American Health, September/October 1983, pp. 42-47 (Reprinted in (1) as "The best way to stop is to stop," Eastern Review, November, 1983; (2) in Health 84/85, Annual Editions, Guilford, CT: Dushkin, 1984; (3) as "Hors du piege de l'habitude," Psychotropes, 1(3), 19-23; (4) in R.S. Lazarus & A. Monat (Eds.), Stress and coping: An anthology (2nd ed.), New York: Columbia University Press, 1985; (5) in W.B. Rucker & M.E. Rucker (Eds.), Drugs society and behavior 86/87, Guilford, CT: Dushkin, 1986; (6) in Best of the first five years of American Health, August, 1987)
Out of the Habit Trap
Five Stages to Freedom
Update from a top addiction researcher: People who quit drug abuse, smoking and other habits do best if they do it themselves
A man who had been drunk every night for many years arrived home late, bombed once again. The next morning his mother, with whom he was living, found him staring at himself in the mirror. He turned to her and announced: "I'm giving up drinking and, while I'm at it, smoking." Then he placed a pack of cigarettes and a bottle of beer on the mantelpiece. "What's that for?" his mother asked. He said: "That's so I'll know where to find a smoke or drink if I want one. Then I can just kill myself instead." He has touched neither cigarettes nor booze for nearly 10 years.
A union official, noting that the price of cigarettes had risen yet again, put the extra nickel in the vending machine. A coworker laughed at him: "You'll pay whatever they ask." The smoker thought: "God, he's right; the tobacco company has me where it wants me." Then and there, he quit his three-pack-a-day habit forever.
Talk-show host Merv Griffin watched a comedian imitating himas a fat man. The comic had stuffed himself with padding and Griffin could not bear the caricature. He put himself on a diet and exercise program, and soon showed off his new, thin self to his audience.
Stories like these seldom make the newspapers; for that matter, people who quit their long-standing habits by themselves often go unrecognized by scientific studies. Instead, we hear dire stories about people who can't seem to quit, and gloomy statistics on relapse rates. Among people in therapy to lose weight, stop smoking, kick a drug or drink addiction, as few as 5% actually make it.
But here's the irony and the hope: Self-cure can work, and depending on someone else to cure you usually does not.
This is the case for addictions like cigarette smoking and alcoholism, as well as for some more complex habits. Obesity, for example, may involve compulsive overeatingan addiction to food that some thin people also struggle with for years. But genetics and a lifetime of inactivity and bad eating habits also play a role. Whatever the cause, though, losing weight takes a major change in lifestyleand the people who do it best are those who do it on their own.
Therapists tend to fail their clients by undermining self-reliance: they encourage people to rely upon others for cure, and to give up responsibility for their own behavior. But because therapy works so rarely, many researchers have come to view addictions as almost impossible to beat. And that mistake makes habits harder to break.
Many have begun to think of addiction as an exclusively biological processone that cannot be overcome by psychological effort or will power. In this view, alcoholics have a "disease," a "genetic susceptibility" to liquor. Obese people have a preordained weight level. Smokers are hooked on nicotine, and their bodies cannot tolerate a depletion of the drug.
All of these theories stem from the grandfather addiction of them all, heroin. Everyone knows the image: the suffering heroin addict, inexorably bound to a physiological dependence. The penalty for withdrawal is intolerable agony, so the addict increases the doses until death. Remember The Man with the Golden Arm?
For more than 10 years, I have been conducting interviews with all sorts of addicts and reviewing the research on all kinds of addiction. Addiction, I've found, may be affected by biological factors, but they are not enough to explain it. True, addiction is caused partly by the pharmacological action of the drug (if it's a drug addiction), but also by the person's social situation, attitudes and expectations. Even people who are constitutionally sensitive to a substance can control their use of it, if they believe that they can.
There is now good evidence for these heretical assertions. The most compelling statistics come from the success of people who cure themselves without therapy:
- University of Kentucky sociologist John O'Donnell, analyzing a national survey of drug use among men in their twenties, found that only 31% of the men who had ever used heroin had touched the drug in the previous year.
- Similarly, when American soldiers who had used heroin in Vietnam returned home after the war, over 90% of them gave up the drug without difficulty. Addiction experts predicted an epidemic of heroin abuse by the vets, but it never materialized. Washington University sociologist Lee Robins found that even among men who had truly been addicted in Vietnam, only 14% became dependent on narcotics in the U.S.
- Harvard psychiatrist George Vaillant found that more than half of the one-time alcohol abusers in a group of several hundred men had ceased problem drinking (the men had been interviewed over a period of 40 years).
- Social psychologist Stanley Schachter at Columbia University, interviewing members of two different communities, discovered that about half of those who had once been obese or hooked on cigarettes had lost weight or quit smoking. The formerly overweight people said they had lost an average of 35 pounds and kept it off for an average of 11 years.
Some of these statistics, admittedly, are open to question. When you're asking people to talk about how they've changed over the past several years, they may paint an excessively rosy picture of their ability to improve themselves. But even if the percentages are inflated, the evidence is still good that people can change for the better, far more than they have been given credit for.
Often people simply outgrow their bad habits. Sociologist Charles Winick of City College of New York has examined the lives of drug addicts. Many, in Winick's words, "mature out" as they get older. Long-term studies of alcoholics and smokers show the same pattern. Some people even outgrow their teenage cravings for Twinkies and sugar "fixes."
Why Biology Is Not Destiny
There's other intriguing evidence that hammers away at the theory of the "biological trap" of addiction. For example, most addicts, of all kinds, regularly overcome withdrawal pangs. As Harvard psychiatrist Norman Zinberg and his associates discovered, heroin addicts often cut down or quit their heroin use on their own. Alcoholics often don't need to "dry out" in a hospital, but frequently just go on the wagon with no particular anguish. Practically every cigarette smoker stops at some pointfor anywhere from a few days to years. (Orthodox Jews quit weekly for the Sabbath.)
It is actually long after the phase of "withdrawal pangs" that most addicts slide back into their habits. When they do backslide, it is not because of a physiological craving as much as it's stress at work or home, or social pressures ("Come on Mort, join us . . . one for the road.).
It's also a myth that a single experience of a drug can catch you chemically (hence the "first fix is free" strategy of drug dealers). Most people have to learn to become addicted. As Zinberg found, hospital patients given strong doses of narcotics every day for 10 days or moredoses higher than those street addicts takevirtually always leave the hospital without even a twinge of craving for the drug.
For an addiction to develop, the pharmacological effects of a drug have to produce an experience that a person with certain needs, in a certain situation, will welcome. When the need is great enough, people can become "addicted" to almost anything. Addicts may switch not only from one chemical substance to another, but from a chemical to a social "high." Valliant reports that former alcoholics often shift to new dependenciescandy, prayer, compulsive work, hobbies, gambling.
Addiction also depends largely on people's beliefs about what a substance will do to them. Psychologist Alan Marlatt at the University of Washington found that alcoholics will behave drunkenly when they only think they are drinking liquorbut when they're actually drinking tonic and lime juice. He also found the reverse: When alcoholics drink alcohol, but believe it's tonic and lime juice, they don't behave drunkenly.
Despite such evidence, the search has continued, unsuccessfully, for a single physiological factor that might be the underlying cause of all addictions. The prime candidates have been endorphins, morphinelike substances found to occur naturally in the body. Some pharmacologists speculated that people are susceptible to drug addiction if their bodies don't produce a normal level of endorphins. Maybe all addictive involvements elevate your endorphin levels, the theory went.
When it turned out that people could even become addicted to serious jogging, biochemical studies of runners were also done. Sure enough, jogging was found to boost endorphin levels. But endorphins failed to explain the difference between those who stop running when they're injured or it's inconvenient and those who behave like true addicts.
One very lean man, who insisted on running hard every day regardless of inclement weather, family obligations or his own injuries, explained his addiction to me this way: "I feel great every day I run; but I'm afraid I'll balloon back up to 200 pounds the moment I quit." His desire to run was more than chemical; he saw running as a magical talisman against returning to his former self.
The best explanation of addiction takes both mind and body into account. The effects of a substance can't be isolated from the context of human experience. Thinking of addiction solely as a "disease" or a "chemical dependency" ignores the power of the mind in generating the need for the drugand in breaking that need.
The cycle of addiction begins as a response to a stressful problem (getting drunk to avoid dealing with a bad job, running to get away from a bad marriage) or as an attempt to produce certain feelings (as Harvard psychologist David McClelland and his coworkers showed, many men feel a sense of power while drunk).
These feelings, in turn, lead into a cycle that makes the addiction harder to escape. For example, a man who abuses his family when he is drunk may feel disgusted with himself when he sobers upso he gets drunk again to boost his self-esteem. Soon the addictive experience feeds on itself. It becomes central to the person's life, and it becomes a trap.
Are You Addicted?
Addictions are not all-or-nothing. Even a casual habit can be mildly addictive. The more "yes" answers to the following questions, the more addictive the habit.
The Steps to Self-Cure
How does anyone manage to kick a habit after years of living with it? To find out, San Francisco sociologists Dan Waldorf and Patrick Biernacki interviewed heroin addicts who quit on their own, and sociologist Barry Tuchfeld at Texas Christian University talked with some 50 alcoholics who recovered without therapy or AA. And in conducting our own field research with addicts of all types, my associate Archie Brodsky and I have outlined the critical steps in self-cure.
The key word is self: taking charge of your own problem. Some psychologists call this self-mastery; others, self-efficacy; others, the belief in free will. It translates into three components necessary for change: an urge to quit, the belief that you can quit and the realization that you must quitno one can do it for you. Once you have quit, the rewards of living without the addiction must be great enough to keep you free of it.
The stages of successful self-cure are remarkably similar, regardless of the addiction:
- Accumulated unhappiness about the addiction. Before a change can take place, unhappiness with the addiction has to build to a point where it can't be denied or rationalized away. This phase of the process of self-cure, to use Vaillant's analogy, is like the incubation of a chick. Just because the chick hatches, rather abruptly at that, doesn't mean it happened spontaneously. A lot of changes go on first beneath the outer shell.
To break an addiction, you must believe the rewards you'll get (from not smoking, from exercising and losing weight, from cutting down on or giving up alcohol or drugs) will surpass what you got from the habit. Heroin addicts who "mature out" typically explain to interviewers that a life of hustling, prison and the underworld was no longer worth it.
- A moment of truth. An alcoholic pregnant woman told Tuchfeld: "I was drinking beer one morning and felt the baby quiver. I poured the rest of the beer out and I said, 'God forgive me, I'll never drink another drop.' " Another woman who had quit (and resumed) smoking several times found herself sorting through the butts in an ashtray late one night, desperate for a smoke: "I saw a snapshot of myself in my mind's eye," she told me, "and I was disgusted." She has not been a smoker for 15 years now.
Most ex-addicts can pinpoint a moment at which they "hatched" from the addiction and left it behind. It is impossible to distinguish the real moment of truth from the addict's previous vows to quit, except in retrospect. But it is just as foolish to disregard these reports altogether. Because they are part of such a high percentage of successful cures, they seem to have an important meaning to the ex-addict.
Epiphanies that work can be brought on by dramatic, catastrophic events: an alcoholic becomes falling-down-drunk in front of someone he admires, or a cigarette smoker watches a friend die of lung cancer. But most moments of truth seem to be inspired by trivial remarks or chance occurrences. Either way, they work because they crystallize the discrepancy between the addict's self-image and the reality.
- Changing patterns. People successful at self-cure usually make active changes in their environmentthey may move away from a drug culture, become more involved in work, make new friends. But some people break a habit without changing their usual patterns. The man whose story began this articlethe heavy drinker and smokerwas a musician who continued to spend nearly all his nights in bars. He wrapped himself in a new identity"I'm a nondrinking, nonsmoking musician"that protected him from his familiar vices.
- Changing theidentity of addict. Once former addicts gain more from their new lives than from the old waysfeeling better, getting along with people better, working better, having more funthe lure of the addiction pales. One longtime heroin addict quoted in the book High on Life quit the drug in his thirties, went to school and got a good job. Later, during a hospital stay, he was given an unlimited prescription for Percodan, a synthetic narcotic. He marveled at how he had no desire to continue the drugs when his pain stopped: "I had a different relationship with people, with work, with the things that had become important to me. I would have had to work at relapsing."
- Dealing with relapses. One of the problems with biologica theories of addiction is the image of imminent relapse it creates for the addictthe idea that one slip is a return to permanent addiction. Many of Schachter's ex-smokers admit having a puff at a party. Half of those ex-addicts who had been in Vietnam did try heroin at home, Lee Robins found, but few returned to a full-fledged addiction. The addict who has successfully modified his or her life catches the slip, and controls it.
The steps out of addiction, therefore, are: to find a superior alternative to the habit you want to break; find people who can help you puncture your complacent defenses; change whatever you need to in your life to accommodate your new, healthier habits; celebrate your new, nonaddicted image whenever you can.
The common feature in all these steps is your action, your beliefs. Self-curers often use many of the same techniques for breaking out of an addiction that formal treatment programs do. But motivated people who have arrived at these techniques on their own are more successful than those in therapy.
Why should this be? One possibility, of course, is that the people who go for professional help are the hard cases those who have tried to change on their own and found it impossible. People may try to quit smoking a dozen times, or lose and regain a few hundred pounds, before deciding they need help. Therapy often represents only one attempt at cure, whereas people usually come to grips with a problem over a period of years.
But I also think that therapy itself may inadvertently impede cure, by lowering the addict's sense of self-mastery and self-control. In turning to therapy, addicts unwittingly acknowledge that they are powerless to break the addiction. Thus medical supervision of drug withdrawal, for example, can actually inflate the difficulty of doing something that drug addicts accomplish repeatedly on their own.
Therapy can be especially demoralizing when it's based on the notion that addiction stems from an unchangeable biological weakness. Such a philosophy can make quitting even more difficult. Sociologist Charles Winick observed two decades ago that adolescents who failed to mature out of heroin addiction were those who "decide they are 'hooked,' make no effort to abandon addiction and give in to what they regard as inevitable."
We now see why that discovery applies to the general problem of breaking self-destructive habits. Only death and taxes, it now appears, are truly inevitable. Everything else is negotiableand open for improvement.
Is Alcoholism Genetic?
People with alcoholic relatives are three times more likely than their peers to have a drinking problem themselves. Does the high risk come from genetic factors, family environment, or a bit of both?
The fault is in the genes, said psychiatrist Donald Goodwin of the University of Kansas, who studied adopted children. He found that those whose biological parents were alcoholicsbut whose adoptive parents were nothad a higher risk than kids who were born to nonalcoholics but raised by problem drinkers.
Other researchers, however, are still not sure. In The Natural History of Alcoholism, Harvard psychiatrist George Vaillant recently reviewed findings from over a 40-year study of some 600 men136 of whom were alcohol abusers at some timeand eight years' work with 100 men and women in his alcoholism treatment clinic. "At the present time," he wrote, "a conservative view of the role of genetic factors in alcoholism seems appropriate."
Vaillant found cultural patterns to be stronger than genetic ones in determining alcoholism. People from Irish backgrounds, for example, were seven times more likely to be alcohol-dependent than those from Mediterranean backgrounds. Yet the Irish also breed many more teetotalers. This indicates the problem is not a gene that commands "drink!" but a view of drinking as an all-or-nothing activity.
Recently, biochemists and neuroscientists have looked for clues to alcoholism in the body and brain. Some have proposed that the problem is abnormal metabolism of alcohol. Such inherited factors, however, may make only a small contribution to an alcohol problem. Asians, Eskimos and American Indians, for example, all show a metabolic reaction to alcohol called Oriental flush, a visible reddening due to acceleration of the cardiovascular system. But though both American Indians and Chinese Americans manifest the same syndrome, the former have the highest rate of alcoholism in the United States, and the latter have among the lowest.
Though biological theories of alcoholism are imperfect, they have been remarkably popular. And they have formed the basis for the disease theory of alcoholism, which presents total abstinence as the only solution to a lifelong "illness." Yet life-history studies have shown that some alcoholics do teach themselves to drink in a controlled manner. In fact, alcohol abusers more often evolve into moderate drinkers than give up drinking completely, according to sociologist Don Cahalan at the University of California in Berkeley.
Vaillant also found that alcoholics recovered as well with the passage of time as they did with treatment in his clinic. The solution to addiction, he concludes, may be found more in the individual than in any therapy.
Stanton Peele, Ph.D., is a social psychologist who has been investigating the problem of addiction for over a decade. He wrote Love and Addiction (with Archie Brodsky). His book The Meaning of Addiction (with Bruce Alexander) will be published next year.