A reader writes in: “Drug abuse. There is a difference between dependence and addiction. Lots of people are on painkillers. Vicodin and Percocet are the most used. It starts out with a prescription for knee, wrist or back pain. Slowly but surely it becomes a friend. At first a person feels euphoric. Then it must be taken to keep from getting a flu-like sickness. Even with a moderate user, slowly your bank account gets empty. Little to no food in the refrigerator. Credit cards maxed out. Then the paycheck is less due to loss of work. YES you might say that was a bad choice not an illness. The illness may be why the person uses to cope in a world that they have to function in. If you have never been addicted or depended on any drug it is impossible to understand what I am saying. It is like losing a friend. Opiates are the type of friend who does not want to leave easy. They will make your life miserable until you either take them back or get rid of them for good. It is like a relationship with a jealous or controlling friend. You have to be there to know.”
Dr. Hurd’s reply: You’re talking about the difference between physical tolerance and psychological dependence. People use these terms differently, and it creates lots of confusion. Allow me to define the terms as I’m using them.
Physical tolerance refers to the context in which more and more of a given substance (alcohol, drug, painkiller) is required (by the body) in order to attain the same desired (physical) effect. In other words, the more you take of something, the more you will want and believe you need.
Psychological dependence refers to a compulsion to keep using a substance, or keep doing a behavior, because of a false or distorted belief that one must, and that to curb or cease the behavior would be a catastrophe. Usually, just the opposite is true. Not only is curbing or stopping the behavior possible, it’s desirable for a healthier and happier existence — or in extreme cases, even survival.
When we refer to “psychological” we’re referring to the automatic processes of the mind. These include thoughts, feelings, and emotions. A person is said to have an emotional problem if his or her emotions (in some regard) are based upon flawed or false thinking. Psychological dependence is a type of psychological problem. It refers not to the behavioral problem itself — the abuse of drugs, the destructive gambling — but to the thinking process occurring in the person’s mind while exhibiting the irrational or questionable behaviors.
People — both in and out of the health professions — have quite often merged these concepts into one and the same. A person who has built up tolerance to a substance is said to be addicted. In a physiological sense, this may be true. But the psychological issue requires introspection, through psychotherapy or whatever other means available. The purpose of introspection is to find out, “What am I feeling while I engage in the compulsive behavior? What are my thoughts and beliefs, before, during and after?”
Introspection — both the identification of the thoughts as well as any attempt to change or correct them — involve repeated acts of free will on the part of the person. There’s no escaping or denying this fact. What happens with addiction is that people observe (often correctly, at least with substances): “My body is building up a tolerance for the substance, craving more and more all the time.” This physiological process within the body is, indeed, automatic, and not directly under the individual’s control — short of stopping the intake of the substance.
Cures for such problems cannot ignore the physiological. However, they cannot ignore the volitional or the psychological, either. The tendency of many people, including some professionals, to ignore the psychological and focus only on the physiological tolerance is a major and misleading error, I would argue.
You mention how the substance or compulsive behavior can become a “friend.” This is actually how it has been described to me by many people. I once talked to a woman who made a difficult (although ultimately successful) effort to quit smoking. When asked why it was so hard she said, “My time to sit and smoke is my only friend. I’m lonely, and it’s the only time I ever give to myself.” In order to quit the smoking, it was more than a matter of getting the nicotine out of her physiological system (although that was surely part of it). She also had to identify and correct such false beliefs as, “I will never be able to make friends with people,” and, “I can’t find other ways to bring pleasure into my life outside of smoking.” The choice to undertake such introspective efforts is, like I said, a matter of choice — not physiology.
I don’t see how you can claim something is totally or exclusively an “illness” unless the problem is being created exclusively by automatic physiological processes. Stopping addictions or compulsions, whenever that’s successful, inevitably involves some kind of self-reflection, verbal / emotional / psychological support, or some kind of inner commitment to stay the course no matter how difficult it seems, at first. These are not medical matters.
Also, not all addictions/compulsions involve physical substances having an impact on the body. People gamble too much; shop too much; stay on the Internet too much; and do all kinds of other self-defeating or self-destructive things which don’t involve creating physiological dependence or tolerance in the body. How does the choice — even a compulsive or anxiety-ridden choice — to spend every day at the casino involve a medical illness? If it did, then the answer would be to find a medication or surgical procedure to externally intervene to make the person stop the behavior. No thought or effort would ever be required. That’s simply impossible. Quitting any addiction or stopping any compulsive behavior will always involve, at the root of it, the carried out commitment of the person doing it. This remains true whether you go to Twelve Steps meetings or not, engage in psychotherapy or not, or simply resolve to go it alone and maintain your commitment.
“You have to be there to know.” You’re probably right that you have to actually be addicted to or dependent on something to know precisely what that feels like. But does it follow that objectivity and understanding cannot be obtained without going through it? I don’t think so. In many ways, not having gone through something makes for a more detached and therefore possibly objective view. I’m not saying a person who has been through addiction cannot be objective about it. But I’m also not saying a person who has not been through addiction cannot gain knowledge about it. In psychology and therapy, we gain understanding of experiences and problems by listening to others and exercising empathy — i.e., trying to see from the others’ point-of-view. To broadly proclaim, “If you haven’t been through it, you just can’t get it” does not represent an objective, scientific or knowledge-advancing view.
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