HammeretalTheexperienceofaddictionastoldbytheaddicted.pdf

The Experience of Addiction as Told by the Addicted:
Incorporating Biological Understandings into Self-Story

Rachel R Hammer, BS,
a third-year medical student at Mayo Medical School, Rochester, Minn. and an MFA candidate in
Creative Nonfiction at Seattle Pacific University, Seattle, Wash.

Molly J Dingel, PhD,
an assistant professor at the University of Minnesota, Rochester, Minn.

Jenny E Ostergren, MPH,
a research assistant at the Mayo Clinic Biomedical Ethics Research Unit, Rochester, Minn, as
well as a PhD candidate in Public Health at University of Michigan.

Katherine E Nowakowski, and
is a undergraduate research student at the Mayo Clinic Biomedical Ethics Research Unit,
Rochester, Minn.

Barbara A Koenig, PhD
a Professor in the Department of Social and Behavioral Sciences, Institute for Health and Aging,
University of California, San Francisco, Calif.

Abstract
How do the addicted view addiction against the framework of formal theories that attempt to
explain the condition? In this empirical paper, we report on the lived experience of addiction
based on 63 semi-structured, open-ended interviews with individuals in treatment for alcohol and
nicotine abuse at five sites in Minnesota. Using qualitative analysis, we identified four themes that
provide insights into understanding how people who are addicted view their addiction, with
particular emphasis on the biological model. More than half of our sample articulated a biological
understanding of addiction as a disease. Themes did not cluster by addictive substance used;
however, biological understandings of addiction did cluster by treatment center.

Biological understandings have the potential to become dominant narratives of addiction in the
current era. Though the desire for a “unified theory” of addiction seems curiously seductive to
scholars, it lacks utility. Conceptual “disarray” may actually reflect a more accurate representation
of the illness as told by those who live with it. For practitioners in the field of addiction, we
suggest the practice of narrative medicine with its ethic of negative capability as a useful approach
for interpreting and relating to diverse experiences of disease and illness.

Keywords
Addiction; substance use dis s; narrative therapy; biological etiology

Corresponding Author: Rachel R. Hammer [email protected] 200 First Street SW, Rochester, MN 55905, USA..

This is an original manuscript; no part of this manuscript has been submitted or published elsewhere.

NIH Public Access
Author Manuscript
Cult Med Psychiatry. Author manuscript; available in PMC 2013 December 01.

Published in final edited form as:
Cult Med Psychiatry. 2012 December ; 36(4): 712–734. doi:10.1007/s11013-012-9283-x.

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Introduction
The National Institute of Drug Abuse’s active endorsement of addiction as a “brain disease”
has been described as an attempt to create “a unified framework for a problem-based field in
conceptual disarray”(Campbell 2007). This increasingly popular biological model –
addiction as a “disease of the brain” – reduces the problem to a system of spent
neurotransmitter-soaked reward circuits, for which an individual may be genetically
susceptible (Dingel 2011; Volkow and Fowler 2000), and seeks the development of
pharmacological treatments to achieve a cure (Kalivas 2005).

Another dominant model – the adaptive/constructionist model – is popular with addiction
treatment counselors and psychologists as it puts more emphasis on the effect of a person’s
environment, relationships, and identity when examining the etiology of addiction (Gergen
2005; Peale 1998). Proponents of the adaptive/constructionist model more readily espouse
talk treatments aimed to facilitate self-realization and self-managed change (Prochaska
1992), a process in which success is gauged by a patient’s ability to talk themselves back to
health (Carr 2011).

Addiction as a socially-constructed illness has been pitted against addiction as a
physiological disease. Some scholars, fed up with the addiction model turf war, have
suggested mounting “a collective refusal against the domination of narratives around
addiction as a disease that requires cure through formal [medical] treatment” (Gergen 2005;
Pryce 2006). Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), on the other
hand, encourage something of a treatment middle ground. AA/NA provides some of the
earliest studies on narrative therapy (Thune 1977), but has also moved to espouse the
concept of addiction as a “disease” insofar as it is of utility to convince addicts1 of the
severity of their situation and the importance of abstinence.

Historically, addiction has been understood in various ways—a sin, a disease, a bad habit—
each a reflection of a variety of social, cultural, and scientific conceptions (Kushner 2006;
Levine 1978). Today there are a myriad of lingering theories addressing the problem of
addiction, and yet, in spite of the diversity of theories and strategies, the problem persists.
Addiction today remains as formidable a reality as it ever was, with twenty-three million
Americans in substance abuse treatment and over $180 billion a year consumed in addiction-
related expenditure in the United States (Executive Office of the President 2004).

The primary aim of this paper is to explore how people who are addicted view their
addiction against the framework of formal theories intended to explain their condition. In
doing so, we will add to the “cultural stock of stories”(Hanninen 1999) that narrate the
problem of addiction and discuss the curious desire for moving toward a more “unified
theory” of addiction when the narratives from those who are addicted seem to reveal that no
such “unified theory” need apply. Regardless of which addiction paradigms patients profess,
clinicians must attend to individual accounts of illness—a practice which the rising field of
“narrative medicine” promises to deepen.

Adding to the Cultural Stock of Stories
Hanninen and Koski-Jannes, in 1999, applied narrative analysis techniques to 51 written
testimonies of recovered alcoholics, bulimics, smokers, and sex and gambling addicts in

1We use the term “addict” as a stand in for other terms like substance user, alcoholic or smoker. Throughout our paper, we have
chosen to refer to participants as they have chosen to describe themselves. Many of our participants self-identified as “addicts.”
However, in our discussion of interview data should the participant self-identify as an alcoholic, we have referred to them as an
alcoholic.

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Finland. They ascertained five dominant narratives from the accounts: the Alcoholics
Anonymous (AA) story, the personal growth story, the co-dependence story, the love story,
and the mastery story.

They analyzed each narrative paradigm for “emotional, explanatory, moral, and ethical
meaning,” for “connections of each narrative type with the story types, belief and value
systems” prevalent in the larger culture, and for significant trends in each story type by
gender or substance used (Hanninen 1999).

Elements of these addiction narratives reverberate in the findings of other qualitative
researchers: certainly in Erica Prussing’s fieldwork on alcoholism narratives of Native
American women (Prussing 2007); also in Deborah Pryce’s work in South Africa in which
she found narrative solutions for what had previously been pharmacologic problems (Pryce
2006); and in Wiklund’s examination of narrative hermeneutics of addiction (Wiklund
2008). What we add to their work is an account of how patients narrate themselves using the
new biological accounts of addiction, an increasingly prevalent cultural story, and one
widely represented in popular media.

Sample and Methods
Participant Sampling and Data Collection Sites

We interviewed 63 people from five sites in Minnesota: 14 from a methadone treatment
program (22%), 29 from nicotine or alcohol inpatient and outpatient treatment programs
(46%), 6 from an alcohol treatment program at a veteran’s hospital (10%), and 14 from
smoking cessation free clinics (22%). These sites were selected in to obtain a socio-
economically and ethno-culturally diverse sample. The five treatment sites were located in a
large metropolitan area and a mid-size city. Participants ranged in age from 25 to 73, with
the majority falling between the ages of 30 and 59. The sample included men (45%) and
women (55%); 19% self-identified as African American, Asian, Native American or Bi-
racial, with the remainder self-identifying as of European ancestry. Of the full sample, 28%
were in alcohol treatment only, 35% were in nicotine treatment only, and 37 % were in
polysubstance treatment.

The treatment sites varied in their approach to substance use. Most offered a combination of
group or individual therapy sessions and pharmacological treatments, including methadone
and drugs such as acamprosate and nicotine replacement therapy. Several programs used
audiovisual aids or treatment strategies that emphasized the biological components of
addiction. One used a brief educational film that highlighted the disease model of addiction;
a second treatment site included a large display of living zebra fish used to study the genetic
basis of nicotine addiction.

Procedures and Analysis
At each site, we distributed information about the study by either affixing a flyer to waiting
room bulletin boards or distributing a handout with the interviewers’ phone number.
Interested patients called to schedule an interview at their convenience. Upon obtaining
participants’ informed consent, we conducted semi-structured interviews of 30 to 45
minutes. Participants were compensated for their time. We used a semi-structured interview
guide that probed respondents’ knowledge of and beliefs about six main topics: 1)
understanding of the patient’s own addiction; 2) conception of free will; 3) knowledge of
addiction genomics; 4) benefits, risks, hopes, and fears of new genetic treatments and tests;
5) willingness to participate in genomics research on addiction; and 6) effect of media and
direct-to-consumer tests. The interview guide was crafted to answer the main questions of a
large study funded by the National Institute on Drug Abuse. That ongoing work examines

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the social impact of an emerging genetic understanding of addiction. At the beginning of the
interview, we asked participants to share the “story” of their addiction. Subsequently, while
answering specific questions, participants were encouraged to draw from their personal
experience to explain their responses.

The interviews were audio-recorded, fully transcribed, and uploaded into N’Vivo 8 software.
We used qualitative content analysis to analyze the interview transcripts. Each transcript was
carefully read by at least two members of the team. We initially assigned codes to segments
of text based on themes delimited in the interview guide, but over time, refined and revised
codes to incorporate themes that emerged from the data. Discrepancies between members’
coding choices were discussed until a common code was agreed upon or a new code written.
Summaries of each code were then constructed based on analysis and discussion of each
category; key quotations describing common themes were noted.

This paper is based primarily on one code: “patient experience of addiction,” and its
subthemes. Participants were classified by self-reported age, gender, and occupation. These
contextual variables were analyzed after themes were distilled from the transcripts
themselves. All names used in the analysis that follows are pseudonyms.2

The Experience of Addiction, In Their Own Words
“People have different experiences with [addiction]” Julia said, and each person has a
“completely different process.” On the contrary, Mike claimed that “people are cut out of
the same cloth,” to say that he believed the struggle with addiction is more or less the same
for everyone.

We examine hence both the commonalities and idiosyncratic reflections on the experience
of addiction expressed by interviewees. Other narrative analyses in the literature, such as the
work of Hanninen and Koski-Jannes, have described a story’s purported “cure” or key to
recovery. As we did not obtain full life histories from our participants, our results describe
mainly participants’ experience of addiction, their understanding of addiction as a disease or
otherwise, and their perspectives on the biological underpinnings of addiction. Also, since
our participants were recruited in treatment centers, these accounts lack the voices of those
who have sought recovery on their own (Cunningham 1999), who have foregone treatment
(Cunningham 2004; Sobell 2000) or who have been denied access to care.

We have organized participants’ responses by the major themes that emerged from our
qualitative analysis of the interviews, rather than by the demographics of respondents or the
particular substance used. The four major themes are: 1) What’s Normal?, in which addiction
is perceived as something a person grows up with, something “inherited,” whether by nature
or nurture; 2) Punctuated Equilibrium, in which addiction follows a pattern, oscillating along
a static equilibrium, flaring with specific triggers; 3) Pedal to the Metal, in which addiction
rapidly causes a person to “lose everything” often before the person is aware they have been
“sabotaged”; and last, 4) The Snowball Effect, in which addiction slowly arises in social
substance users over a prolonged period of time, quantity and frequency gradually
increasing until the accrued momentum makes it too difficult to stop.

Trends in gender, age, and substance are mentioned within the discussion of each theme. We
note where participants’ views reflect a biological understanding of addiction, and how they
hypothesized whether these conceptions were or were not useful to them in their quest for
recovery.

2Interview guide available upon request.

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What’s Normal?
A 50-something homemaker, Jill, described her alcoholism as a longstanding problem: “I
was raised in a family that at five o’clock it was cocktail hour—every day…So I didn’t know
it was weird to drink everyday. I thought everyone did that, and all their friends,
everybody.”

Jill’s story was similar to eleven others (19% of the sample) who understood addiction as
something they grew up with, something “inherited” whether by nature or nurture. Ten of
the twelve comprising the What’s Normal? theme were women, most of these mothers, who
were in treatment for alcohol or nicotine addiction.

The interviewer asked if she thought her alcoholism was genetically predisposed: “Mm-
hmm, it was just normal.” The interviewer probed further asking, “Why do you think it was
a predisposition?”

Jill said that her biological relatives, grandmother, her grandmother’s sister, her mother, and
her aunt were all heavy-drinkers, never treated. “Also, I have low self esteem. And not a lot
of confidence or anything, so it would loosen me up.” She recalled how she started:

Everyone else did it…The first time I got drunk I was 15 and I was living at my
parents’ house and they were gone and I opened a bottle of gin and drank almost
the whole thing and got violently ill. Had to be taken up to my bedroom by some
friends, threw up all over my bedroom.

The interviewer surmised, “So, a lot of social influence to start drinking then?”

Mm-hmm. And that it was just normal…I really thought everyone had a cocktail at
five. And when I think back, I think, well, [so and so]’s parents never did that…but
all of my parents’ friends did.

Another mother, Latoya, in treatment for heroin and nicotine addiction, believed that
addiction was a part of human nature: “I feel like everybody got addiction, you know what I
mean, ‘cause they have addiction to smoking, addiction to going to work, you know, so
somebody has an addiction somewhere in them.” Connecting her experience to a trend she
perceived in others, Latoya had developed a sense that her addiction, though problematic
and disabling, was not unique to her, but in fact, a common experience along the spectrum
of “normal” human behavior.

Seven of the twelve with the What’s Normal? theme felt that a genetic understanding of
addiction was useful to them. Jill stated that because she thinks she has a genetic
predisposition to alcoholism, an “addictive personality,” she is “very careful about pills
because I figure I could become addicted to anything because I have an addictive
personality. When they say have a drink, a drink, well, I’ll have more than a drink.” She felt
that if she had been told she was genetically susceptible to addiction before she took her first
drink, it may have had a preventative effect.

Perhaps owing to the majority of mothers comprising the theme, as well as a tendency to
embrace the idea that addiction was heritable and environmentally pressured, many3 in the
What’s Normal? theme mentioned the hope to author a “new normal” for their children.
Some highlighted the biological understanding they were taught as part of treatment. In this
way, the biological component of their story was a useful fuel for vigilance in parenting of

3Generally, if we say that “the majority of participants expressed” or “many” we are referring to a proportion greater than two-thirds
of the cohort.

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children who may have a genetic vulnerability to addiction. Even if they didn’t find the
genetic understanding useful for themselves, they thought it might be useful information for
their children. Tanya, a mother in treatment for nicotine addiction, said:

I seen my mom smoke; I was like, oh, that’s cool! I should smoke. And I have been
smoking since I was 15. Now I’m 37 and I kind of want to make a good influence
on my daughter – so she sees how hard it is for me to stop smoking. Hopefully, she
will never pick up that first cigarette and get addicted to it.

Routine and ritual, a large component of the addiction experience described by nearly all of
the participants, tended to be discussed more often among those who “grew up” with
addiction. Participants described their smoking habits with the warm nostalgia that many
would use to talk about how their mother had chocolate chip cookies on the table every day
after school. Jill admitted that she “never thought of abstaining” because drinking was such
a normal, ritualized part of her day:

I was drinking after I got up in the morning. I would have a Coke, and then I’d
make a drink and drank all day long…I didn’t drink until the bottle was gone, I’d
drink until it was half gone and then I would go upstairs and go to bed and get up
the next morning, have a Coke, make a drink.

From the accounts of participants who used substances because it was “normal” at home to
do so, once the context of “normal” changed (in a new environment), the stigma they felt
being suddenly “abnormal” was a commonly reported motivator for starting treatment.
Abby, a late-forties smoking mom, decided to quit when she started working for a firm that
did cigarette litigation. “It was really frowned upon [at the firm], it was like a taboo to be a
smoker.” Irene, a smoker in her fifties, blamed her thirty-year habit on Hollywood’s
glamorization and “the Marlboro man, he was just too sexy for life.” She also attributed her
smoking to “watching my parents all my life smoke cigarettes. [I thought] that it was just a
general part of life. I mean, I really thought everybody did this.” When asked what led her to
seek treatment, she described a cultural shift in stigma against cigarette smokers.

People started making me feel like I was a convicted felon…Now all of a sudden it’s
a filthy, dirty disease that everybody is shying away from…We used to walk into a
loaded elevator with a cigarette and not one person would ever say ‘[cough] Excuse
me, I don’t want you to smoke!’ It was socially accepted and everyone kept their
mouths shut… I mean, before I quit smoking, I told my husband, I said, ‘I wanna
move to Missouri where smoking is still legal because they make me feel so
terrible here.’

Irene’s comments bear the flavor of oppression and victimization that characterize aspects of
Hanninen and Koski-Jannes’ personal growth stories where the recovery comes only after
the “butterfly breaks out of a cocoon.” It follows that if addiction stemmed from oppressive
relations or even oppressive traditions within a rigid family structure, then the solution was
to be found in the agency and authenticity gained when the storyteller breaks loose from co-
dependency and listens to their own needs and desires.

The What’s Normal? perspective also echoes elements of Hanninen and Koski-Jannes’ co-
dependence story in which addiction is a familial pattern or curse that extends across
generations, caused by secrecy and repression of truth, and results in an external locus of
self. In the co-dependence narrative, addicts were not morally guilty but victims of victims.
Hanninen and Koski-Jannes observed that the cure for this group was achieved through an
individual’s courage to stop repressing negative feelings or secrets and embrace openness
and awareness about themselves and their family. Awareness could “break the curse.”

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The sense of normalcy with substance abuse inherited from and triggered by their family
environment, or in mimicry of family behaviors, easily fit with the biological narrative, and
the idea that one’s susceptibility to addictive behaviors could be transmitted through genes.
For some, an awareness of their genetic status seemed like it could offer a similar awareness
of “the curse.”

However, for five respondents in What’s Normal? the biological understanding had its rub.
“It’s scares me for my children,” Elise said. She said that nobody wants this for themselves
or their family, but she felt powerless and susceptible, and imagining that it was biologically
linked made it worse. Irene described feeling biologically ostracized in response to the news
of recent addiction genetics research and felt that scientists were “delving too deep” with
DNA studies:

You know what I mean by the lesser in society?..People with the weak genes. We
only want to keep the bright, intelligent, normal, non-addictive. I think we’re
getting into some danger zones when we start getting too deep in this stuff. I really
do. … All of a sudden I’m a leper. … It makes me feel bad and it makes me feel like
my parents were little lepers of society. And if given the choice, the powers that be
would get rid of the leper.

Suffering societal stigma was mentioned by nearly all participants, across all themes. For
Irene, oppression and judgment for her morally-charged behavior seemed to be just one
more problem she had accepted as “normal” behavior of others.

Punctuated Equilibrium
Joe, a self-described blue-collar worker in his late forties, shared what he believed to be a
strong connection among his mental health, employment, and alcoholism cycles:

It is anxiety and stress that I was dealing with. [Alcohol] just calmed me down so
that I used it as a tool, like a self-medication for me…I have depression and anxiety
and overwhelming problems with employment, it was very stressful…but it has
nothing to do with family or anything…I would quit for a month here and there; I
have quit for a couple of weeks here and there. But I always went back when the
anxiety and depression set in when I’m dealing with work.

Overall, Punctuated Equilibrium was the most common theme among all of the interviews,
representing 22/63 of respondents (35%). Titled to make a loose analogy with evolutionary
genetics, this theme describes addiction as a problem that oscillates along a static
equilibrium, flaring only with specific triggers. Most respondents with this theme reported
being employed and many described work as one of the significant stressors, or
punctuations, contributing to their addiction. The Punctuated Equilibrium theme was more
common among middle-aged males, mainly alcoholics and smokers.

Joe placed his alcoholism in the flux of cyclic depression and anxiety. He relapsed and
remitted upon the tides of his mental health and employment status. A common factor that
influenced his drive to drink or empowered his abstinence was the amount of stress in his
life:

I resigned one job due to the stress and then I would start another one and that is
the one I’m at now and I enjoy the job, but the increase in work duties just kept
piling up where the stress was built up again for me. You know, in this day and
age, they try to put as much responsibility as they can on people …I mean
management does, basically to cut costs and that hurts the blue-collar people. I
mean, and the stress just got worse and that is why I started again. It just kept back
and forth, back and forth.

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Joe described some of the limiting factors that have kept him from straying too far from his
equilibrium. One of the most significant influences to curb his drinking and restore balance
was his wife:

My support has always been my wife. She pointed out that if I didn’t quit, she
would leave. … There were divorce threats; that is basically it. I just quit, and, you
know, just go for awhile and then the tension would build up, the stress would build
up again and I would go back to it.

The Punctuated Equilibrium theme has much in common with the stress-based theory of
addiction. This model assumes that people spend a significant portion of life in
“equilibrium” with euthymia, solid relationships, and reliable employment. This steady state
is disrupted when their threshold for stress is surpassed, an adverse event takes place, or
some other anomaly occurs to punctuate that even ground with a change in slope, causing
their addictive habits to return.

Many of these individuals did not describe physiological withdrawal when they remitted
from their substance abuse. Nor did they commonly describe severe cravings when in
equilibrium and in the absence of a trigger. But most could identify and predict the context
or stressor that would trigger them into relapse.

Most often, the trigger was emotional stress or mental illness. Depression and anxiety were
mentioned most frequently as cyclic patterns of instability that trended with substance abuse,
as well as self-reported diagnoses of bipolar dis and post-traumatic stress dis
(PTSD). Dave, who had a shaved bald head and carried an army camouflage backpack,
remarked that his “crazy anxiety” was a significant trigger for his abuse. Rick, who suffers
from PTSD, said, “I was never relaxed, which resulted in chronic muscle strain, nerve
impingement, and those physiological results of fight and flight reactivity, that was constant
for me. And the cigarettes really did help me relax.”

Several mentioned that they thought their treatment was more effective if it involved
relieving symptoms of mental illness or resolving the emotional stress. Otherwise, the
temptation to self-medicate with an addictive substance was too great. Dawn concurred with
Rick and Dave: “[My addictive substance] calms down the anxiety…it takes the depression
away, makes me feel like superwoman.” She described how her relapses were connected to
her anxiety attacks and relationship problems:

[Treatment] helped to a point; I mean every time I went to treatment I had some
good clean time behind me, but I don’t know, I always went back to using again.
And…where I get in trouble is with my anxiety. So, I mean if something happens,
something…say, for instance, right now, my significant other has been AWOL
since Tuesday, so the only time he does stuff like that is when he relapses and he is
out there walkin’ the streets. So, you know, somethin’ like this usually, …