Author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, Maia Szalavitz discusses years of research surrounding the neuroscience of addiction. Explaining the affliction in the context of a biophysical response to stress, loneliness, and rejection, she also highlights addictive behaviour as a malfunctioned offshoot of learning.
Tracy: In a recent interview with Democracy Now! you mentioned that when people experience addiction, there's often a void of adequate relationships to other people, so they've now found themselves in a relationship with a drug. Can you explain this a bit further?
Maia: Absolutely yes. You could define addiction as falling in love with a drug rather than a person, and that is really what goes on in the brain. The same kinds of brain systems and chemicals are involved in both love and addiction. If you listen to love songs, you could easily replace the 'you' lyrics in the song with the name of a drug, and everyone who has ever had an addiction would identify with it, because it's the same template. We can understand addiction once we understand love because it requires the same neuro-pathways. What happens is that the biological drive that mammals have for love, which is critical to reproductive success, gets transferred to this drug. When youdon't have that drive for love towards other humans, you often have it for a drug or substance that gets abused.
If you look at the bad behavior people have during affairs, it's virtually the same as you see within individuals afflicted by addiction. Aside from some of Bill Clinton's biggest haters, most people wouldn't wish prison on an individual who can't control their behaviour surrounding affairs. We know that if you don't go out with that person, you're not going to have a problem with them. They're not horrendous people in a different context (if you're not married to them or dating them). Similar with addiction. We shouldn't send these people to jail because they can't control their impulsive behaviour, we should be offering them help. And while yes, there are certainly antisocial people within [the addicted population], not all people with addiction have antisocial personality disorder. But it's those that do who are the addicts that lie and are more prone to theft.
For a more lasting solution we should look at this as a condition to offer assistance to, not throw someone in jail for.
Exactly. That inherently human, biological drive that is supposed to exist within an individual to either A) make them take care of their child, or B) assure they're able to stay in a relationship with their partner, well that gets misdirected towards a drug. It changes their priorities and it can make them do things that they wouldn't necessarily do to another person.
That said, it does not turn people into sociopathic killers, as the 80s led us to believe. The people who become sociopathic killers have pre-existing [traumas] that led them to be so, not their addiction to drugs. Some people in the recovery community like to say, "Just because you haven't robbed your grandmother yet, doesn't mean you won't." But this is just not true. Some people would simply never do that. It wouldn't matter how far along they got: grandma's not getting robbed. Yet for others, even non-addicts, well, they would rob their grandmother stone-cold sober. Drugs and addiction only exaggerate traits that already exist. They don't create these traits.
When researching addiction, the first thing that goes out the door is the notion that it's the drug's fault and only the drug's fault. It's a disproven theory. Some say it was merely the excuse used over the past two decades to shame and criminalize addicts. Your most recent book Unbroken Brain highlights this as well?
Yes, and if you think about it, gambling addiction occurs with no drug whatsoever. You can also have obsessive compulsive disorder, but it's not that you are addicted to soap. If you ban the first soap you used to compulsively wash your hands, you'll find a new soap. If you ban all soap, you'll still compulsively use hand sanitizer or water. You can't ban things to address the OCD. Similarly, by taking away heroin, you might push somebody to, say, Fentanyl - but then you've absolutely done harm because you're putting them at higher risk. But if you manage to push somebody from heroin to marijuana, that's a plus; that's a harm reduction outcome. But the underlying thing is that if people are alienated, traumatized, desperate, and often mentally ill, just taking away the drug is not going to solve the problem.
The crisis of opioid overdoses and overprescription in white America right now shows that even if people can avoid something like crack-cocaine, under certain conditions they will become addicted to something else, like prescription painkillers. Your article in The Guardian pointed to the fact that curbing over-prescription still won't address the addiction to these painkillers.
Precisely, you haven't addressed why they became addicted. An important thing to note is that this crisis is happening in the the lower middle class of white America. If you look at the statistics, an individual making under $10,000 a year is 3 times more likely to be addicted to heroin than an individual making $50,000 a year. What is going on with white people here, is that if you look at the black community before the crack cocaine epidemic hit in the '80s, there were very high levels of unemployment, high levels of despair, an increase in crime, and all sorts of other social problems going on. Then Regan made tremendous cuts to social programs, crack-cocaine exploded, and they started locking up all the users and dealers. Today the white middle-lower class is experiencing those same levels of stress, same levels of uncertainty, same lack of employment opportunities, and surprise, surprise, the drug they have access to is becoming overprescribed, and abused.
I can tell you from personal experience that it is possible to be a middle-class person with an addiction, but if you look at the class structure in general, middle-class people are generally the most protected from addiction because they are the most likely to have a structured life with meaningful work, and more secure relationships. But we see higher addiction rates within the super rich, because their life isn't especially structured. If you have everything, life can be just as meaningless as having nothing, and it is often hard to genuinely connect to others when you're among the super rich. So both at the very top and at the very bottom, have elevated risk compared to the middle class. Now, I'm not going to care too much about the top because they have the resources to deal with the outcomes of their addiction. Those at the bottom are who we have got to worry about here.
If society is structured in a way that is not conducive to healthy human connection, or doesn't offer opportunities to make a decent living, then people's brains [and nervous systems] are affected. Given this, addiction to things like shopping, exercise, overeating, or, as you said, gambling, makes sense. It sounds like self-medication by those trying to reduce that stress.
Absolutely. It's a very real problem to think that we can get rid of substances without addressing the cause of the overuse of the substance. If an alien came tomorrow and sucked every illegal psychoactive substance off the earth, would we have no addiction problems anymore? Of course not. First of all, those drugs would be rapidly replaced by new ones, but second of all, people have been getting high and seeking chemical escapes since before we evolved into people. Bears will seek fermented honey, cats will seek catnip - these are shown early in our evolutionary history. The problem is when the compulsive overuse of these things gets in the way of our everyday lives. And if someone constantly needs to escape by getting high, then we've got to address why that is. What's causing that stress for that individual?
If drugs, alcohol, exercise, money, food, sex, and other things that in moderate amounts can be good for us, why is it that an individual is becoming addicted?
There are many answers, but a huge factor is that we have certainly created an environment that is not conducive to allowing people to get the social support that they need in their lives. When people can not get child care, when life requires that both parents work so they rarely get to spend time together, when jobs are insecure, and robots have replaced most services, when you can't get adequate healthcare or an MD to see your family for long enough, well, all of these things put huge amounts of stress on people.
The world is appearing much more uncertain to people and that uncertainty is right in your face and that creates all this additional stress. Now the best thing for humans to relieve stress is being with other humans; warm connections and reliable connections to others. But the way we've set up society works against human connection because when you have inequality, you have competition. You also get all this racist behaviour that we're seeing now. But the very thing that we need in order to avoid addiction, mental illness, and some physical illnesses, is just loving support from each other.
You wrote a book called, Born for Love: Why Empathy Is Essential--and Endangered. You make many strong points about connection being the best way to relieve that stress. How does loneliness play into addiction?
If addiction is misguided love, which there's a good case to be made for that being true, then having enough love in your life means you're going to be at less risk. If you are lonely, that is one of the most stressful states for a social mammal like humans to be in. There's a reason that tribes expelled people; that was a punishment worse than death. Solitary confinement is one of the most abusive things we could possibly do to people. Immediately, mass amounts of stress hormones spike, and there's no wonder that people start hallucinating very quickly. An individual will get dire mental health problems very rapidly from things like solitary confinement and chronic loneliness.
If you can't find the social support and connection that humans need to survive, your stress system is going to be constantly activated. When a baby is born, the baby can't yet control its stress system and is entirely dependent on its caregivers to relieve it of stress. The baby's nervous system learns through nurturing from an adult how to self-regulate emotions. If it learns that mommy does it, they will grow up healthy. Additionally, you can have an 89 year old mom and a 60 year old kid and the hand hold from that mom will lower the blood pressure on that 60 year old.
If you're lonely, you have this stress system that gets easily out of control. Now that can kill brain cells, so it's actually very dangerous. The result of this is that your stress system will make you want to get high, make you want to drink, make you want to overeat, make you have less control over these pleasure-seeking things. Loneliness is exacerbated by all these same factors. I personally can't help but see how the insidious nature of inequality seeps into everything, because not only does it make you feel the need to be competitive, but it also makes you want to hide what's going on from other people. Falling out of the middle class is something you certainly don't want your neighbours to know, so everyone is running up credit card debt pretending they still have the status that keeps them in a social circle, but when we find this out, we see them as trivial for that.
In addition to that, if you're a kid in high school trying to get into a clique or just trying to have friends, well from personal experience I can attest to the fact that the druggies will have you when everyone else won't. And that's an important thing to look at. For the most part, to fit into that social circle, all you have to do is A) use drugs, and B) not tell.
For those who don't find inclusion with friends, when you have a substance you can focus on instead, it gives you that same excitement you would have normally gotten from social inclusion. Loneliness and rejection cause severe depression, so those motivating brain chemicals like dopamine don't fire--until you get excited about the intense reward (endorphins) activated by a drug.
Yes when people are feeling chronically alone, they just don't have that excitement about things that would normally get them excited. When you can no longer feel pleasure and you don't want to do anything because you have so little dopamine activity, you have very little desire to get out of bed. What also happens when you are isolated is you become afraid of people, and that becomes a vicious cycle. I know we've all thought, "Oh God, I know if I go out I will actually have a good time, but I really don't want to deal with a crowd on the way there." or the like.
I also know a lot of technology pushes us in this direction because it's so much easier to write an email than deal with someone on the phone. But it pushes us away from the biology of human life. Connecting by voice is still vastly better than connecting with words on a screen. This is not to say that there aren't great things about the ability to connect online, but we still need the other side. It's important to realize that if we have a tendency to stay in more often than not, to push ourselves through it, if possible.
Much of the research surrounding addiction has highlighted, not only what we're talking about here with rejection and loneliness, but it has also been noted that addiction is rooted in the remnant effects of childhood trauma. What is your take on this argument?
I personally believe that around 60% of individuals with addiction have at least one severe childhood trauma. Of course, the more trauma in your childhood, the higher the risk of addiction. That said, there are people with addiction like myself who have no obvious trauma in their childhood who can become addicts, and there are many people with trauma who do not become addicted to narcotics. That said, it's still enormously important because if you were traumatized early in life, your stress system becomes dis-regulated. You learn to associate people not with help (as we should normally believe) but with harm. These individuals will either dissociate from others (self-isolate) or they may have hyper vigilance (be jumpy and on edge). These outcomes and the list of other outcomes that can happen are not going to suit you very well in life. For example, a lot of children who might look like they have ADD in school, may in fact just be looking to see if someone's coming to hit them.
Because they have over-reactive stress systems that are trying to get them out of harm's way.
Yes so it's critical to figure out if trauma is playing a role in someone's addiction. You don't want to probe for it, but you want them to feel safe about coming to you with it. In a perfect world we would want to have an environment that is trauma-sensitive, so that people who have been traumatized don't have to be triggered as often as they are, but something as simple as me raising my arm too fast might induce a trauma response in a child who is hit too often.
So aside from securing professional help for those individuals with childhood trauma or even PTSD, we can't really make sure that everything we're doing won't trigger a survivor. However, what we can all do is work towards a society where we're not all yelling at each other and humiliating each other in our jobs, schools, and homes. Because those are normal triggers that affect people who are not traumatized. People who aren't traumatized benefit greatly from being treated with dignity and respect, and not being ignored or screamed at. Not to mention the fact that being rude and disrespectful is actually counterproductive anyways.
If we can create a relationally healthy climate for people, precisely that is what provides resilience for everyone, even if trauma occurs. My co-author [Bruce D. Perry M.D., Ph.D.] on the book we touched on earlier about empathy Born for Love, also co-wrote another book with me called The Boy Who was Raised as a Dog where we described his work with some of the survivors of the Waco siege where a [cult center] burned down after FBI went in to make arrests. About 75 people died, but the 24 children that survived lost their entire families. [Perry] was working with those kids before the siege because [the cult leaders] were slowly letting a few of them out, but after the whole disaster, he had to help them find a new family or find other family members who were still alive. I bring this up because what he had found out over the years of staying in contact with these kids, was that those who did well were not the kids who lost the least - they were the kids who had the most social support. They found a family with a ton of other people in it, or a lot of high-quality relationships, or just one really strong, reliable person who was always there.
Mounds of data that we now have, shows that in order to be resilient, or to remain healthy after abuse and neglect in childhood, you need at least one person in your life who believes you, and who will always be there. Oftentimes it's amazing to see how some of these kids show resilience just from having a bus driver who chats with them every day. Most kids obviously need a lot more than that, but that one adult can be that link to normality: that sense of connection they didn't have elsewhere. It's incredibly powerful, and again that is shown in the data - it's no longer just anecdotal. This is also important to know because just by being nice to kids, you never know how much of an impact that could potentially have.
We're all familiar with those stories of kids who grew up in horrific environments, and just by having a neighbour or a teacher who ended up taking an interest in them, helped save their lives, or built their resilience. Just having someone who would let those kids know that what's going on at home is not normal and that they don't deserve it, is tremendous for recovery. The book is filled with stories like this.
It even shows up in fiction: Roald Dahl's Matilda had a teacher who took her under her wing.
Yes, and I think that's because we've been observing this as a human species since the beginning of our evolution. So it's important to recognize now that we finally have the research and the data to show it, that addiction is a developmental disorder. The risk factors that make you genetically sensitive to mental illnesses or having a dis-regulated stress response system are wide-ranging.
The research in the field of epigenetics shows how early environmental factors can either switch on, or switch off a gene that they previously found to be one of those risk factors for addiction and many illnesses.
Yes, it's a huge advance in the field. Environmental adversities like neglect, abuse, parental loss, or bullying can also have different effects on individuals, because we haven't looked at what was going on elsewhere. Neglect from one parent might not have significant adverse effects on a child because it provided relief from an overbearing or suffocating second parent. The death of a parent might not have assevere of an effect on a child if that parent was abusive or neglectful, and the death actually relieved them from that trauma. Personally, I decided for some reason that I was a horrible person because I was bossy. But I was bossy because I was trying to deal with my sensory sensitivity. I was also quite obsessed with various things that no one else was interested in, so I thought I couldn't connect with people which led me to develop a certain level of self-hatred. But if I had known that we are all wired differently, and that people have a wide spectrum of sensitivities, then my life might have panned out very differently from the drug route. Because parents don't know what children are going through internally, so we need to make the world more friendly and not come down so hard on children for their differences.
Another trauma that's often overlooked, is stressed out parents who can't emotionally give the child what it needs to develop in a healthy way. If an infant is left alone in their crib, cries because their biological need for attachment isn't being met, but then is responded to by the parent closing the door, its stress response goes into overdrive. The infant's nervous system reacts in a near-death manner because not being responded to for long enough causes brain damage and can even result in the baby dying.
And that's something that when an individual is asked about childhood trauma, they just would not be able to remember. A child in the 0-5 range needs the attention of at least two loving caregivers in order to be relationally healthy, which is not to say they need a two parent family, but they need adults who are present and attentive. Kids that age need consistent attention - they just do. Locking a child in the closet for 6 hours is traumatic whether the child remembers it or not. That is considered an adverse childhood experience [ACE] right there. I like to say that neglect is often neglected. People don't realize that leaving kids alone is abuse. But these are the kinds of abuses that other people will not even be able to see, yet they're hideously harmful to children. Of course we can't all be perfectly attentive parents who are emotionally available every second. So just as we were talking about earlier, what can we do about society that allows for an environment that isn't so immensely stressful to parents and caregivers?
For sure. We can't shame or blame parents because A) they're not told about the research on neglect, and B) they've been given very stressful work and social circumstances: trying to raise a child in a destructively competitive society that only rewards individuals who "do it all on their own".
Right. So this why inequality and poverty in particular are so insidiously bad for children: parents are inevitably stressed. Especially if we look at the case of the single parent with no family support, mixed in with a serious lack of daycare, healthcare, access to healthy produce, even clean water in some States. These things make parents irritable and depressed, in which case they can't be fully present for their child. So all of these instances are absolutely things we can do something about. If you look at the way Scandinavian countries deal with these basic necessities, it'll blow your mind.
[Laughter] Exactly. What I can't understand is how we don't even have Family Leave. Hopefully that gets fixed soon, but it's mind-boggling. A baby during its first year of life needs attention from at least two different people. We can't just say, "Okay I'm going back to work now!" two weeks later. I mean, the biology is quite obvious. Understandably but unfortunately, parents of addicts hate to hear that trauma is involved, because they think fingers are being pointed and blame is being laid, but a lot of these things are societal and structural.
We've addressed two things here in the context of physiological reaction: the 1st being the effects of loneliness and rejection, and the 2nd being the effects of childhood trauma. I see addiction as 3-fold, so the 3rd is something you've covered a lot: addiction as a maladaptive form of learning. We all learn throughconditioning. You've written a lot about operant conditioning: how the repetition of a behaviour ingrains that behaviour, making it extremely difficult to stop?
Yes. When you repeat an action, it becomes easier and easier to do. We all know that when we start thinking a certain way it becomes easier to continue down that path, and keep thinking that way - because the brain connects [neuro] pathways around that thought. Conditioning is largely based on a brain chemical called dopamine [the motivator chemical]. If something good happens, or if you get a pleasurable result from doing something, then your brain's reward center gets activated, and so you store the information surrounding that 'reward'. If you realize that you got a great cup of coffee that came in this kind of cup [holds up paper cup with logo] well, this kind of cup gets stored in your memory so the next time you walk by and see that kind of cup, you're going to get a dopamine burst to motivate you to walk in and order another great coffee. This is because you've learned that drinking it was a pleasurable experience: that kind of cup held a great cup of coffee.
And the more you repeat that, the more ingrained ordering coffee at that specific spot becomes?
Yes, it's also called positive prediction. Learning relies on predictions (that cup must equal that coffee), and this gets wired into us. When you repeat an activity, it's added to your mechanical brain system, so this directs the way you learn. It also assures that you respond appropriately to the sensors around you.
We are wired to learn through pleasure and through when pleasure is not delivered. One of the things that this unfortunately makes us susceptible to is intermittent reinforcement. So if you get a reward every time you do something, like open the cupboard to grab a bag of chips, you'll be focused on opening the cupboard every time you A) see the cupboard and B) feel like a reward, and especially if in addition to C) are feeling stressed out. How intermittent reinforcement works is that sometimes, but not every time, the behaviour produces a reward. So if you go to open the cupboard and that bag of chips isn't there, your dopamine activity is heightened, your craving for those chips becomes greater, you have to work harder for it (walk to the store to get them), and the reward becomes greater, or more pronounced.
A huge name in this field of research was B.F. Skinner. His work with rats in conditioning chambers showed us exactly how motivating dopamine can be, and exactly how intermittent reinforcement and repetition can teach us to do something without too much thought getting in the way, and so then, how difficult to control your behaviour will become once a it has been ingrained in us by these mechanisms.
Well I could chat with you about all of this forever, but we've gone into such great detail already. So thank you Maia, your work is revolutionary, keep it up.
Anytime Tracy, it was a pleasure.