"An inherent limitation of the medical model is ignoring the fact that 'pathological dependence' implies that a relationship, one that is emotional and psychological in nature, has formed with the substance or activity (i.e. gambling, porn, etc.) The 'pathological dependency' is a pathological relationship, one in which there is continuous and increasing emotional involvement."
The application of the disease concept to alcoholism, chemical dependency and addiction by the American Medical Association in 1956 marked a turning point in how addicts are viewed by treatment practitioners, significant others, the addicts themselves, as well the population at large. This turning point served to lessen the impact of stigma. There is less shame and secrecy associated now with being an addict, clearing the way towards seeking professional help. The shift in perception allowed for a more objective understanding of the disease and had a humanizing effect. The disease concept streamlined the process of assessment, diagnosis and treatment.
However, despite its reliance on objective, measurable data and tried and proven research, and beyond meeting the necessary criteria to be labeled a disease, we actually know little else about the emotional and psychological aspects of addiction.
The "Pathological Dependence" is a Pathological Relationship
An inherent limitation of the medical model is ignoring the fact that 'pathological dependence' implies that a relationship, one that is emotional and psychological in nature, has formed with the substance or activity (i.e. gambling, porn, etc.) The 'pathological dependency' is a pathological relationship, one in which there is continuous and increasing emotional involvement. The relationship with a source of relief that serves primarily to provide relief from emotional pain or frustration by bringing on a rush or high, pleasure, excitement or as an escape.
It's possible that the medical establishment never focused on or embraced the relationship aspect of addiction because the concept of relationship is subjective, immeasurable and not provable scientifically, and therefore ignored it. Yet it's clear to all of us that a relationship does exist; one that can be likened to a secret love affair.
Certainly the term "pathological" to describe this relationship is apt in a number of ways, beginning with the underlying obsession and desperation that drives the relationship, as the addict is out of control, unable to stop thinking about or pursuing it. The relationship is carried on behind a cloak of denial and deception, separate from the rest of the addict's life. This relationship immediately becomes the primary relationship, more powerful than any other. While the substance or activity provides much needed relief, it feeds the addiction by further starving the addict emotionally. As time goes by, the addict is becoming increasingly cut off from the rest of the world, from other people and relationships and is actually worse off than before s/he got involved in this relationship as the level of (pre-existing) pain increases over time. It's a relationship that offers no real emotional nourishment -- nothing healthy -- only an artificially induced high and temporary relief along with a number of harmful effects.
Etiology & Pre-disposing Conditions
Addiction is the result of non-emotionally nourishing relationships. The Relationship Model of Addiction is based on the premise that a relationship with a source of relief is driven by the need for relief from unmet emotional needs. The need to relieve pain is considered to be a basic human need, whether physical or emotional, and often becomes overpowering depending on the extent of pain. Human beings tend to avoid pain at all costs. Behaviorists have established the need to avoid pain as well as the need to relieve pain as primary motivational forces, i.e. negative and positive reinforcement. Emotionally based pain comes from unmet emotional needs, and leaves one in a dysphoric state thirsting for euphoria, or the most easily accessible, effective means of relief possible.
What happens when we're deprived of emotional nourishment? When we are unloved, don't receive the affection, attention, acknowledgement and appreciation we require? When we don't feel heard and understood? When we don't feel like we belong, or are special in any way? When we don't feel connected to someone? There is a build-up of hunger, shame and emptiness and the need to relieve this pain takes over. At some point, desperation sets in. One way or another, we'll find relief. We'll either find external sources of relief in the form of substances, activities or other relationships, or rely on tried and proven defense mechanisms at our disposal in the form of denial, delusion and deception.
Defending against pain involves and results in losing touch with our feelings. When losing touch with our feelings, we become more isolated and deprived, which leads to increasing pain, and the subsequent increasing need for relief becomes part of an endless vicious cycle, one in which self-growth and intimacy are impossible. Depending on the amount of pent-up pain, defending or coping can become overwhelmingly difficult, which is why there are so many people who commit suicide, suffer with depression, go crazy, become dependent on mind/mood-altering substances, or find other means of relief.
Why are so many people in so much pain?
Addiction doesn't occur in a vacuum. When we put the quality of relationships or the inability to communicate intimately under the microscope, a bleak image emerges. There are a lot of people fending for themselves in emotionally barren terrain. The overwhelming majority of families and relationships, including family of origin as well as current ones, are dysfunctional, non-intimate, non-emotionally nourishing.
Expanding the focus beyond family and current relationships to the rest of the world leaves an even bleaker image. Television and newspaper headlines inundate us daily with lurid descriptions of atrocities committed by human beings upon one another. We are bombarded by excess in the economic realm - by greed and corruption - as well as in the political realm by rampant abuses of power, terrorism, war, gangs, hatred, and seemingly endless cases of abuse, rape, kidnap and murder. And this is only the tip of the iceberg. We all know stories that never make the news - the secret horrors of violence, abuse and insanity in so many homes; homes that are the breeding grounds for what we see reported in newspapers and on television. All of this drains our vitality and reinforces the need to further insulate ourselves. After a while, apathy, alienation and emotional numbness become a state of existence.
Why do some people get addicted and not others?
The medical model approach to these questions is that alcoholism and chemical dependency are largely the result of genetic and biochemical factors. Evidence suggests that a history of addiction in one's family of origin or prior generations predisposes one to becoming addicted. Evidence also suggests biochemistry -- the unique combination of chemicals in the brain with mind/mood-altering substances brings about some kind of extraordinarily pleasurable experience and irresistible craving.
However, there are those who have addiction running rampant in their families or who have a biochemical predisposition for becoming an addict who do not become dependent. The same goes for a chemical imbalance. We may surmise, therefore, that becoming addicted involves more than just genetics or biology. By the same token, we know that the incidence of abuse in one's family of origin also correlates, but we don't know exactly why or how significant a role it has. Some people with a history of family of origin abuse may experiment with various mind/mood substances or activities, but don't become addicted. We might, therefore, strongly consider the level of pre-existing (emotional and physical) pain at the time of discovery another way to explain why some people and not others become addicted.
Perhaps the simplest explanation for the phenomenon of addiction is that it is a matter of the right chemistry. It is when the "right" person discovers the affect that a need for more develops. The right person could be anyone whose level of pre-existing emotional pain causes an extraordinarily pleasurable or pain-relieving gratifying experience.
The Relationship Model of Addiction establishes a new standard for understanding and treating addiction. It expands the disease concept by re-defining addiction as a relationship. The model accounts for the cause of addiction as related to the preponderance of non-emotionally nourishing relationships, unmet emotional needs, the resultant pain and need to relieve that pain. It identifies pre-disposing conditions as a backlog of pain, general state of dysphoria that goes beyond past and current relationships and includes the much larger social context. We know that despite the fact that this pain is subjective in nature, it is no less real or consequential than physical pain. Therefore we may assume that the greater the emotional deprivation, the greater the pain, the greater the need to relieve that pain and the more susceptible one is to becoming addicted.
The Relationship Model brings forth phenomenological or experiential, humanistic and existential perspectives; sheds light on the psychological dynamics of addiction; and holds profound treatment implications. We know that recovering addicts must eventually make the transition from "pathologically" dependent relationships based on the need for relief to sober healthy, intimate, emotionally nourishing relationships. Regardless of one's experience in past and current relationships, learning some basic principles, pitfalls, challenges and skills, can be an empowering turning point and unleash one's creative potential.
Daniel Linder MFT is a licensed psychotherapist in the San Francisco Bay Area, Relationship Trainer, Addiction Specialist; Author: Demystifying Addiction, Relationship Recovery and numerous related articles; and to be released May, 2007: Intimacy, The Essence of True Love. Addiction CEUs: Relational Recovery Training (8 CEUs), The Relational Model of Addiction (6 CEUs), Stigma, The Game of Appearances (3 CEUs), Diagnosing Addiction and Mastering Intervention (2 CEUs each) Advanced Clincial Training (2 CEUs.)
E-mail: Daniel@RelationshipVision.com Addictions Recovery and Relationships blog: [http://www.sober.com/blogs/relationship_recovery/]