Episode #134
Just say no. You should just quit. So and so just stopped doing it, so can you. Some people believe that willpower should be all someone needs to overcome addiction. Willpower is a part of how people make change and make new habits. But willpower isn’t enough to overcome addiction. In fact even problematic use isn’t that simple to change either. Today we’ll talk about the role of willpower in substance use.
Transcript
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance Podcast. This is episode 134. The month of June is a big deal for me in that the doors to my main program charting the course are finally open. This is a six week live taught course with 12 CEUs attached for a small cohort of people, maximum of 10. This program is the culmination of me putting together all the information over the last 20 years that I’ve gained as a therapist and as a person in recovery, and tailoring a program for mental health therapists to build confidence and competence in addressing client substance use.
As I looked online at the courses that are available, they fall into two categories. One is they are far too big and overwhelming. There is more information in those courses than you need to know. It seems like these companies that create these courses are just throwing in all sorts of things that they think sound reasonable and could be interesting to make it seem like it’s more worth the money.
The problem is, none of us have that kind of time and you don’t wanna specialize otherwise you would. So those courses are there, but it’s hard to pick and choose what it is you’re gonna need to know because you don’t actually know what you need to know, at least not fully.
The other course offerings ala cart you pick a thing because you wanna know about it, and it could be super detailed, like the impact of opiates on trauma survivors that also are diagnosed with bipolar disorder. Those kinds of niche training can be helpful if that’s what you want. But what about general things that you need to know in order to work with client substance use. That isn’t really there.
It feels like there’s either too much or not enough. That’s why I created Charting the Course. I know it’s a big statement to say that I feel like I know what you need to know, but I’m gonna make the statement anyway. I spent 12 out of the last 20 years of my career training other therapists to do this very thing.
Over the years, I whittled down what I would have taught and came up with a list of things I feel like are the most helpful. And then additionally, I decided to add consultation calls just in case there was something that came up for you that I hadn’t covered. We know that clients surprise us all the time, and so we can count on that happening.
The doors are open during June and we start on July 11th. Head over to betsy byler.com/course and check it out. I am so excited about it and I’m gonna be talking about it quite a bit this month, inviting you to come and join me in the July cohort.
The podcasts over the month are going to be what I think is going to be helpful in preparing for people to join the cohort. There are some basic things that I feel like we need to have established, and I wanted to share where my stance is on these things so that everyone knows.
I’m pretty sure not everybody here has gotten a chance to listen to all 133 episodes that I’ve done, because of that, I’ve picked out a few that I’m going to be reposting because I feel like they are super important and I’m gonna be recording my usual podcasts with some specific themes.
Today I wanna talk about a myth regarding substance use and addiction action. The myth states that. Willpower should be enough to reign in problematic substance use or to stop addiction. That somehow willpower alone should be enough.
The reason that I wanted to address this particular myth that willpower should be enough is related to the conversation that happens all the time when it comes to substance use and in treatment circles about harm reduction versus abstinence. Very briefly, abstinence is abstaining from all mood altering substances.
Harm reduction has to do with reducing harmful behavior, reducing harmful use of substances, or reducing harmful outcomes or consequences of substance use. So damage control, basically. When it comes to addiction, I fall in the abstinence category. I don’t believe that true addicts and alcoholics can moderate period. I think their moderator is broken. And I have never seen it come back.
When it comes to problematic use, harm reduction fits really well. We’re not dealing with a full-blown addiction, and so we don’t know that the person’s ability to moderate is broken. There are lots of folks in the middle in problematic use who were able to scale it back, who can moderate. I think it’s an interesting experiment for folks to figure out if they are able to moderate or not, but that’s a very individualized thing.
Now, even in the addiction realm. I am a supporter of harm reduction. Anything that keeps somebody alive is something that I’m gonna support because as long as there is breath in someone’s body, there is hope for change. There is hope for something different. And so if somebody can’t do abstinence because it’s too hard for them and they’re not able to get clean time pulled together, then let’s go for harm reduction. Let’s keep them alive.
There are a lot of strategies for harm reduction that people get really touchy about because they feel like it’s giving addicts permission to use or excusing bad behavior. Remembering that what we’re dealing with is some very serious biological forces that are at work.
So as we talk about willpower and whether or not it’s enough, I want us to have that in the background the concept of abstinence and harm reduction.
When I’ve talked with people about substances, inevitably somebody says, I used to drink or use drugs all the time, and I just stopped. If I can do it, anyone else can do it. So there’s always a few things that run through my brain when somebody says something like that.
I never wanna invalidate someone’s experience and we can’t compare one thing against another unless we are very certain that we’re talking about the same thing. In that statement, I question what a lot of drugs or alcohol was and for how long that period of time was and how out of control or not, was that use? Then I question, what did they do to stop? Did they do it on their own? What do they mean by that? A lot of times I think they mean treatment. Sometimes they mean that they just decided one day to quit and they did.
There’s a lot of things that go into it. When someone is curbing their substance use, there’s thought beforehand, there’s preparation that they do. There’s new habits that they’ve tried to instill. Sometimes it’s getting support from a friend or family member or a coworker.
And then I think about the idea that they stopped. What does that mean? Does that mean they don’t drink ever, or they don’t use any drugs ever? Does that mean that they found moderation? Does that mean that they stopped for three months and that’s the moment in which they’re telling me that they were able to kick it? Or does that mean that this was 20 years ago and they haven’t used a drop since? All of those factors impact how we understand someone’s experience.
I have yet to meet someone who had addiction level substance use that was able to wake up one day and stop with no cravings and no difficulty. That people woke up one day and decided that today was the day and never picked it up again. Yeah, that happens, but it sure as hell not just because it wasn’t just a decision they made. There are a lot of things that people do in order to keep themselves from going back to a particular habit.
I will say that it is possible that somewhere, A person was able to just stop and never miss it. What I would say in response is that they weren’t addicts all along. There are lots of reasons why I say that, and that isn’t just me ignoring someone’s experience or trying to push my agenda, so to speak.
So let’s first talk about what we mean when we talk about willpower. Willpower is something that tends to be translated as. If somebody wants something enough, they can make it happen. Willpower is something that we are told. It can overcome anything, any obstacle, any issues that pop up. It’s at the heart of the American dream. The problem is that the American dream isn’t accessible to everyone.
It isn’t true that if you work hard enough that you can achieve anything. There are real issues that get in the way of hardworking folks achieving things, whether it’s systemic racism, prejudice, lack of opportunity, poverty, trauma. Or any other thing that can get in the way. Sometimes sticktuitiveness willpower perseverance isn’t going to accomplish the thing that we want.
Saying that willpower is enough about substance use, feels like a simplistic view of what substances do in and for a person, that it is a matter of taking it or leaving it. Oftentimes it has to do with responsibility.
People who say that willpower should be enough, often are upset about a person in their life who was using substances and hurt them or someone they loved. They wanna make it a choice that the person had and therefore their fault that they did the thing. I’m not totally sure why those two things have to go together.
We can have responsibility for our actions, even if it’s not completely our fault. This is one of those black and white things that people struggle with. Because either someone is at fault or they’re not at fault. And if they’re not at fault, well then there’s no one to blame. And if they are at fault, then there’s no excuse for why they’re at fault. It’s a really confusing and highly emotional conversation that happens around this idea of willpower.
Willpower is also used as something that is also used for people to beat up on themselves about why they failed at something. Willpower as it comes to dieting and exercise or other health related goals can be very difficult. People feel like they are just too weak and they didn’t have enough willpower to stick to it, rather than thinking about the fact that what they were trying to stick to might not work for them and so perhaps it isn’t their fault. Perhaps they need a different plan.
The dieting industry is based on the idea that you can choose to do a thing a certain way and that it will work. If you follow this plan, if you follow these guidelines, then this is the outcome you will get. Even though in the very same breath there is the statement that these results are not typical. Because willpower isn’t like that.
It is not the answer to all the things. It is something that exists that we certainly have the power to exert our will over certain things, and we don’t have the power to guarantee an outcome. We can certainly exert our will over something or attempt to. The outcome of that thing though isn’t within our control all the time.
There is a lot that can be done through perseverance and hard work. I am not suggesting that we should be fatalist and decide that nothing we do impacts anything and so fuck it all. I do think that there is room for people to make different choices for them to challenge old ways of thinking so that they can have a different outcome this time. I just wouldn’t call it willpower.
Willpower as it relates to substance use typically is you just have to want to quit enough or you have to want to moderate enough and you just have to say no. No matter what happens. It sounds simple, and it would be really great if it was that simple. What we know anecdotally and also with research is that it’s not that simple at all.
There is a large amount of research about how we make decisions, how people can achieve goals, what willpower and what being strong will does in terms of meeting goals. There’s even research specifically about the impact on drugs and alcohol and recovery.
In one particular study, which I’ll put in the show notes. They found that most of the participants who described themselves as very strong-willed, it seemed that there was no correlation between having a self-assessed strong will and recovery status.
What made the difference was the number of strategies that participants said they were using that distinguished those in stable recovery from those who weren’t. Willpower remained important, but willpower in and of itself was actually used strategically in someone’s development of their recovery. These strategies typically involved trying to control for the environment that they were around, people, places, and things.
In my mind, we have two different types of substance use that we need to talk about today. The first one is about addiction, and the second is problematic substance use. So we’ll start with addiction because I think that the research is extraordinarily clear about where this relates to willpower.
This is a very important topic and question that everybody has to decide for themselves because it changes what they think about people who struggle with addiction. Is addiction a choice or not?
There are a lot of people who are uncomfortable with the idea that addiction isn’t a choice. They struggle with it, and usually it has to do with what I talked about just a few minutes ago when it comes to fault. If addiction isn’t a choice, then what does that say for the things that people do while they’re using, and by whether or not it’s a choice.
Here’s what I mean. Does an individual have a decision to make? Is it their fault that they became addicted or is it not their fault were they a victim of circumstance? Trying to put this in a black and white binary fashion isn’t really helpful.
It gets really murky really fast. What we know from research is that there are qualitative differences in the brain that are visible on brain scans of an addicted person versus a person who is not addicted to substances. We know that there are three main changes that happen in the brain in different parts of the brain that are responsible for perpetuating addiction and come from the repetitive use of an addictive substance.
I did an episode on this back, it’s probably episode six or seven I want to say, so quite a long time ago, and we’re gonna be talking about this and the implications of it in Charting the course when we start in July.
It isn’t just the reward pathway that causes people to continue substance use. Yes, that is absolutely a thing when we talk about dopamine spikes and the fact that it feels good and our body wants to do things that feel good, those things are meant to keep us alive. Like sleeping, eating, and having sex.
Those are the things that we need to continue the human race. And so our body is designed to spur us to do those things just like it does, just like that. It just like it exists in animals. They have the same drives. Because that’s what our body needs in order to survive and keep making more of us.
So it is part of the system .When you are using drugs or alcohol the dopamine spikes that people get from that are much higher than we can get naturally. The highest point that we can reach of dopamine naturally is about 150. So if zero is a baseline and 150 is where sex shows up, a hundred is about where it gets to when we eat. Gets to be about 200 with alcohol, three or 400 with cocaine and opiates, and 1400 with meth.
There is nothing that we can do without drugs that will get us past a certain point of pleasure. When we use an outside substance, a mood altering substance, we are using it and it is spiking dopamine. The body doesn’t care where it came from. It’s experiencing it the same way. It’s experiencing pleasure.
When we drop down from some kind of high like that, then a normal level of pleasure in the day-to-day feels kind of mundane. The more people do that and have that increase and try to keep that increased dopamine up, the more they want it because it feels bad without it.
So yes, of course the reward pathway is one part of why addiction develops. The body very simply wants what it wants. But there are a couple other reasons why this is so hard, why addiction develops. One of those places has to do with the ability to manage distress. So distress tolerance.
Without getting into a lot of detail, something that happens as a result of chronic use of a mood altering substance is that one of the changes in the brain makes it harder for someone to handle distress. That their actual ability to handle and to withstand distress goes down, which makes their body asking for more pleasure seem even more necessary.
The other change has to do with the person’s ability to judge risk and consequences. When someone is using substances in an addictive way, there is a change that happens in a specific part of the brain that makes their view of what is dangerous go down. So they don’t judge accurately what the consequence is for what they’re doing.
It’s not just something that they’re choosing to ignore. It’s that they legitimately can’t see the risk as being as high as we do. Perhaps the risk to us is a giant red flag, but to them is kind of a yellow flag. The further they are into it, that discrepancy grows even bigger. Addiction is not a choice. And here’s what I mean.
When someone chooses to use drugs or alcohol, they are not choosing to get addicted. They’re choosing to experience what the substance is like. That is a super normal human behavior. Humans use mood altering substances, period. Yes, of course there are folks who have abstained and have always abstained. It’s not the majority though.
In our cultures it is really normal to use a mood altering substance. It’s just not an everyday thing. It’s usually for special occasions of some kind. So a person who got addicted was using the substance just like everybody else. What they didn’t realize was that their body was changing because of it.
That they weren’t able to judge risk appropriately. That they thought that they were using just like everyone else, and that everyone else seemed to be doing okay. And so surely it must be okay for them too. Yes, there is a point at which choice makes a difference. Most people aren’t going to choose to use meth. Most people aren’t going to choose to use a lot of different drugs.
That person who chose to use those other drugs was experimenting. They weren’t trying to get addicted. They didn’t realize what kind of power that was gonna have over them. This doesn’t change responsibility though. The part that I try to make really clear is that just because I say addiction isn’t a choice, that doesn’t change that the person who was using, that the person who was addicted, is somehow not to blame for their choices or shouldn’t be held accountable.
As an addict in recovery, I am very clear about the choices that I made when I was using. I didn’t mean to get addicted. It wasn’t on purpose. It certainly wasn’t fun in the end. And I did some shitty things while I was using, as addicts and alcoholics tend to do. And in fact, people who are using problematically also tend to make a lot of choices that aren’t great.
I’m still responsible for the things that I did while I was using. Addicts and alcoholics with any kind of recovery will tell you the same thing; that they are a hundred percent responsible for the choices they made.
It’s the same thing when we make mistakes of any kind or we hurt people in any way. There may have been extenuating circumstances and we are still responsible for the things that we did. The addiction itself, though that’s a biological circumstance. The American Society of Addiction Medicine, as well as the American Medical Association, recognize that this is a biological illness.
It’s the pain that people go through as a result of an addict or an alcoholic in their life that makes people feel differently. There are a lot of people who have a lot of judgment on addicts and alcoholics because they look at their behavior and it seems so incredibly selfish and so incredibly self-destructive that they can’t imagine what would cause someone to act like that.
What I say to that is it must be something really powerful then. It could be that all of those folks are just terrible people.
Addiction is ugly. It is painful. It is destructive. By the time addiction sets in, substance use is no longer fun. It stopped being fun a really long time ago. It’s necessary at that point. Yeah, there may be some enjoyable times, but a person’s life is spent in how are they gonna get what they need and how are they going to deal with the come down after and get high again? That’s the cycle. There really isn’t this middle ground where you get to enjoy being high or drunk or whatever it is.
Because of the brain changes inherent in addiction, addiction is not beatable by willpower alone. I think that the research and simply logically thinking through it, we can see that willpower is not enough to counter addiction and isn’t going to be enough. It doesn’t matter how much somebody wants it, they have to have other things in place in order to overcome addiction.
So let’s talk about problematic use. So what I mean by problematic use is, , use of drugs or alcohol that falls outside the norm for a given culture and causes harm to the person or to the people around them in some way, shape or form.
We are talking about what is outside the norm that often can trip people up because what is normal in one area of a country or amongst one group of people group is gonna be really different among others. So for instance, where I live in Northwest Wisconsin, drinking alcohol is really common.
The level that is considered normal around here is much higher than I knew to be normal when I was growing up in Chicago land. Even though I know I grew up in a family that aired on the non-drinking side, I had plenty of friends whose families had alcohol regularly, but what they considered normal was also a lot less than what it is up here.
Part of that is just the culture. It is something that developed over time. We don’t, and we don’t totally know why. I’m sure there are lots of reasons, sociological and otherwise that contributed to that. I’m sure there are pockets of people up here that isn’t normal for them because of another factor. It could be religious in nature. There are a number of faith traditions that ban alcohol of any kind. And so for them, any alcohol use isn’t normal.
That can make it hard for us to talk about what is problematic, so to speak, because who defines what is normal. So in order to not derail the whole conversation, we’re gonna say that normal is what the CDC or the Center for Disease Control, or the NIH, which is the National Institute on Health, says is normal when it comes to alcohol consumption.
We don’t have standards for what is normal about marijuana use or meth or cocaine or whatever. So we have standards for alcohol and that’s about The only thing we can really quantify is what those two government agencies, at least in the US have decided is normal.
Based on the standards there, which without going into a ton of detail, one drink a day no more than seven per week for females and two drinks a day, no more than 14 per week for males. With the amount of alcohol that constitutes a drink being defined by them as well. That’s 12 ounces of beer, five ounces of wine, one and a half ounces of hard liquor counts as a drink.
That puts a number of people in this sort of gray area. Where they drink more than is quote, considered normal, but they’re not at a place where they’re meeting criteria for alcohol use disorders according to the DSM. They might meet criteria for a mild use disorder, but it depends because while tolerance might be present, withdrawal typically isn’t.
Certainly when we get into moderate or severe though, that is typically in the addiction range. People in this gray area. I would also put as potentially problematic use. It’s kind of a spectrum though, from just over normal to a little bit of misuse where we get further in and where it is problematic. And for each person, that’s gonna be really different.
So let’s pretend that we know what problematic is, that we have this definition, and I did do an episode on this about when alcohol use might be becoming problematic, and I’ll link that in the show notes as well. The question today is about whether or not will power is enough.
I think that the general population would say that yes, willpower is enough to curb substance use as long as someone isn’t addicted yet. I can understand why people would say that, and I think in some ways there is some truth because we don’t have the brain changes yet, which are completely out of that person’s control.
However, we don’t know where those begin and where they’re set in. We don’t have information yet about when those brain changes occur, so we can’t totally know that. But we can agree that this is a non addiction place that someone is using, that they’re using more than normal, and it’s starting to cause problems or consequences in a couple areas of life.
When we think about that, I still think it is simplistic to say that willpower should be enough. A similar question is, is willpower enough to overcome other bad habits? When I ask it like that, I think it’s harder for people to say yes. I think the logical answer is, well, it depends on what the habit is. What are we talking about here?
Usually what that has to do with is what the behavior is and how it impacts that person’s life. That usually determines for us how embedded this behavior is in somebody’s lifestyle. The more embedded, the harder it is and the less willpower is gonna matter. I do think that willpower is important.
I think that it does matter because we know from the literature on change that people have to be ready to change, that they have to be on board. Otherwise it’s not gonna work. And so that to me is evidence that willpower is important, and in that sense, I’m making willpower be the desire to change.
The perseverance to do so is dependent I think on other factors. It could be the amount that they’re changing relative to their community. Are they doing something that most of the community is gonna be on board with, or do they have to fight against the current? So for someone up where I live to choose to not drink for non-religious reasons, that sometimes gets met with a lot of pushback.
It is surprising to me how many people get shit for not wanting to drink. And for women it’s often, are you pregnant? Or are you doing it to make sure you don’t gain weight? And for men, it can even be about how manly they are if they don’t drink. And it seems to be one of the only substances that you have to defend your non-use of, or your limited use of..
So earlier when I talked about harm reduction, the idea behind it is that we are using strategies to help curb someone’s use so they’re not doing as much damage to themselves, their lives and their loved ones, and the people who come in contact with them. It’s not really willpower. It is strategies similar to the ones we use with addiction, of trying to help someone change their behavior.
There is a lot there that has to do with the stages of change and secondary gain. We can’t get into all of that today, otherwise, this would be a super long podcast. So later this week, I’m gonna republish the episode that I did on the stages of change, and then next week we’re gonna be talking about the role of secondary gain. I feel as though secondary gain is an incredibly important concept when it comes to understanding any behavior of anyone.
All of the things we talked about today, willpower, stages of change, harm reduction, abstinence, and secondary gain are a vital part of understanding our client’s substance use. This is part of the information that we’re gonna be working with in Charting the Course, which is the six week live taught program that I put together to give you the information that you need as a mental health therapist and a non-specialist to work with your client’s substance use.
Remember that the doors are open in the month of June and we start on July 11th. You can check out all the details and the frequently asked questions@betsybyler.com slash course.
If you have any questions about the program and you wanna talk with me, I would love to share emails or schedule a time for us to talk on a Zoom call. I am so excited for this cohort of charting the course.
I’ll be back next week with another episode. I hope you’ll join me for that podcast. And until then, have a great week.
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