumbled upon them when we needed something to survive, and for all of the faults about those solutions, there were good points too. Sometimes that is the feeling of being high, sometimes it is oblivion, sometimes it is not caring about the worlds griefs anymore. It was nice.

Craving a state of bliss, oblivion or apathy is a strong sign that your life circumstance isn’t bad. That can be a social problem, where the people around you are toxic; a financial problem, where you can’t afford to live; or a biological discomfort problem as covered above; and generally a combination of several. Once these factors have been addressed, the craving for these states will significantly reduce. It turns out that living well is nice and we don’t seek to escape from it. To make good changes to what is driving this type of craving requires working out which of the factors are creating discomfort and logically and practically addressing them.

I have written on how to Change Habits and Solving Problems here.

• Changing Habits breaks down the autonomous solution system into deliberate steps to make better choices.
• Solving Problems looks at how we figure out what the problem is and begin the process to make solutions.

Medication First, Managing Behaviours Second

Imagine that for some reason your supply to very necessary air was cut off. It would not take you long to experience significant distress. At some point, your distress is going to reach a point where you are no longer able to logically make decisions and be proud of your choices.

Under the current default treatment plan for many countries and services, we would at this point demand that you behave nicely or we won’t give you access to your air.

Your brain’s survival mechanism is very likely going to rebel at this and act to save your life (as it perceives it).

A much better treatment plan is to give you a way for your body to get its necessary oxygen and then we can work on behaviours. In a very similar way, as we have covered, addiction is mostly about self-medication through substances or behaviours that drive up the bodies internal necessary substance. If we can address that neurological biochemical need first, then behaviours become quite easy.

Where this fails is when either the necessary biological need has not been correctly addressed (wrong medication), or the person lacks the capacity for insight (some kind of cognitive / intellectual limitation). Our job as therapists and allied health is to ensure that the insight impairment is not cause by the wrong medication or absence of medication.

This is why I argue for medication first, to manage the requirement for harmful self medication, before we address the behaviours.

Managing Addiction – The Nine D’s

Finally we are on to what we can do about addiction. Coincidentally, most of these already began with the letter D.

Understanding Your Addiction

Diamond of Addiction – Understanding your drivers of behaviour

The Diamond of Addiction is a tool for understanding what your addictive substance or action is doing for you – that is, when you feel compelled to do the substance or action, what discomfort does the substance or action relieve?

The Diamond of Addiction takes us through four major drivers for substance use or behavioural action:

• Brain Chemistry
• Feelings / State of Mind
• Physical Habit (Autonomous Behaviour)
• Social Angle

This helps us to understand the Addiction Cravings as covered above.

Brain Chemistry

The most common reasons why people have an addiction is to address brain chemistry. We have covered that above in Neurology of Addiction. Most commonly, this is around the Dopaminergic System, needing to adjust Neuronal Dopamine, Noradrenaline and or Adrenaline. You may also be attempting to address physical or psychic pain (grief, sadness, displacement).

Often the type of addiction can tell us a great deal about what brain chemistry you may be trying to adjust.

Once you know what the brain chemistry is, you can now consider alternatives for what may do better. Ideally, this will be a medication, but in the absence of being able to get a legal script for that, there are likely less harmful substances that may be used if you are quick enough. Take a look at Different Substances and Drug, Scripts and Medication for more details on this.

Feelings / State of Mind

A Feeling is how you feel – safe, scared, satisfied; while a State of Mind is a thinking pattern you have, such as intoxicated, at peace, not ruminating.

We are frequently either trying to achieve a particular Feeling / State of Mind, or trying to avoid one. The most common that I see is trying to not feel anxious (scared), trying not to feel angry or trying, wanting the feeling of intoxication or trying to avoid thinking about something. For most, this step is really about what you are trying to avoid far more than it is about what you are trying to achieve. The exception to this is for people who have experienced opioid bliss.

For the majority who are trying to avoid a Feeling or State of Mind, you can now start to work out what brain chemistry is involved in those, or for some, the circumstances that may be driving that Feeling you wish to evade.

If you are trying to attain that opioid bliss, I’m sorry, but you can never get back to that. It is time to work through your grief and cut your losses.

Physical Habit

Physical Habit is about recognising when you mindlessly do the behaviour, or where you feel greater urgency to do so (often to blend in). For example, you may habitually grab a can from the fridge when you come home and start drinking before you remember you don’t want to do this anymore; or you may find that when you go to the pub, it becomes very hard to not drink.

If this is occurring, you can take a look at the steps Disrupt the Behaviour and Deliberate Actions.

One last aspect of the Physical Habit to consider is when you find that you are doing things. This could be tied to fatigue, or when medication runs outs, or struggles going to sleep (Pre-Sleep Anxiety) or some other clue that can help you understand why you use the addiction.

The Social Angle

We may find that we feel the urge to do the addiction when we are near certain or any people. If it is certain people, it is wise to evaluate if these are actually good people for you, and if not, work towards getting away from them (this may include Escaping Abuse, or just finding a better friend group). If it is people in general, then you may be dealing with Social Anxiety.

Some people avoid others when they feel the urge to their addiction. This is often caught up in feelings of shame or guilt. An important component to consider is whether this is also about fatigue (end of work / school day) or when a medication’s effects runs out (eg sun downers). Fatigue and medication running out can strongly drive feelings of shame and guilt, either about the substance / action use or a Feeling / State of Mind that you are avoiding.

Managing Unexpected Urges

Delay

Delay adds time between now and when you might do fulfil the urge.

Put off the urge to satiate for a bit. The most important component of this is “not now” combined with “maybe in a bit”. If you can keep this going, then we decrease the strength of the urge.

There is a pop psychology idea that if you manage to not do something for 21 days, then you can break a habit. The opposite pop psychology idea exists where if you do something for 21 days then you have formed a new habit. This idea is vaguely right, but is specifically wrong, in that the amount of time varies for different things you are trying to modify and some people never form good habits through repetition.

Even so, Delay leans into adding space between the last time you did something and the next time you fulfill the urge. At some point, the delay gets big enough that the strength of the urge is decreased. Repetitions of this lead to a point where the delay gets so big that it seems foolish to give the urge any credence – the urge has no strength and fulfilling it seems foolish.

Distract

Distract is about shifting your focus from the urge to something else.

Much like when we are in pain, if we focus on the pain, we find it feels stronger. Trying not to think of the pain effectively means you are thinking about the pain. What is better is to focus on something else and try to become engrossed in it.

Another analogy for this is, when someone says “don’t think about Pink Elephants”, in our effort to not think about pink elephants, we keep checking to see if we are succeeding in not thinking about pink elephants. If you instead do your best to remember the plot of that story you love, and a conversation that two of the characters had, you’ll find you are thinking more about that than anything else.

Distract is finding something else to focus on, which has the added bonus of making Delaying easier.

Drink Water and Eat Food

We often mistake the urge to satiate thirst and hunger for the urge to do the action or substance we know isn’t good for us. If you haven’t drunk anything for a few hours, or eaten for at least 4 hours, then perhaps you are actually thirsty or hungry?

Rate your desire to do the urge out of 10. Eat and drink something, mostly healthy with a bit of sugar and fat (if not diabetic) and after 10 minutes, rate again strong your urge is. If eating and drinking helped, then your second number should be lower.

Pre-Empting the Urge

Disrupt the Behaviour

Disrupting the Behaviour is all about creating conscious decision points in otherwise automatic actions.

Let’s say that after I come home each day, I go to the fridge, grab a can, sit down at the TV and watch something while I sink the can. If this is a low cognition action, then it is effectively automatic and it will be hard to stop myself from mindlessly going to the fridge and grabbing that can.

What I can do to change this is to move the cans out of the fridge, perhaps putting them in the cupboard.

I now come home, mindlessly go to the fridge to grab a can… but there aren’t any there. Darn it, why not? Oh right, they are in the cupboard.

Right there is a conscious decision point. Do I really want the can, or do I really not want it? Not only do I have to go to the cupboard today, there is added friction (less nice) because the can is warm instead of chilled.

Today, I really want it. I goto the cupboard to get a can. It’s in a box with a note on the top that says “are you sure?”

This is another conscious decision point.

No, I’m not that sure. I’m going to listen to my past self and not get a can. And hey, while I’m at it, instead of just sitting down at the TV, I’ll go and empty the bins instead.

Deliberate Choices

Deliberate Choices continues the theme of conscious decisions over automatic decisions.

In this case, let us say that I am trying not to drink alcohol. I know that seeing my friends at the pub is going to be somewhere that alcohol is easy to order and drink. I can make a few decisions before meeting my friends.

• When I enter, I’ll go straight to the bar and order a lemonade (or similar). I’ll slowly drink that and when it runs out, I’ll go home. I won’t accept any drinks from anyone, even if it is for free.
• I will allow myself one standard drink of something throughout the entire afternoon, and no more.
  • If you can keep to just 1 standard drink.
• I will ask my friends to meet me at a cafe instead, where there is no alcohol. They can then go later to the pub if they want.
  • If my friends only want to meet in places where I struggle with alcohol, are they actually my friends?

By making these decisions before I meet them, I set boundaries that I can stick to around my next bit of time. I need to stay alert and aware, so that I can stick to my choices. If I find that I am struggling to keep to my choices, then I should exist and be away from temptations.

This process can be morphed to any kind of situation where it is hard in the moment to decide – so long as you can predict when that is likely to happen , can prepare beforehand and can match your decisions with actions. Keep in mind that the longer the plan needs to go for, the more costly it becomes to stick to the plan, so start off short and grow plans as you gain practice and strength.

Managing the Urge

Different Satisfactions (Substitutions)

When we are self medicated with a substances of neurotransmitter chasing behaviour, we are trying to address a biological need in an efficient, but not terribly safe or effective way. There are other methods that we can address that biological need. Ideally, we would use medication (next section), but outside of that, we may find another substitute substance or behaviour that can address enough of our need, but is less damaging or costly.

Often we have a substance or action that efficiently meets several different kinds of need for us. To break that down, efficient means that it works quickly, addresses several different kinds of need, and thus we can just use that when we feel out of sorts. With some careful thought and consideration for our past behaviours, perhaps with some careful experimentation, we can figure out what the various symptoms are for each kind of need we have are, and what those needs in particular are.

Once we have that, we can figure out some safer and less costly substitutes. Each substitute is likely to be a bit slower to meet the need, and will likely only meet one or two variants of need. This means you will need to figure out what the early tells are that you are heading towards needing to self medicate via the substance or action, and figure out what the likely specific sub-need is so that you can use the substitute early enough that you retain control.

It won’t be as satisfying, but it will over all mean a better outcome.

Drugs, Scripts and Medication

As indicated in the Different Satisfactions section, one can substitute the biological need for a substance or action with another thing. This is less efficient, but often far less costly and harmful. Ideally, though, we want to use a medication to address the biological need that drives us.

Medication is a form of drug that is given at the right dose to meet the right biological need. This is not an addiction as it is scripted by your doctor or psychiatrist. To get the right medication, we need to figure out what the biological need is that you are addressing, and then get a script for the medication that meets that.

While not full proof, here is a quick guide.

• Dopamine raising (agitant or reuptake inhibitor)
  • Actions: Gambling, sex, gaming
  • Substances: Amphetamines, opioids, party drugs
  • Symptoms: Brain fog, poor focus, poor concentration, disassociation
• Noradrenaline raising (agitant or reuptake inhibitor)
  • Actions: Adrenaline junky, aggressive behaviour
  • Substances: Caffeine / energy drinks, alcohol, nicotine, sugar
  • Symptoms: Depression, anxiety (negative self talk variety), self harm and or suicidal ideation
• Noradrenaline dampening (Beta blocker)
  • Substances: Alcohol, opioids, benzos, cannabis
  • Symptoms: Anxiety (flight / fight variety), paranoia, thought disorder

While this is an anecdote, I find that most of the people who see me for addiction are undiagnosed and or unmedicated ADHDers.

Diluting and Ceasing

Diluting and Ceasing is useful to reduce the quantity to safer levels. Not all people can cease without replacing the addiction with a medication or substitute, since if the root cause is biological, the biology isn’t going to go away just through will power.

In the case where an addiction was acquired (dependency) or developed over time (repetition or in response to an extreme circumstance) in the absence of a root biological cause, the reduction via dilution of the addiction can be continued until you have ceased the substance or action.

In some instances people can go straight to ceasing. Ceasing may not be medically safe for certain substances, such as high levels of alcohol, or opioids – check with your GP to see if it is safe for you to do so. There can be secondary costs to ceasing that may not be safe, for example if you are aggressive without your substance, then you may do yourself or someone else harm without something to moderate you.