Why Don't They Just Stop? Addiction and the Loss of Control
A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D. , edited by C. E. Zupanick, Psy.D.
The definition of addiction involves the repeated involvement with a substance or activity despite negative consequences. Friends and family members beg the addict to stop but they seem unwilling or unable to do so. Most addicted persons describe a genuine desire to stop. They feel guilty for breaking their promises to their loved ones. It appears they have lost all control. Discussions about "loss of control" sometimes overlook that control is rarely lost entirely. When we carefully interview someone with an addiction, we can usually identify these limits. For instance, there are heroin addicts who will steal to get money to buy drugs. However, they will go through drug withdrawal, rather than steal from family. There are individuals who drink excessively but not if they need to drive. There are cigarette smokers who will refrain from smoking if the smoke would bother someone nearby. Even in severe cases (e.g., a "skid-row alcoholic"), someone may share his alcohol with a friend, if that friend would otherwise go through alcohol withdrawal.
We have been discussing that "repeated involvement despite substantial harm" is a defining characteristic of addiction. This leads to some baffling questions, "Why would someone continue to engage in something that is harmful?" "Why don't they just stop already!?"
There is considerable disagreement about how to answer these very sensible questions. There are two possibilities: 1) A person develops a complete loss of control over their behavior; or 2) A person develops a decreased ability to control cravings for pleasure. It may seem like splitting hairs. However, the distinction between a complete loss of control and decreased control over cravings has big implications with respect to fixing this control problem.
Some people experience their addiction as a complete loss of control. These people believe they are incapable of managing their own behavior. Therefore, regaining this control would clearly require a power greater than themselves, such as divine intervention, or medical intervention. If this is the case, it seems pointless to ask them to control their behavior since by this definition, they cannot. From this perspective, only medicine or God can rescue them from their addiction.
Other people experience their addiction as an extreme difficulty resisting powerful cravings for pleasure (impaired control). These people will benefit from learning how to regain control over these cravings. Perhaps they may need professional assistance but the goal is to gain self-control. They may also find it beneficial to explore healthier ways of receiving pleasure.
It becomes evident that the difference between a complete loss of control and impaired control has significant implications for recovery from addiction. According to "reduced control" perspective, anyone will control their behavior if the consequences are immediate and severe enough. For instance, consider an imaginary "gun-to-the-head test." First, give an "alcoholic" a drink to consume in order to trigger significant cravings. Then give the alcoholic a second drink to hold. The alcoholic will experience powerful cravings to drink the second drink and will do so. However, if you hold a gun to his head and tell him you will pull the trigger if he drinks that second drink, he can control himself. While his cravings create a powerful motivator to drink that second drink, the gun to his head creates a more powerful motivator to resist those cravings. Of course, this is the kind of "experiment" that no ethical person will conduct, so we don't really know the outcome. However as some see it, this imaginary gun-to-the-head test illustrates that given sufficient motivation (consequences) anyone can demonstrate self-control.
Obviously, our gun-to-the-head test is artificial and does not resemble real-world situations. In our everyday life, the consequences of actions usually do not occur until the somewhat distant future. We work for two weeks or more before we receive a paycheck. Most people realize if they continue to overeat they eventually become overweight. Smokers realize the risks they take when they smoke. Unfortunately, overeating and smoking do not have immediate negative consequence so control is more difficult.
When someone eats that extra piece of pie they do not immediately blow up 10 sizes larger. When someone smokes a cigarette, they do not keel over and die. Instead, the only thing they immediately feel is a sense of pleasure or gratification. There are no immediate negative consequences associated with these choices. This problem is not unique to addiction. People with diabetes know they must control their blood sugar or they will suffer serious health consequences later in life. Yet, many people with diabetes do not regularly monitor their blood sugar levels. In other words, people have difficulty with self-control when the negative consequences of an action occur in the distant future as is the case with addictions. Therefore, to possess "self-control" one must develop the capacity to act with long-term consequences in mind, rather than requiring an immediate and severe consequence such as a gun-to-the-head.
So now what do you think? Is craving is an irresistible temptation followed by a complete loss of control? Or, is craving simply a very powerful temptation that leads to reduced control? As you ponder that question, consider the similarities between eating and addiction. Eating is satisfying, pleasurable, and rewarding. This means the next time we are hungry, we are probably going to eat. Oftentimes the most pleasurable foods are also the most harmful. Many people crave these harmful foods even when they are not hungry. Addiction works the same way. Through experience we learn that some substance or activity is pleasurable. As a result, we develop a craving to re-experience that pleasurable substance or activity. We go into a state of well-being or pleasure for a little while, followed by a return to normal mood. Then, the craving returns and the cycle of craving-use-pleasure-rest begins again. Learning to cope with cravings is fundamental to addiction recovery.