 Presenting on the topic, Sainsa, Cognitions and Emotions, Three Sides of the Same Coins. So, Dr. Sam Bhuknin, can you please start sharing your screen? I don't have a screen to share. I prefer to talk to my colleagues rather than visuals. Okay, you can go ahead. Thank you very much. So, thank you for having me. I'm delighted and proud to be the first speaker. And I would like today to present a view of addiction, which is somewhat unusual, non-conventional. We have this perception that addicts are slaves to their addictions. We tend to consider addiction as a kind of morality play, good versus evil. The addict is sometimes the good guy, or the good girl, is a victim of his own circumstances, his upbringing, his cultural, societal context, what society has done to him, etc., etc., etc., crime. Or sometimes the addict is presented as the evil axis, the evil person, the person who would steal his mother's own money to purchase the next fix. And it is like a medieval morality play. Of course, morality plays have no place in psychology. And conflating the two, like Scott Peck has done in his books, conflating the two is, in my view, bad praxis, bad praxis both for morality and for psychology. And the other approach to addiction is to medicalize addiction, to consider addiction a brain disease or a brain disorder. And this flies in face of most of the evidence we have. The psychological component in addiction is so massive that to claim that addiction is merely a biochemical aberration, a problem with conductance in the brain, a problem with wiring or neuroplasticity of the brain, a disease of the brain, trying to find all kinds of ratios between white matter and glia, and so on and so forth, is in my view a reductionist approach, which this approach doesn't give us any added insights, any added insight that is meaningful in the understanding of addiction and in the treatment of addiction. It is important to accept that addictions are actually the natural state, the baseline. They are not aberrations. They are not diseases. We start off, we start life by getting addicted. We get addicted to mother. We get addicted to her milk if she is breastfeeding us. And we continue to develop addictions throughout life. What is a habit? A habit is a form of attenuated addiction. What is love? The biochemistry and frankly the pathology of infatuation, limerence and falling in love resemble a lot, a lot, the biochemistry and pathology of addiction. What are automatic negative thoughts? Automatic negative thoughts are addictive, as we know. They tend to propagate and multiply. What are obsessions? What are compassions? They are all forms of addiction. Addictions are powerful organizing principles. Addictions give meaning and direction and goals to life. They are explanatory, hermeneutic principles and they endow life with meaning and purpose. Addictions provide boundaries as any junkie would tell you. Addictions provide rituals, timetables, order to life. Addictions are like exoskeletons. Addictions are also ways to regulate dysregulated emotions, to modulate interpersonal relationships and communication and to reduce the liability of moods. Addictions, as I said, are the scaffolding of life itself. Have a look at our brain. Our brain is programmed, constructed, designed, built for us to be constantly addicted. Our brain is an addiction machine. The dopamine pathway occupies around 20% of the brain. If you add all the parts of the brain that directly or indirectly lead to addiction or are involved in addiction, you get anywhere between 40% to 60% of the brain. Half our brain is dedicated to engendering addiction and perpetuating addiction. A high is the desired permanent outcome, Freud called it the pleasure principle. Addictive states must serve some evolutionary purpose. They must be some kind of beneficial adaptation, not maladaptation. There is no other explanation why our brain is an addiction-creating, addiction-generating machine. Nature tolerates no inefficiency, no redundancy that is not needed as an operational principle. Nature would not have created, would not have given us a brain which is dedicated to addictions if addictions were not important. In the process of socialization, we internalize inhibitions, we internalize introjects. It's the inner critic or the superego or whatever you want to call it. And these inhibitions and introjects, they work against certain addictions so as to render us functional and useful in human communities and environments. Other addictions mediated via institutions such as the church or the family, these other addictions to love, to religion, to child rearing, these are all addictions. They are encouraged for the very same social reasons. Non-conforming and defiant addicts are conditioned to self-destruct and to self-defeat and to love themselves. Conforming addicts, people with addictions are socially acceptable, socially correct, sublimated. These addicts are encouraged actually to enhance and amplify their addiction. If you have two children, you should have three. If you fall in love, you should really love. If you worship God, you should do it in a ritual, a series of rituals in church. These are all clinically addictions. Addictions are individual. Their prescription and inhibition is social. No wonder that addictions are associated in clinical and abnormal psychology with anti-social or even psychopathic and sociopathic traits, behaviors and personalities. The addict seeks to alter his perception of reality. Addictions are both intersubjective theories of mind and theories of the world. When you consume drugs, alcohol, you're trying to alter the way you perceive reality and the way you perceive other people. You are trying to rewrite, to reinvent, to reframe the theories you have about other people and about the world. Many addictions come replete with or in the context of ideologies. Addiction spawns subcultures and it provides a social milieu. Any alcoholic will tell you that one of the main reasons they get drunk is for social purposes to be socially disinhibited and be able to function socially. Addictions, post-traumatic behaviors and pathological narcissism are strongly correlated. Narcissism is a reaction to childhood trauma and abuse and it's a form of complex post-traumatic stress disorder, CPTSD. And narcissism often leads to lifelong substance abuse. Dual diagnosis of personality disorders, especially cluster B personality disorders and substance abuse, this dual diagnosis is very common. Indeed, CPTSD, complex trauma, is indistinguishable from cluster B personality disorders with a dominant dimension of narcissism, such as borderline personality disorder. One could say that narcissism, pathological narcissism, is an addiction, an addiction to attention, an addiction to narcissistic supply And all three mental health issues, addiction, complex trauma, personality disorders All three resemble dissociative identity disorder, what used to be called multiple personality disorder. In all three cases, personoid, personality-like, mental construct or structure, takes over the self. There's a personality-like structure that takes over the self. The addictive personality, the post-traumatic personality and the false self in narcissistic disorders, they are all personoids, they are all personality-like. When the trauma threshold is crossed, when the person is exposed to a number of triggers simultaneously, all three phenomena, mental health phenomena, are expressed and they feed on each other. It's very common to see someone who had been traumatized in her past, had developed a personality disorder and also has a habit, a substance abuse habit. She is an alcoholic or she consumes drugs. This is a very, very common combination in therapeutic and clinical settings, as you well know. And the usurping personoid, the personality-like construct, this usurping structure is dissimilar in some important respects to the person's normal personality. So we end up having two structures, one overriding structure which is personality-like and one real personality. The personoid, the personality-like construct is devoid of inhibitions, lack sympathy, sports little or no impulse control, is unable to delay gratification, engages in dichotomous thinking, splitting or idealization, devaluation. His poor judgment of future consequences is reckless and is infantile and aggressive. I have just described actually a psychopath. Traumas can be habit-forming. They can constitute the core of a comfort zone. Trauma victims often engage in variations of the same set of self-defeating, self-destructive, self-trashing and reckless behaviors. Why? Because they seek to re-traumatize themselves in order to reduce anticipatory anxiety. And at the same time, they also consume drugs or they consume alcohol for the very same reason. So trauma, trauma and alcohol and drugs, they go together. Traumas fulfill important psychological functions and may become addictive as the victim gets habituated to intermittent reinforcement, operant conditioning and abusive misconduct. That's what we call trauma bonding. That is the Stockholm syndrome. It's an addiction to trauma. One of the most critical functions of traumas is to help make sense of the world by perpetuating a victim's stance, a victim role, self-imputed role often. Traumas are powerful organizing and hermeneutic, interpretative, exegetic, explanatory principles exactly like substance abuse. The junkie's life obtains meaning and structure because he has to chase his next fix. Then he has to chase his next fix, gives him a direction, a purpose and aim in life and then consuming the drug gives him a ritual, gives him the rudiments of a religion. The same goes with traumas. Traumas have exactly the same structure. So traumas and substance abuse, traumas and addictions resonate and one can easily get addicted to traumas or easily be traumatized via substance abuse. Regrettably, treatment modalities, psychotherapies for post-traumatic stress disorder and complex trauma focus on behavior modification and prophylaxis prevention. These therapies rarely if ever deal with the etiology of the trauma or with its compulsive and adaptive aspects and dimensions, the trauma's survival value. Trauma victims are taught how to avoid triggers and to refrain from certain types of decisions, choices and attendant conduct but they are rarely forced to confront and exercise the demons of trauma, the ghost in the machinery of pain, bewilderment, disorientation, a labile sense of self-worth. All these give rise to horrible tragedies that keep unfolding and recurring in the patient's lives. Anyone who's been exposed to trauma, especially in early childhood, is prone to trauma throughout their lives. According to my new theory of addiction, addictive behaviors are the normal state. They are underpinned by vast, dedicated neurological structures in the brain and in the CNS. Addictions are positive, advantageous, self-efficacious, evolutionary adaptations whose role is to resolve several types of dissonances and the anxiety that arises from these dissonances. Addictions prevent the addict from getting overwhelmed by dysregulation, liability and retraumatization. Like every other healthy, healthy mental process, addictions can go awry. Of course, anything can go awry. Parenthood can go awry. Anything exaggerated becomes malignant. When carried to extreme, addictive routines become self-destructive and self-defeating. There's no dispute about this. They coalesce, they interact with other maladaptive traits and behaviors. Addictions can feed on grandiosity, defiance, rage, depression, delusions, anxiety and an impaired reality testing. These are all sick things, unhealthy things and the addiction can feed on them or they can feed on the addiction. The way we treat addiction is all wrong. No wonder that the rates of relapse, the rates of recidivism are sky-high. 60-80% of rehab patients remit and relapse within the first year, in the case of alcoholism. Recovery is rendered a lifelong endeavor. One addiction often replaces another. You get rid of alcoholism, you become addicted to love, to infatuation. You get rid of this, you become addicted to a drug or to shopping or to working, to work, workaholism or to gambling. The correct way to treat addiction is to encourage the addict to adopt a healthy, disciplined, goal-focused, self-nurturing variant of his or her addiction. There is no point in trying to eradicate the addiction. The addiction fulfills too many crucial psychodynamic roles and functions and it fulfills them well. Instead, the addict should learn gradually, incrementally how to control, manage and regulate his behavioral patterns, his dependency, tendency to be dependent. An alcoholic, for example, should be taught and trained how to drink, not how not to drink, to not drink. If you try to teach an alcoholic how to not drink, you are setting yourself up for failure. Alcoholics drink, drink and will drink forever, regardless of your efforts, until something happens to them endogenously and they decide to stop. There is nothing you can do except teach the alcoholic how to drink responsibly, not how to abstain, not how to go sober, but how to control the drinking. Regulate it, modify it, modulate it. A narcissist, another form of addiction to narcissistic supply. A narcissist should be coached to extract narcissistic supply from his sources without harming them, without traumatizing other people. Chopaholics, pathological gamblers, should institute reinforcement and reward themselves for perspicacious money management. Alcoholics should merge life and work seamlessly. You should go with the flow, you should go with the addiction. It's like in Kung Fu or Jiu Jitsu, whatever it is in martial arts, where you use the momentum of your adversary, the momentum of your enemy against the enemy. You should use the power, the considerable power and the adaptive value of the addiction against the addiction. You should collaborate with the addiction, you should work with the addiction, you should accept the addiction, even welcome and embrace the addiction. To allow the addict to not feel ashamed, to not feel guilty, to not feel dissonant, to not feel egodystonic, but instead focus on managing this aspect of his personality responsibly and in a regulated, non-label manner. There is no shred of evidence that any addiction is a chronic disease, none. I read all the medical reports and everything, it's one big hype. I don't want to use the word nonsense, bordering on nonsense. Natural selection would have long eliminated addictions if they did not play a positive role, positive adaptation in the survival of the species. We need addiction, it's built into us by evolution, by nature. It's time to begin to accept addictions as powerful therapeutic tools, not as demonic entities to be appreciated. There is a strong connection between addiction and personality, but there is little convincing empirical research about the correlation between personality traits and addictive behaviors. Substance abuse and dependence, alcoholism, drug addiction is only one form of recurrent and self-defeating pattern of misconduct in these people. People are addicted to all kinds of things, as I said, shopping, gambling, internet, reckless and life-endangering pursuits, adrenaline junkies, the connection between chronic anxiety, pathological narcissism, depression, obsessive-compulsive traits and alcoholism and drug abuse. This connection is well-established and is common in clinical practice. But not all narcissists, not all compulsives, not all depressives and anxious people turn to the bottle or to the needle. Frequent claims of finding a gene complex responsible for alcoholism have been consistently cast in doubt, if not worse. In 1993, Berman and Noble suggested that addictive and reckless behaviors are near emergent phenomena. They may be linked to other, more fundamental traits such as novelty-seeking or risk-taking. I refer you to the paper Childhood Antisidence of Substance Misuse in the Current Opinion in Psychiatry Vol. 6, Issue 3, June 1993. Psychopaths, patients with anti-social personality disorder, have both qualities, addictions and novelty-seeking and risk-taking. In ample quantities, we would expect psychopaths, therefore, to heavily abuse alcohol and drugs. And indeed, this is exactly what happens. As Lewis and Buck Holtz, convincingly demonstrated in 1991, psychopaths do abuse drugs and alcohol way, way disproportionately compared to the general population. I refer you to the article Alcoholism-Antisocial Behavior in Family History in the British Journal of Addiction Vol. 86, Issue 2, February 1991. And still, only a negligible minority of alcoholics and drug addicts are psychopaths. So what I'm trying to say, I'm trying to say that there are mega-structures, hyper-structures, that yield addiction personality disorders and are amenable to modification and activation via trauma. Addiction is an organizing principle in an hour attempt to decipher the human psyche, which in itself is a construct, not an ontological entity. We have come up with two answers. One, that behaviors, moods, emotions, cognitions are wholly reducible to biochemical reactions and neural pathways in the brain. This is a reductionist, medicalized view of what it is to be human, and it's hotly contested. The second approach is that behaviors, moods, emotions, and cognitions can be explained and predicted by the introduction of scientific theories based on primary concepts. So we have psychoanalysis. It's an early and now widely disregarded example of such an approach to human affairs. And the concepts of addiction, and similarly the concept of narcissism, they were introduced to account for often recurring amalgams of behaviors, moods, emotions, and cognitions. Shemas. Both addiction and narcissism are organizing exegetic principles with some predictive powers. Both hark back to Calvinist and Puritan standards and strands of Protestantism, where excess and compassion inner demons were important topics. It is not by accident, it is not an accident of history, that the modern science of psychology and definitely the study of addictions had emerged in Protestant countries, in Germany, in Austria, among Jews, not among Catholics, in the United States. The religious background was still very dominant and prevalent. Moral judgments were still very much in the mind of those proto-psychologies. Many of them were experimental psychologies, but they designed the experiments to conform to value systems, to beliefs, including religious and moral beliefs. Psychology, to start with, was tainted, tainted and was very biased in favor of middle-class Protestant, possibly Jewish values. And to this very day it was unable to get rid of this legacy and this baggage of its early history. When addicts engage in addictive behaviors, they are activating and exercising parts of the brain that have their roots 400 million years ago. Animals engage in addictive behaviors with plants. This is something biological and it has psychological manifestations that far outweigh the biology because the psychological manifestations have synergy with other aspects of the human mind. The human mind can never be reduced to a gene, can never be reduced to a pathway or to a biochemical or to any combination of these. The human mind interacts with society, with others, with itself, with self-invented constructs like the false self, with, you know, it's a universe to reduce addiction, to police enforcement, morality play, or some glitch in the brain, is to ignore 99% of everything we know about addiction. That would be a great pity because it led us nowhere. We are utter failures in treating addiction. Psychology, psychiatry, we have failed dismally in treating addiction of all kinds starting with the oldest alcoholism and ending with the newest opioids. We need to wake up. Something is wrong with our paradigm and it is our obligation and responsibility towards our patients to change it, to shift it. Thank you for listening.