Craving (10 page)

By now, you may be able to see some of the cognitive biases in his thoughts, and there are several. But another force is at play here: the craving itself led to a
behavior
(purchasing a pack of cigarettes and saving them) that was also a setup for further cravings. Most smokers who are attempting to quit will tell you that if there are any cigarettes hidden anywhere, the thought of those cigarettes can be downright overwhelming. The behaviors that result from acting out on cravings are themselves a setup for further cravings. (Tom’s case is also a great example of “attentional bias,” where the addict preferentially notices the cigarette display and turns his attention away from all the other displays and toward the cigarettes. Several researchers have suggested that there is a relationship between attentional bias and cue-related craving.)

There are countless examples of this phenomenon. I usually tell my patients to delete the contact information from their cell phones of anyone whom they wouldn’t contact except to act out on their cravings. Now, if you think about the phone numbers stored in your cell phone, you probably haven’t memorized most of them. You rely on your cell phone to find and dial the number for you. But with cravings, these numbers have a funny way of getting into your memory, where it’s much harder to “delete” them. The result is even more cravings. The craving leads to a behavior (not just calling a co-conspirator, but focusing on and remembering the number) that ultimately leads to more cravings.

Beyond these superficial examples of how cravings lead to behaviors that drive cravings is a deeper cycle, driven by the emotional consequences of acting out on cravings. This phenomenon was described in 1939 in the book
Alcoholics Anonymous.

They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks—drinks which they see others taking with impunity. After they have succumbed to the desire again, as so many do, and the phenomenon of craving develops, they pass through the well-known stages of a spree, emerging remorseful, with a firm resolution not to drink again. This is repeated over and over, and unless this person can experience an entire psychic change there is very little hope of his recovery.
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The sense of remorse and shame that follows acting out addictive behaviors can be powerfully debilitating. No discussion about cravings is complete without addressing shame. As a psychiatrist, I unfortunately know of many cases where a patient’s last words were remorse over acting out on a craving of some sort or another. Common sense would suggest that when people engage in self-destructive actions, particularly those that are socially unacceptable or hurtful to others as well, shame would be common.

Much has been written on the shame that is involved with addictive or self-destructive behaviors, and unfortunately very little of it has been in the academic/research literature, but one thing is clear: shame appears to be extremely common in people who struggle with cravings. John Bradshaw, in his book
Healing the Shame That Binds You,
describes the experience, hypothesizing that acting out on eating disorders is essentially a substitution for shame-bound interpersonal needs. In other words, in these people, the desire to be loved, nurtured, and cared for is unacceptable, and inexorably bound up with shame. Food is therefore substituted. However, as Bradshaw writes:

Food can never satisfy the longing and as the longing turns into shame, then one eats more to anesthetize the shame. The meta shame, the shame about eating in secret and binging, is a displacement of affect, a transforming of the shame about self into the shame about food.
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Although people sometimes use the terms “guilt” and “shame” interchangeably, from a psychological or treatment perspective we think of them quite differently, and most people seem to sense this difference, even if they don’t express it. In addiction treatment circles, we view shame as the sense that you are particularly flawed in some fundamental way that renders you bad or unworthy of love. With shame, the core thought is “I am a bad person.” On the other hand, guilt is the sense that you’ve done something wrong. The core thought here is “I’ve done something I shouldn’t have.” Guilt is often a healthy emotion, telling us that we need to make things right with someone or that we need to correct our behavior in the future. However, with shame there are no amends or corrective behaviors that can resolve the feeling that you are bad. In this way of looking at shame and guilt, guilt does not threaten a person’s core identity. Shame, however, is devastating to the all-important sense of worth and value that people need in order to navigate their lives with dignity and integrity.

Culturally, our sense of shame has changed over the last few decades. Some groundbreaking work by Thomas Scheff of the University of California-Santa Barbara has demonstrated that Western societies tend to suppress shame. However, in that same research, Scheff also found that the threshold for shame in Western societies has been decreasing.
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What that means is that we are both more likely to experience shame and more likely to suppress it, which should be considered a recipe for disaster. As the gap between what we experience and what we can express grows, we get sicker.

Sometimes people with addiction are so disconnected from their emotions as a result of acting out that they demonstrate what psychologists call neurotic defenses, such as emotional detachment, rather than overt shame. This appears to be more common in men.
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In those cases, people who are experiencing shame may actually come across as an “emotional wall.” To an observer, they may look as though they aren’t experiencing any emotions at all. They may seem unflappable, as if they are numb or immune to situations that would cause most people to experience (and express) profound emotions. It’s very easy to look at people who are expressing self-pity or self-loathing and see that they are dealing with shame. It’s much more difficult to see the shame behind the tough exterior and detachment of those who seem emotionally numb. In both cases, however, dealing with shame is critical if there is to be any relief.

Because shame is uncomfortable, many people try to avoid it or pretend it isn’t there, and psychotherapists are not immune to that either. I’ve seen many cases where therapists treated shame in a very superficial way, often because of their own discomfort with the topic. At any sign or expression of shame that a person might show, the therapist pulls away, tries to redirect, or glibly explains away the notion. For example, a patient may express a shameful thought or belief (either verbally or nonverbally), and the therapist immediately jumps in and tries to convince the sufferer that it isn’t true—that really they are a good person. As a result of this reaction, the patient’s experience is not validated, the real issues are avoided, and the shame grows covertly. The original shame is still there, plus now the person feels ashamed for ever having such feelings in the first place.

In my experience supervising therapists, this is much more common than most people realize. Essentially, an unconscious collusion develops between the therapist and the patient to avoid dealing with the issue of shame, and that severely limits any progress. What makes this even more difficult is that if you ask the therapist how the therapy is going, they will often reply that it’s going swimmingly. In the meantime, the issues that really need to be resolved aren’t even being touched.

In my clinical experience, for many people who suffer from cravings, trauma, addiction, or any number of self-destructive behaviors, shame plays a key role in fueling addiction. Thus, shame seems clinically to be both a contributor to addictive behaviors and a result of addictive behaviors.
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And, as we’ll explore later, only love can neutralize shame.

***

In this chapter, you have learned that your cravings and the resulting behaviors aren’t just unpleasant nuisances. They actually can lead to changes in your thoughts and behaviors that make it more likely for you to crave in the future. You’ve learned that your brain tricks you into accepting false beliefs about yourself, your cravings, and the things you crave. You’ve seen how tenacious these cravings can be, and you’ve learned that one of the most powerful toxic elements in the craving cycle is shame. Later, in
chapters 6
–
10
, we’ll discuss the types of simple actions you can take to neutralize the powerful forces that drive cravings and addictive behaviors. But first, it is important to examine how the various addictive behaviors are similar across the spectrum, how they are different, and how your thoughts and actions can actually change your brain.

…

4

Addiction Is Addiction

How Gambling, Food, Sex, Alcohol, and Drug Addiction Are Related

“Just because you got the monkey off your back does not mean the circus has left town.”

— GEORGE CARLIN

The old adage that there is no accounting for taste is only partially true. We do know that powerful genetic factors drive many addictive disorders; the most robust associations are with alcoholism. Decades of research have shown that genetics account for about 40–60 percent of the risk of acquiring alcoholism.
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Half of the brothers of the first alcoholics in a family have alcoholism, and a quarter of the sisters of the first alcoholics in a family have alcoholism.
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Adopted twin studies (where identical twins are adopted into separate families) have shown that the increased risk occurs even when the child is raised in a nonalcoholic home.

The brothers and sisters of the first cocaine-dependent person in a family are 1.7 times more likely to have cocaine dependence than the general population. Similarly, the siblings of a marijuana-dependent person are 1.8 times more likely to develop marijuana addiction. With habitual nicotine smokers, the relative risk is also about 1.8. The list goes on, but the bottom line is that genetic risk does play a role in developing chemical addiction. Thus, there is at least some accounting for taste.

Cross-Addiction

Among people who treat addiction, and among communities of recovering alcoholics and addicts, the notion of cross-addiction (being addicted to multiple substances or behaviors) is frequently encountered. Recovering alcoholics and addicts have discovered that the use of intoxicating substances such as painkillers or marijuana increases their risk of relapsing to their drug of choice and can produce dependence “as devastating as dependence on alcohol.”
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And yet it’s nearly impossible to completely avoid all mood-altering substances; in surgery and following physical trauma, taking pain medications is often necessary.

In academic circles, cross-addiction is described as the “comorbidity” of addictive disorders. Studies have examined myriad aspects of these comorbidities, looking at a broad range of questions, from “How often do heroin addicts abuse alcohol?” to “How common is cocaine abuse among alcoholics?” and so on. The general consensus is that these disorders often do run together, and many people with addiction will abuse more than one substance. We have known for a long time, for example, that alcohol use increases cigarette cravings.
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Similarities in Process and Behavioral Addictions

Research has also shown a link between chemical addictions and so-called process addictions or behavioral addictions (such as compulsive eating, compulsive gambling, compulsive shopping, kleptomania, and sexual addictions). The academic community has not universally accepted these disorders as addictions; for example, they are not generally classified as addictive disorders in the fourth edition (text revision) of the American Psychiatric Association’s diagnostic manual
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In fact, some of what I refer to as process addiction is currently defined as either obsessive-compulsive disorder (OCD) or impulse control disorder, and for some process addictions there are not yet any widely accepted diagnostic standards. However, from a clinical standpoint (and certainly in my experience), these process addictions exhibit most of the core features of addiction, including craving, tolerance and withdrawal, using more and longer than intended, unsuccessful efforts to control or limit the behaviors, and acting out despite significant, debilitating, and adverse consequences. Furthermore, many studies have shown similar neurobiological changes in process addictions as in chemical addictions, and imaging and genetic studies reveal some similarities as well.