Addiction is not a brain disease – and it matters

By Leith Hillard

To understand any unhealthy behaviour pattern that causes harm leading towards addiction, including gambling, ‘you must understand the internal emotional world. Feelings guide behaviour,’ according to eminent psychiatrist and psychotherapist Dr Eli Kotler. ‘They tell you if your needs are being met or not.’

Dr Kotler specialises in the underlying emotional and personality factors that predispose people to, and perpetuate, addictions. He is passionate about helping people with addictions achieve recovery through a greater understanding of their own psychology and personality.

In a presentation hosted by the Victorian Responsible Gambling Foundation, Dr Kotler took us through a potted history of 20th century thinking about the brain. He began in the 1950s with neurophysiologists Olds and Milner who sought to uncover the seat of emotions in the brain, and ‘discovered’ what they thought were the pleasure centres of the brain in rats, activated by positive reinforcement.

‘Behaviourism was all the rage in those days,’ said Dr Kotler of the theory of learning based on the idea that behaviours are picked up through conditioning.

‘ … addiction is primarily about the mind and subjective experience …’

By the late 1970s, Roy Wise had made significant findings on dopamine which led to a widespread view in the 1990s that addiction is all about dopamine or a reward hit in the brain’s pleasure centre. Dr Kotler noted, however, that dopamine is now understood as motivational or seeking, rather than a ‘pleasure’ circuit.

Dr Kotler then talked back to a pivotal 1997 paper by Alan I. Leshner that declared ‘addiction is a brain disease’.

Not so according to Dr Kotler. Such thinking ‘assumes that the mind IS the brain,’ he said, ‘but addiction is primarily about the mind and subjective experience, not the brain. Saying that addiction is a brain disease can also whitewash the social issues that may drive addiction. It dismisses the fact that a disease can be mental or psychic.

‘At the core of addiction is the human experience of suffering.’

‘By effectively removing the concept of subjective feelings from the domain of research, what began as a search for the seat of emotion in the brain ended in a brain-disease model of addiction.’

Dr Kotler believes that limiting the understanding of addiction to it being either a brain disease or a choice is a false dichotomy.

‘At the core of addiction is the human experience of suffering,’ he said.’

Dr Kotler also disputed the prevailing medical assumption that brain changes represent disease, leading to a disease model of addiction.

‘Perhaps those changes represent a learning or developmental process,’ he said, ‘which might include learning through trauma or through issues with attachment.’

‘ … what happens between the stimulus and the response … is the feeling.’

He cited Dr Marc Lewis, a neuroscientist who has written extensively about his own drug addiction, who also believes that addiction reflects natural learning processes.

‘You grow into addiction,’ Dr Lewis told the Guardian Australia in 2015. ‘It takes place in a sequence or a progression through repeated trials, through repeated exposure, repeated actions, and through practice.’

Dr Kotler is also a proponent of the views of neuroscientist Jaak Panksepp.

‘He points out that what happens between the stimulus and the response – whether gambling, drug taking or other harmful behaviours – is the feeling.

‘I am yet to meet a person with an addiction who is not escaping a difficult emotional experience.’

So what does this mean for Dr Kotler’s practice in treatment and patient recovery?

He works with patients through intensive therapeutic rehabilitation. The in-patient component can last four to six weeks but he generally encourages a year of regular intensive therapy in total.

‘Healthy changes can happen,’ he explained, ‘but people have to feel their feelings.

‘If addiction is an escape from an intolerable internal experience, then the intolerable experience must be faced. If human suffering lies at the heart of addiction, then we focus treatment on facing that suffering.’

‘Healthy changes can happen, but people have to feel their feelings.’

Dr Kotler sits with the person as they work through their childhood experiences and their current difficulties.

‘In my practice, the ability to sit with difficult experiences seems to make the difference.’

Patients are also encouraged to learn cognitive and behavioural strategies to push back against the harmful behaviours.

These strategies may be understood to start with seeking help. Tick: a person attending in-patient treatment has acknowledged they need help. Further strategies may be understanding their triggers; setting clear boundaries and sticking to them; and finding other sources of gratification and meaning.

While these are commonly accepted treatments for addictions, Dr Kotler stressed that they need to be performed in parallel with the internal, exploratory emotional work.

Dr Kotler is also a medical director at Malvern Private, a residential addiction and trauma hospital. He is part of the AFL Players’ Association referral network for addictions and an adjunct lecturer at Monash University, where he oversees medical students on addiction medicine rotation. He sits on the Victorian Medical Panels as an expert witness in historical abuse cases and is a member of the Victorian Responsible Gambling Foundation’s Clinical Advisory Group.