Addiction Recovery Basics

Moyers: So while the rational brain has said “never again,” the emotional brain circumvents it?

Hyman: That’s right.

Moyers: So which part of the brain ultimately determines our behavior?

Hyman: Well, it’s both really, but this emotional brain has an awful lot to say about our behavioral priorities. As I said, emotional circuits are survival circuits. And when they get literally perverted by drugs, they still have an awful lot to say about what we should do first and what we should think about. Just consider the behavior of an alcoholic or a drug addict. First of all, many long term alcoholics stop enjoying alcohol, either because of tolerance or physical illness, so they’re not even getting pleasure from it anymore. And they may recognize that they have wrecked their family life. Their job is in question, or it’s gone. They’ve lost their social status, and yet they keep drinking. How is it possible for people to do that? What I would say is that the critical circuit in the brain, which is involved in setting our behavioral priorities, has been usurped by the drug. The long term interest of the person — rationality — is barely audible in the calculations of a drug-impaired brain.

Moyers: It’s no longer driving the assigning of value, the creation of motivation?

Hyman: Right. And we can sit here and talk about it, but it’s actually people’s stories that really take your breath away. I mean, when you hear the story of a woman ignoring or even selling her children to get more crack cocaine, it’s easy to say this must be a bad person, but that’s not necessarily the case. This is someone whose behavior has been totally usurped by drugs, whose ability to set priorities has been totally deranged by drugs.

Moyers: Is this why you call addiction a disease of the brain?

Hyman: This is exactly why I call addiction a disease of the brain. What happens is, in the vulnerable brain — not everyone who experiments with drugs is going to get addicted — in the vulnerable brain, if you use drugs at a high enough dose, frequently enough, and for long enough, you literally change the way the brain works, you change the way nerve cells communicate in such a way that you develop this compulsive, out-of-control use despite knowing that all kinds of terrible things can happen to you, and despite even experiencing many of those things.

Moyers: Do you have any hope that we might be able to identify the vulnerable person early enough to intervene?

Hyman: I think that we’re going to be able to identify vulnerability, and then it’s a different question as to how we intervene. For alcohol, I think it’s pretty clear that those people who have the early-onset, severest forms of alcoholism are genetically predisposed.

Moyers: But even when we say it’s genetic, there’s still more to say, isn’t there? My brother became addicted to cigarettes. He died very early because of his addiction. But I never felt addicted to tobacco.

Hyman: Well, you might not have shared all of the same genes, but what you’re saying is actually quite important. Which is that for things as complicated as behavior we don’t have any situation that I know of where genes have all of the say. Where we have total genetic determinism. Rather, for behavior what we have is a complex dance of genes and environment building a brain as we develop, creating us as we experience the world, and as we behave. It’s a very complicated dance that we’re only just starting to unravel. But I don’t think that we are ever going to find a piece of DNA that will make someone an alcoholic 100% of the time. Rather, what we’re going to find are pieces of DNA that are part of the instructions for building a brain. These instructions are read out in the context of our environment. Starting before we’re born, in utero, and continuing well after we’re born. And in combination with many other genes, we emerge as people with certain traits that the genes give us a bias toward. For reasons that we don’t yet understand, some genes create a risk of alcoholism — in some young men a risk that may be as much as tenfold greater than in people who don’t have those genes.

Moyers: What’s your response to someone who says to you, “Sure, Doc, I’d like to quit, but my DNA won’t let me?”

Hyman: That question gets to the heart of the controversy over the disease model. We know that addiction looks every bit like a disease. But the problem is that the disease model can be misinterpreted. An addict could retort, as you suggest, “Gee, I’d like to say no, Doc, but I’m just a helpless tool of my DNA.” But the disease model doesn’t mean that we can’t ask people to be responsible for themselves. Because the brain doesn’t have only one pathway. It has this remarkable complexity of myriad circuits and trillions and maybe quadrillions of synapses.

Moyers: It’s a universe.

Hyman: Yes, and it divides up tasks — it’s redundant, if you will. So while part of the brain may be perverted by the drug, and one set of circuits may be really out of whack, there are other circuits at work. People who are addicted still remain engageable. Other parts of their brain are still working. Now, it’s not easy to engage them. And it’s not easy because in addiction, literally, the organ of compliance, the part of the brain that’s involved in setting behavioral priorities, is affected.

Moyers: Well, if the brain has been compromised by the drugs, and if the desire to use has become a commanding motivation, is that person capable of responsible choices? Is the addict still a moral agent, capable of free choice?

Hyman: I believe that the addict is still a moral agent, but his ability or her ability to exercise free choice is very much compromised. And I believe it is the job of the family, the employer, the doctor, the community, to serve almost as a prosthesis.

Moyers: Explain that.

Hyman: Everyone around the addict needs to work together to bolster what’s good and capable in the patient. To prop up his motivation to change and help this addicted person to recover. People need help to counter the intense desire for another drink or “hit.”

Moyers: I see so many mothers and fathers and sisters and brothers and friends and employers get so angry and frustrated at somebody they love or care about who just won’t stop. The addict seems to willfully disregard all of our efforts to help.

Hyman: Well, yes, in the beginning picking up a drink is a voluntary act, but we have to look past that and ask about the motivation. The addicted person is not able to select his or her motives. The part of the brain that is selecting behavioral priorities is compromised. So the motor behavior, picking up a drink, seeking drugs, smoking cocaine is really the downstream expression of something that’s broken, which is this whole set of motivations. We can’t see them — from the outside, an alcoholic taking a drink looks like anyone else engaged in that behavior. But what’s happening in his head is different. The important thing for us to remember is just how hard it is for the addicted person to stop. And how much support they need in order to be able to stop. Take heart patients. We don’t blame them for having heart disease, but we ask them to follow a certain diet, to exercise, to comply with medication regimes. So it is with the addicted person — we shouldn’t blame them for the disease, but we should treat them as having responsibility for their recovery. One critical difference between addiction and heart disease is that the substance — illicit drugs or alcohol or nicotine — can markedly diminish the ability of the patient to follow through on medical advice. So the patient’s family, friends, employers, etc., must shore up whatever strengths the patient has in order to help him stop. We have to help addicts get treatment, and support them in staying with it.

Moyers: So even though drugs have changed the brain, it can be changed back?

Hyman: I don’t think that you can have your brain back just the way it was, but I certainly believe recovery is possible. There are some changes in your brain that may be irreversible, especially the kinds of emotional memories that we talked about, they may really be indelible. But people who have a stroke are able to recover by using other parts of their brain which weren’t affected. It seems extreme, but you might think of someone who is addicted almost as if they’ve had a peculiar kind of stroke, which affects their motivation and self-will.

Moyers: What can we expect from the addict?

Hyman: Well, my experience as a clinician is that many addicts are just not ready to give it up. Drugs are too important. They still are experiencing mostly positive consequences from using. But eventually, people very often get into a position where the negative consequences of their addiction begin to outweigh the positive.

Moyers: They hit bottom, in the language of AA.

Hyman: Yes. Now, some of these people actually stop by themselves. It’s really quite remarkable. But many people, perhaps most, need treatment. And when you address somebody like this, often you’re met initially with anger or denial. After all, what you’re saying is, “I’m going to ask you to give up the central thing in your life. That thing without which you think you can’t go on.” So it’s not surprising that people don’t say, “Sure, Doc, fine. Where’s the nearest treatment program?” You have to be persistent. And non-judgmental. I think what you really have to do is sit with the addicted person and face the problem together and say, well, “How about the traffic accident you caused? How about this abnormal liver test? What are we going to do about it?” You start to engage the person, but recognize that it might well take time before he or she quits entirely.

Moyers: If I were your patient, and I relapsed once, you would not consider our relationship a failure?

Hyman: Absolutely not.

Moyers: If I relapsed a second time?

Hyman: I would not consider it a failure. But if you keep relapsing and we sit here and talk about your alcoholism at every session and you do nothing to get treatment, then we’re not doing something right. It would be easy for me to say that you’re so sick that I can’t help you. It would be easy for me to say, “I’ve done my job because I’ve issued a stern warning.” But what we really have to do when somebody either doesn’t get treatment or keeps relapsing is to ask, “What am I not mobilizing to get this person into treatment?” Maybe I have to get the family and the employer involved. Maybe I need to approach you differently. This disease is a terrible enemy once it is dug in.

Moyers: Do you think we will ever eliminate the desire people have to try drugs?

Hyman: No, I don’t think so. I think that part of our humanity is that many people are curious about transcending themselves. People are curious about new experiences. Some people are suffering and looking for ways of feeling better. And people will experiment with drugs. In a healthy society we can help people avoid the most dangerous drugs and we can help people get well if they become hooked.

Moyers: If addiction is about learning, why doesn’t the addict learn that withdrawal in certain cases is so painful, so abominable, so awful that the brain says, “I don’t want to go through that again, so I won’t use.”

Hyman: One of the really striking things about human beings is that we have a lot of trouble thinking about long-term risk. We are very short-term creatures indeed. Also, you see, withdrawal is very painful, but it’s not actually associated with the drug. What’s associated with the drug is pleasure and relief. The withdrawal syndrome is occurring in isolation and without the drug. Indeed, it is accompanied by intense craving for the drug. So the withdrawal does not in any way extinguish or do away with the impulse, the craving, the desire for drugs. Indeed, one of the important challenges to us as a species is how we can figure out ways of dealing with our inability to conform our behavior to our long-term best interest.

Read From the beginning Part 1

This is an edited transcript of an interview by Bill Moyers with Steven Hyman, M.D., on the brain and its role in addiction. Hyman directs the National Institute of Mental Health. Portions of this interview appear in the CLOSE TO HOME series.

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