4:00 P.M.

November 20, 1997

A New Paradigm For Understanding
& Treating Addictive Disorders

by Durand F. Jacobs Ph.D.

Assembly Room, A. K. Smiley Public Library

Biography

·Diplomate in Clinical Psychology, American Board of Professional Psychology

·Chief, Psychology Service, Jerry L. Pettis Memorial veterans Hospital, Loma Linda, Calif. 1977-1990

·Professor of Psychiatry, Loma Linda University School of Medicine, Loma Linda, Calif.

·Clinical Professor, Fuller Graduate School of Psychology, Pasadena, Calif.

·President, California State Psychological Association, 1989

·Vice-President, National Council on Problem Gambling, 1995

·Charter member California Council on Compulsive Gambling; contributing editor to the Journal of Gambling Behavior.

·Dr. Jacobs has been involved in treatment, training of professionals, and research on addictive behaviors over the past thirty years. He was instrumental in establishing the first inpatient treatment program for compulsive gamblers in 1972.

He has reported his research on compulsive gambling and means for identifying and intervening high risk youth at national and international conferences and in a number of journals and books.

His work describing gambling among teenagers and the special vulnerability of children of parents who gamble excessively appeared as two chapters in Compulsive Gambling: Theory. Research and Practice (Lexington Press), edited by Howard Shaffer et al. This book is based on presentations made at the First Invitational Symposium on Compulsive Gambling, held June 3-4, 1988 at the Center for Addictive Studies, Harvard University Medical School ·Dr. Jacobs is a recipient of the Herman Goldman Foundation Award:

"In recognition of your dedication, support, and continuing research efforts highlighting the consequences of compulsive gambling on families and youth. "

·Recipient of award from Harvard University, Division of Addictions ( April 7, 1995) "For lifelong contributions to Youth Gambling"

A New Paradigm for Understanding
and Treating Addictive Behaviors

by Durand F. "Dewey" Jacobs, Ph.D.

At the present time, the understanding and treatment of "addictive" and "impulse disordered" behaviors is in a chaotic state. This continues to be so, despite ever increasing worldwide prevalence rates. Attempts to control this class of disorders have produced a litany of failures despite monumental expenditures by both public and private sectors.

There is great need for some overriding conceptional framework; namely, a credible and testable theory, supported by an empirically-derived data base, that clearly addresses the probable causes and course of addictive behaviors.

This in turn will lead to the development of new treatment strategies and methods directed to the amelioration of underlying causal factors, rather than focusing on abstinence alone.

The high relapse rates among graduates of today's addiction treatment and self-help programs should be telling us something.

When I first proposed and began testing a General Theory of Addictions in 1980 (using the compulsive gambler as the prototype subject) there had been little systematic searching for common denominators among various addictions that might argue for their being treated as a unified class of behavior (Jacobs & Wright 1980).

Indeed, as late as 1985, Milkman and Shaffer had concluded that: "At present, no single theory dominates clinical thinking in the field of addictive behaviors." Two years earlier, after completing an exhaustive six year meta-analysis, financed by the National Institute on Drug Abuse, Levison et al reported that: "In general, scientific knowledge does not at present provide the basis for a comprehensive theory of excessive, habitual behavior encompassing the available sociocultural, psychological and biological evidence" (page xvi).

Today's presentation titled, "A new paradigm for understanding and treating addictive disorders" will attempt to provide an overview of my work over the past seventeen years in developing and testing what I've termed: A General Theory of Addictions (Jacobs, 1980,1984).

According to the General Theory, two interacting sets of causal factors must be present that predisposed affected persons to pursue an addictive career. The first is an abnormal physiologic arousal state ( either hypertensive or hypotensive). The second is a set of childhood experiences that have produced a deep sense of personal inadequacy and rejection. All types of addictions are hypothesized to follow a similar three-stage course, (that is, Discovery, Resistance to Change, and Exhaustion).

According to the General Theory, a common. dissociative-take state is expected to prevail among different types of addicts while they are indulging in their respective addictive patterns of behavior. The extent of this dissociative-like state will significantly differentiate them from normative samples of youth and adults who have indulged in the same activities and substances.

The strategy selected for testing the general theory was a matrix approach. Extensive comparable information was collected and analyzed involving a sample of over 400 compulsive (pathological) gamblers, alcoholics, and compulsive overeaters. (Jacobs, Marston & Singer 1985). The matrix design also included data from an normative sample of over 1,000 adolescents and adults who had responded to the same basic Health Survey instrument (Jacobs, 1982). To the best of my knowledge this approach was the first in which information regarding similar indices had been collected and systematically compared across several different types of addicts, as well as normative samples.

The applied goals of this research were " (1) to construct descriptive models that will provide a better understanding the addictive process; (2) to use this information to improve treatment methods, (3) to facilitate early identification and prompt intervention for juveniles and adults at high risk for developing addictive patterns of behavior, and (4) to guide primary preventive strategies.

From the onset, my aim was to construct a conceptual model that would encourage researchers and clinicians to focus on the similarities among addicts who exhibited involvements with very different substances and activities in order to distill out what may be the essence of addictive behaviors.

To this end l have proposed that any and all addictions be defined as: "A dependent state acquired over time by a predisposed person in an attempt to relieve a chronic stress condition."

My approach highlights the primary role of stress as the trigger for initiating and maintaining an addictive behavior pattern. This view departs radically from other definitions of addiction.

For instance, the Standard Medical Dictionary (Dorland 1974) had defined addiction as "a state of being given up to some habit, especially strong dependence on a drug." In the context of this definition four criteria are listed as being characteristic of an addictive state: "1) an overwhelming desire or need (compulsion) to continue use of the drug and to obtain it by any means; 2) a tendency to increase the dosage, 3) a psychological and usually a physical dependence on its effects; 4) a detrimental effect on the individual and on society."

In 1977 Peele proposed redefining the historical, biologically-rooted term "addiction" so it may be dealt with in a much broader and socially relevant manner. He proposed (1979) that "an addiction exists when a person's attachment to a sensation, an object, or another person is such as to lessen his appreciation and ability to deal with other things in his environment, or in himself, so that he has become increasingly dependent on that experience as his only source of gratification" (p. 56).

In an article on alcohol addictions, Cummings (1979) makes the point that "addiction is not merely popping something into one's mouth, but is a constellation of behaviors that constitute a way of life" (pp. 1121-1122). Compulsive gambling has been referred to as the "purest addiction," because no external substance is introduced into the biological system (Custer et al. 1975).

My approach to addiction tends to espouse the breadth of Peele's approach, the specificity of criteria listed in the medical model (but without anchoring the concept to drugs alone), and Cummings' observation that over an extended period of time addictive behavior comes to dominate one's way of life.

Addictive patterns of behavior may involve substances such as food, alcohol, other licit and illicit drugs, as well as activities such as, but not limited to, gambling, overeating,

sex, firesetting, overspending, and overwork. An aspect stressed by Jacobs that has been given far less emphasis in other treatises on addiction is the function of virtually any addictive pattern of behavior as a learned defense against enduring present or anticipated physical and psychic pain.

Recall that Jacobs (1980, 1982) has deemed addiction as "a dependent state acquired over an extended period of time by predisposed person in an attempt to correct a chronic stress condition."

Viewed in this light, addictive patterns of behavior may be conceptualized as a form of self-management and self-treatment. This perspective offers some advantages to clinicians when engaging addicts in treatment. While recognizing the influence of predisposing physiologic and psychologic factors, (over which they had little control initially), it now holds the patient responsible for acquiring or strengthening more adaptive alternatives that will replace the former maladaptive and damaging efforts the patient had been making to cope with the perceived stress condition.

At this point it is useful to consider at greater length the two coexisting and interacting predisposing factors that are held to potentiate and maintain an addictive pattern of behavior. Physiological Predisposition

First, there is an abnormal a physiological arousal ~'e' that is perceived as chronically hypotensive or hypertensive. The literature has referred to a minority of persons at either extreme of the normally distributed range of resting arousal levels as "reducer" or "augmenter" types (Petrie 1967,1978; Ogborne 1974). Either of these extreme arousal states is held to be aversive (Petrie 197X). Consequently, one would expect that those at either pole would be predisposed to seek and engage in activities that would make them feel better.

Petrie (1978) offers a persuasive array of evidence from perceptual, kinesthetic, and neurophysiological experiments with normal and clinical populations to support her contention that because of their constitutional makeup, persons found to be at the extreme ends of the "perceptual reactance" spectrum tend to manifest very different forms of social behavior. Subjectively, the ''reducer'' l hypotensive type) tends to decrease the intensity of what is perceived. At the other extreme the "augmenter" (hypertensive type) tends to increase the intensity of whatever stimuli are received from his internal and external environment. While not concerned with the matter of addictions, per se, Petrie did report that alcoholics (found earlier to be hypertensive augmenter types) were "particularly susceptible to a pronounced change toward the reducing end of the spectrum after (consuming alcohol)" (p. 38).

At the other extreme of the physiological arousal spectrum, Petrie (1978) reports that juvenile delinquents were significantly more pronounced reducers (i.e. hypotensive types) than control subjects. Petrie related these findings to complaints of delinquents that they suffered from chronic boredom, monotony, isolation, and enforced inactivity. A delinquent girl was said to justify her association with peers who had run afoul of the law by explaining she "hung around with those kids because they were always doing something. Regular people don't do nothing" (p. 87). Like Petrie (1978), Gorsuch & Butler (1976) also view extreme arousal states as strong motivators for social behavior.

The clinical histories of compulsive gamblers are replete with themes similar to those recounted by Petrie's young delinquents, plus reports of the unexcelled pleasure ("high") of sustained "action" afforded by gambling and gambling-related activities. In Jacobs' theoretical framework most problem gamblers would be expected to fall within the hypotensive (reducer) category, consistent with their frequent reports of feeling bored, numb, dead inside, and finding life dull and empty, except when gambling. "For them, the excitement of gambling replaces their depression or boredom with exhilaration and a feeling of being "acutely alive," (Jacobs 1984, 120)

From Germany, Meyer (1987) argues that the "actual aim of dependent (i.e. addicted) people is an immediate change in their emotional state toward an intensified wellbeing; (either) a satisfaction or euphoria, or a complete turn-off from the outside world (p. 102). Based on his research, and consistent with Jacobs' earlier findings, he described gambling as a "release mechanism which facilitates an increase in physiological arousal levels" (p. 102).

Not all reducers and enhancers are prone to acquiring an addiction, according to Jacobs" theory. The persistence of what is subjectively perceived as an aversive physiological arousal state is only one of the two necessary predisposing conditions for developing an addiction.

Psychosocial Predisposition The second precondition that theoretically must exist before the stage is fully set for acquiring an addictive pattern of behavior is a childhood and adolescence Sparked by deep feelings of inadequate, inferiority, guilt, shame' anger, low self esteem, and a pervasive sense of rejection by parents anal signify cant others. Typically, such reactions emerge as a result of severe psychological, physical or sexual trauma.

Such feelings would be expected to stimulate behaviors and activities that would produce relief from this severe psychological distress. Several alternatives would be available to persons in such unhappy and frustrating circumstances. First, these might include responding adaptively by increasing efforts that would gain recognition and acceptance. A second reaction would be to retaliate with angry and aggressive acting-out behavior of a delinquent or antisocial type.

A third much less frequent reaction to feeling inferior and rejected would be to pretend not to care and to conceptually leave the offending field through escape into wishfulfilling fantasies wherein one is successful, powerful, loved, and admired.

The General Theory predicts that persons with a chronically abnormal arousal state who also tend to respond to feelings of inferiority and rejection by flight into denial and compensatory fantasy are at the highest risk for acquiring an addictive pattern of behavior.

However, Jacobs cautions that both sets of predisposing factors must coexist and be exercising their respective effects before an individual will maintain an addictive pattern of behavior in a conducive environment. Viewed in this light, only a limited segment of the population need be considered at risk for any given addiction. Moreover, even persons in this group may remain latent, unless and until they encounter a chance, relief producing event in their daily lives that is of sufficient clarity, novelty, and intensity to motivate them to deliberately arrange future experiences of this type. This triggers the initial Discover Stage of the addictive process. Addicts frequently recall the impact of this discovery in terms of "Oh Wow! Where has this been all my life?" (See Figure 2-1).

Given these interacting predisposing conditions in n con~lucive environment, Jacobs' theoretical position is that, whatever the potentially addictive substance or activity encountered, its continued use into a frank addictive pattern of behavior will depend largely on its continuing to possess the following three attributes: 1. It Blurs Reality Testing. Specifically, one's attention is temporarily diverted from the chronic aversive arousal state. This may occur as a result of the physiologic affects of an ingested substance and/or by the manner in which an activity (such as gambling, sex or work) so completely concentrates one's attention on a series of specific here-and-now events that coexisting aversive aspects of one's physical' mental and/or social life situation are "blurred out" (also see Goffman 1961; Sullivan 1956; Hilgard 1997; Sanders 1986). The resulting "distancing of awareness" from a painful reality is evidence for an altered sense of consciousness. 2. If Louvers Self-Criticism and Self-consciousness. This is accomplished through an internal cognitive shift that deflects painful preoccupation from one's self-perceived inadequacies (Sanders 1986). Often this is reinforced by the special circumstances that prevail where the addict chooses to pursue (and thereby disguise) the addictive pattern of behavior. . . such as with peers in a bar, in a gambling casino, a restaurant or when partying. Each of these environs tends to accord acceptance, even encouragement, to behaviors that would be frowned upon or rejected in other company or in other settings. Addicts frequently describe this process as "turning off the negative tapes in my head".

3. It Permits Complimentary Daydreams about Oneself; These wish-fulfilling fantasies which surface as a natural aftermath of (1) and (2) serve to facilitate the assuming of an altered identity.

Whether the addictive pattern of behavior is practiced in solitary or in social settings, as the number and intensity of these three attributes increase, so does the likelihood that the person will actually "cross over" into a frank dissociative-like state. Measures designed to tap this dissociative-like state may well provide key pathognomic "hard signs" that will differentiate potential and actual addicts from those who indulge in an abusive manner. Jacobs has proposed (1984, 121) that it is the intent to achieve and act out an altered state of identity that distinguishes the "true addict" from the superficially similar excesses of the abuser. Abusers seek only to reduce situational stress, while retaining their usual identity and continuing in their established social and occupational roles.

One major difference emerging from the author's theory that distinguishes it from those advanced by others is the author's conclusion that a given addictive behavior can occur only in a relatively small proportion of the population. These persons must be predisposed both biologically and psychologically before certain experiences can acquire addictive qualities for them. This theory emphasizes the fact that repeated, intense or prolonged use or abuse of a substance or behavioral pattern does not of itself produce an addictive pattern of behavior.

A dramatic illustration of this point was the tens of thousands of military personnel whose urine tests confirmed heavy use of heroin and other drugs while in the Vietnam. It was anticipated that, upon their return, the nation would be faced with a massive drug treatment and rehabilitation problem. It is a matter of record that this did not materialize. Upon their return to the United States the overwhelming majority of these veterans abruptly ceased their use of these substances, with few reports of withdrawal problems and with no evidence of resumption. (Robins, David and Nurco, 1974).

This massive unexpected test of the historical conviction that addiction is a direct function of continued and excessive use should have sparked a major reexamination and revision of prevailing concepts and theories regarding the causes and course of alleged addictive behavior. Unfortunately, this was not the case. Not only have time-honored theories about drug addiction persisted, but use of other substances such as foods, and other activities such as compulsive gambling, have been prodded to fit into the faulted model.

The Central Importance of an Altered Estate of identity for Understanding Addictive Behavior

In the context of the General Theory of addictions use of an addictive substance or activity is conceptualized as a "vehicle" that is chosen to carry the individual away from a painful reality. At least during the early and middle stages of the addictive career, it serves a friendly transport function. At a certain level of indulgence (either physiologically, neurochemically, psychologically, and/or via some as-yet unknown combination of these mediators) it carries the person to a point where he becomes so detached from reality, so freed from negative ruminations, and so engrossed in subjective fantasy that he or she experiences an altered state of consciousness, which includes a more desirable altered state of identity. This altered state of identity constitutes the end goal of a self- induced dissociative process.

For some addicts the sought after altered state is oblivion: the total elimination of one's identity in order to blot out all the painful things associated with being who they are. Other individuals in this altered state find it easy to create and act out roles consistent with their idealized self-images.

Those who have experienced this altered state of identity report believing they somehow become "more so" with regard to positive features of their personality, physical appearance, social graces, sexuality, and/or competent functioning. Concurrently, they feel "less so" about what they had perceived as their negative or deficient features. This improvement in subjectively perceived psychological well-being also is said to be accompanied by reduced awareness of previous physical pain or limitations. While individual reports vary, aspects of this same mix of experiences are said to occur whether the addictive behavior is practiced under social or solitary conditions. A closely-held secret shared among many different kinds of addicts was that "when it was working," their addiction was the best friend they'd ever had!

Therefore, I have concluded that the addict's pursuit and over indulgence in alcohol, other drugs, food, gambling, sex, over work or whatever is not the addicts problem.

On the contrary, a person's addictive pattern of behavior represents that person's best SOLUTION to the stresses generated by their long-standing underlying problems.

An addictive pattern of behavior provides a desperately-sought avenue of escape from an aversive state of both physiological and psychological distress.

Moreover, for the addict it provides a means for creating a more rewarding state of consciousness: either oblivion, or a self designed altered state of identity.

From the perspective of learning theory, one gains further insight into how the process of developing and maintaining an addictive pattern of behavior is so extremely restrictive to change:

·First, the behavior is doubly reinforced. Added to the reward of escaping from a painful reality, is the attainment of a far more pleasurable state of consciousness.

·Secondly, as the method becomes one's "magic button" for escaping from stress, the addicted person tends to disregard and reject other forms of coping with stress.

This combination of heavy and repeated reinforcement, coupled with a progressively reduced repertoire of alternative stress-reducing skills produces the addict's extreme resistiveness to change . . . much to the chagrin of pleading family members, frustrated employers, demanding correction personnel, and discouraged health professionals.

My research and clinical experience have convinced me that one deliberately learns to become an addict. The popular concept of a person getting involuntarily "hooked" by a substance or activity flies in the face of reason.

This is why I chose to define addiction as "a dependent state acquired over an extended period of time by a predisposed person in an attempt to relieve a chronic stress condition."

I have found that a more rational and productive approach is to consider a person's addictive pattern of behavior as a conscious, deliberate, selective, ego-syntonic, problem-solving attempt acquire and maintain (at whatever cost) a highly preferred set of stress management behaviors.

I believe that this way of conceptualizing the basic nature of addictions opens new and promising opportunities for public education, intervention, treatment and prevention.

Jacobs' theory does not propose that the addicts altered state of identity is a form of multiple personality or a full-blown fugue state. This would be an erroneous and oversimplified interpretation of what I believe is happening. However, after discovering that addicts become engrossed in a dissociative-like state as a necessary step toward assuming an altered identity, one confronts a set of conditions that has not been fully explored in the past. These phenomena are expected to lie on a continuum somewhere between the clinically extreme dissociative reactions of the classic fugue state or multiple personality and the more familiar dissociative occurrences in everyday life wherein persons find themselves in such a pleasant state of reverie that they temporarily absent themselves from the facts of their usual reality.

Goffman (1961) speaks eloquently about the more familiar portion of this middle ground: When an individual becomes engaged in an activity, whether shared or not, it is possible for him to become so engrossed in it that there is an effortless dissociation from all other events."

"Under such circumstances, persons can be so engrossed in an encounter that it is practically impossible to distract their attention; in such cases they can hardly feel ill at ease. Since we have this capacity to become engrossed, how is it we do not more often use it to avoid dysphoria?" (page 43).

For purposes of testing this central feature of the General Theory, evidence for experiencing a "dissociative-like state" was operationally defined as a subject responding affirmatively to the following four questions about his or her subjective experiences during, or immediately following, a period of indulgence (Jacobs 1980, 1982). The first question reflected a blurring of reality testing: After (activity noted) "have you ever felt like you had been in a trance?" The second question measured a shift In person: "Did you ever feel like you had taken on another identity?" The third question was designed to capture an out-of body experience: "Have you ever felt like you were outside yourself--- watching yourself (doing it)?" The fourth question inquired about the presence of amnesia: "Have you ever experienced a "memory blackout" for a period when you had been doing the given activity?" When responding to these questions, the subject must stipulate: "never'', "rarely", "occasionally," "frequently," or "all the time".

RESULTS

As predicted, moderate to high frequencies of each type of dissociative-like experience were reported by each addict group. Compulsive gamblers and alcoholics consistently reported a higher incidence of these reactions than did compulsive overeaters (p < .01). However each of the three addict groups reported significantly more (p <.001) dissociative-like reactions on each indicator that did normative groups.

These findings support Jacobs' central theoretical position that, when indulging, persons known to be addicted to different substances or activities will tend to share a common set of dissociative experiences that differentiate them from nonaddicts. This is described as "a state of altered identity." Theoretically, this end state is held to be the ultimate goal of all forms of addictive behaviors, regardless of the diverse means used to attain it.

Conclusions

One may confidently conclude from these findings that addicts of markedly disparate types share a common set of dissociative-like experience, when indulging, that clearly sets them apart from normal groups of adolescents and adults who also indulge in the same types of substances or activities.

Further research undoubtedly will explore the prevalence of dissociative-like reactions among still other types of addicts.

Meanwhile, the type and extent of dissociative-like experiences that a person associates with a given form of indulgence may serve as clinical "hard signs" for early identification of high-risk adolescents and adults before they become enmeshed in an addictive pattern of behavior.

The ultimate goal of the author's entire program of research is to augment and encourage systematization of the knowledge base about addictions, so that one day timely interventions can be designed to prevent them.

References

Jacobs, D. F., & Wright, E T. 1980. A program of research on the causes and treatment of addictive behaviors: Using the compulsive gambler as the prototype subject. Loma Linda, California: Veterans Administration Hospital. Unpublished.

Jacobs, D. F. 1982a. Factors alleged as predisposing to compulsive gambling. Paper presented at the Annual Convention of the American Psychological Association, Washington, D.C.

Jacobs, D. F. 1982 The Addictive Personality Syndrome (APS): A new theoretical model for understanding end beating addictions. In W. R. Eadington (ed.) The Gambling Papers: Proceedings of the Fifth National Conference on Gambling and Risk Taking. Reno, Nevada; University of Nevada.

Jacobs, D. F. 1984. Study of traits leading to compulsive gambling. In Sharing Recovery Through Gamblers Anonymous. Los Angeles, California: Gamblers Anonymous Publishing, Inc.

Jacobs, D. F., Marston, A. R. & Singer, R. D. 1985. Testing a general theory of addictions. Similarities and differences between alcoholics, pathological gamblers and compulsive overeaters. In J. J. Sanchez-Soza (ed.) Health and Clinical Psychology. Amsterdam, The Netherlands: Elsevier Science Publishers B.V.

Jacobs, D. F. 1980. Holistic strategies in the management of chronic pain. In F. McQulgan, et al. (eds.) Stress and Tension Control. New York; Plenum.

Jacobs, D. F. 1986. A general theory of addictions: A new theoretical model. Journal of Gambling Behavior, 2, 2, 15-31.

Jacobs, D. F. 1989. A General Theory of Addictions: Rational for and Evidence supporting a New Approach for Understanding and Treating Addictive Behaviors. In H. Shaffer et al (eds.) Compulsive Gambling: Theory. Research. and Practice. Chapter 2 (35-64) D. C. Health and Company; Lexington, Mass.

APPENDIX

An Overarching Theory of Addiction: A New Paradigm for Understanding and Treating Addictive Behaviors by Durand F. Jacobs, PhD. ABPP. Clinical Professor, Lorna Linda University Medical School, California. Presented at the national Academy of Sciences, Washington D.C. on September 3, 1998

At the present time, the understanding and treatment of "addictive" and "impulse disordered" behaviors is itself in a disordered state. Attempts to treat or ameliorate this class of disorders have produced a litany of disappointing results . . . despite monumental expenditures by both public and private sectors—and great, yet immeasurable, social costs to tens of millions of addicts and their families and associates in the broader society.

To bring more order, and hopefully more success to our collective efforts, there has been a great need for some overriding conceptional framework; namely, a credible a.nd testable theory, supported by an empirically-derived data base that clearly addresses the probable causes and course of addictive behaviors.

This in turn will lead to the development of new treatment strategies directed to the amelioration of underlying causal factors rather than attempting to maintain abstinence alone. The high relapse rates among graduates of today's addiction treatment and self-help programs should be telling us something.

In answer to the concerns noted above, in 1980 I formulated a General Theory of Addictions, looking for commonalities across different addictions, and using the pathological gambler as the prototype subject.

To guide the series of investigations that followed, I defined addiction as "a dependent state acquired over time by a predisposed person in an attempt to relieve a chronic stress condition"

Two interacting sets of factors are held to predispose persons to addictions. These are:

I. An abnormal physiological arousal state, either hypotensive or hypertensive. (For the abnormally hypotensive person, incoming stimuli from both internal and external sources are muted and reduced in intensity, causing this person to feel chronically bored and empty inside. For the abnormally hypertensive person, the reverse is true. Incoming stimuli from both internal and external sources are increased and augmented in intensity causing this person to feel chronically tensed and over- mobilized.) Childhood experiences that have produced a deep sense of personal inadequacy and rejection. Given these two interacting, predisposing conditions in a conducive environment, Jacobs' theoretical position is that, whatever the potentially addictive substance or activity discovered, its continued use into a frank addictive pattern of behavior will depend largely on its possessing the following three attributes:

1) It Blurs Reality Testing Functionally, the person's attention is temporarily diverted from the chronic aversive arousal state. This may occur as a result ofthephysiologic effects of an ingested substance, or by the manna in which an activity (such as gambling) so completely concentrates one's attention on a series of specific here-and-now events that coexisting aversive aspects of one's physical, mental and/or social life situation are "blurred out". In either case, an altered state of consciousness is produced. 2) It Lowers Self-Criticism and Self-Consciousness. This is accomplished through an internal cognitive shin that deflects preoccupation from one's self-perceived inadequacies, i.e. turns off the negative tapes in one's head (e.g. "You're no good", "Can't you ever do it right", etc.) 3) It Permits Complimentary Daydreams About Oneself. These wish fulfilling fantasies, which surface as a natural aftermath of(l) and (2) above, serve to enhance the altered state of consciousness, and often facilitate the assuming of an altered sense of identity, wherein, while indulging in the chosen potentially addictive behavior, one perceives his or her self-image as greatly enhanced and his or her related social interactions and performance as highly successful. For instance, a rather short, unattractive woman I treated for her gambling problem reported that while she stood at the craps table in a casino, she got taller and her face changed to resemble that of her beautiful aunt. For some addicts, the sought after altered state is oblivion These altered states of consciousness are obtained by a self-induced dissociative process.

We're all familiar with dissociation. From my perspective, dissociation can be defined as "a normal, sometimes automatic, sometimes deliberate we all use against distractions in everyday life. We also use dissociation as a defense when high levels of psychological distress, physical pain, or a sense of helplessness caused by a traumatic incident or a continuing aversive condition overwhelms a person's resources for coping with the stress it engenders."

Functionally, dissociation permits a psychological escape from the offending reality circumstance when other means for escape are blocked or unavailable. Thus, dissociation is used as a method for problem-solving.

The General Theory holds that a given individual's addictive pattern of behavior represents that person's deliberately-chosen means (i.e. vehicle) for entering and maintaining a dissociative-like state while indulging.

For purposes of testing this central feature of the General Theory, evidence for experiencing "a dissociative-like state" was operationally defined as a person responding affirmatively to each of he following four questions about his or her subjective experiences during or immediately following a period of indulgence. The first question reflected a blurring of reality testing: "After (activity noted) have you ever felt like you had been in a trance? The second question measured a ship "Did you ever feel like you had taken on another identity' The third question was designed to capture an out-of-body experience: 'have you ever felt like you were outside your body searching yourself(doing it). The fourth question inquired about the presence of amnesia: "Have you ever experienced a 'memory blackout' for a period when you had been (doing the given activity) Men responding to each of these questions, the person must stipulate "never", "rarely", "occasionally", "frequently", or "all the time".

Afer finding support for these propositions in an exploratory study of compulsive gamblers, a matrix design was applied to collect similar information from 407 very different kinds of addicts and a normative sample of over 1,000 adults and adolescents.

As predicted by the General Theory, a common and pervasive dissociative-like state was found to prevail among adult compulsive gamblers, alcoholics and compulsive overeaters, while indulging in their respective addictive behaviors. This significantly differentiated them from normative samples of youth and adults who also indulged in the same activities and substances.

Jacobs has defined addiction as a "dependent state acquired over time by a predisposed person in an attempt to relieve a chronic stress condition". Viewed in this light, addictive patterns of behavior may be conceptualized as a form of self-management of self-treatment. This perspective offers some advantages when engaging addicts in treatment. While recognizing the influence of predisposing and driving physiologic and psychological factors over which they had little control initially, the therapist now holds the patient responsible for acquiring, or strengthening, more adaptive alternatives to replace the maladaptive and damaging efforts currently being made to cope with the perceived stress condition.

In representing a new paradigm for understanding addictions, the General Theory conceptualizes an addictive pattern of behavior as a desperately-sought attempt to escape from an aversive internal state of both physiological and psychological distress. Moreover, addicts use their substance or activity "vehicle" for transporting them to a more rewarding state of consciousness -- either oblivion or a fantasized altered state of identity.

In this context it appears that the addict's pursuit and over-indulgence in gambling, alcohol other drugs, food, sex or overwork is not the addict's "problem" On the contrary, a person's addictive pattern of behavior represents that person's best solution to the stresses generated by their long-standing underlying problems.

Last year a team of researchers at McGill University (led by Rina Gupta) designed an extensive study to formally test Jacobs' General Theory of Addictions. The study incorporated 817 adolescents, aged 12 17 years. After analyzing their results, they state, "Strong support for the applicability of Jacobs' General Theory of Addictions for adolescent gamblers was obtained. Sixty-five adolescents classified as problem and pathological gamblers (based on their DSM IV J scores) were found to have exhibited evidence of abnormal physiological resting states, showed evidence of greater emotional distress, reported greater levels of dissociation, and reported higher rates of comorbidity with other addictive behaviors than did their peers.

A path analysis testing a model adapted from the General Theory of Addictions was found to fit the data, providing impressive validation of the theory. The model tested shows a strong path from both the physiological and emotional predisposition to a deliberate need to escape (through dissociation) into increased involvement with gambling.

The statistical results of the path analysis also indicate that the model fits the data very well. All the variables together explain 95% of the variance in the model. The total coefficient of determination for the latent variables is .75, indicating they account for 75% of the variance. The measured variables were found to account for 98% of the total variance.

Thus, gambling severity was empirically found to be caused by the need to escape, or dissociate, which is filled by aversive physiological and emotional states. Gambling, therefore, according to the model and Jacobs' theory, is a solution, or coping response (albeit a negative one) to aversive life conditions."

They conclude, "We are now one step closer to understanding the etiology of gambling dependency in adolescents. It is hoped that others will continue to test Jacobs' theory, with use of different addictions and with different populations. Further validation of the theory will sense provide addictions research with still more tangible and reliable experimental evidence of a General Theory of Addictions, and make an important theoretical and clinical contribution" (Gupta, R. ~ Derevensky, J.L., 1997).

Therefore, when considering treatment, I believe a more rational and productive approach is to confront (cautious and gently) the patient's addictive pattern of behavior as a learned response. It represents a deliberate, selecting, ego-syntonic, problem-solving attempt to acquit e and maintain (at whatever cost) a highly preferred set of stress management techniques.

Evidence gained from over a decade of testing Jacobs, General Theory of Addictions has consistently supported this new paradigm for understanding the etiology and course of addictive behaviors (including pathological gambling). This work also offers a robust alternative approach to treatment of addicts.

This "multi-modal" approach to treatment that I recommend integrates a mix of stress management applications (to avoid relapse and to divert physiological needs for novelty and excitation into constructive activities); therapeutic counseling techniques (to address and mitigate underlying problems), and targeted coping skill training (to facilitate community adjustment).

In my clinical practice, I have found that this approach, individualized to each patient's circumstances, and coupled with supportive family intervention, has shown promise in the treatment of pathological gamblers.

The stage is now set for a series of investigations by independent researchers and clinicians to critically evaluate the efficacy of this first, theory-driven model for treatment of pathological gamblers and other addict groups.

Should any of you decide to pursue this challenge, I wish you well.

References

Brown, I. (1996). The role of dissociative experiences in problem gambling. Paper presented at Second European Conference on Gambling and Policy Issues. Amsterdam September.

Derevensky, J. L. ~ Gupta, R. (1996). Risk taking and gambling behavior among adolescents: An empirical investigation. Paper presented at Tenth National Conference on Gambling Behavior, Chicago, IL.

Gupta,R. & Derevensky, J.L. (1997). An empirical examination of Jacobs' general theory of addictions: Do adolescent gamblers fit the theory? Paper presented at the annual meeting of the National Conference on Compulsive Gambling, New Orleans. August.

Hardoon, K. et al. (1997). Dissociative-like experiences among social and problem gamblers. Paper presented at Annual Convention of the American Psychological Association, Chicago, IL.

Jacobs, D. F. (1998). A theory-driven multi-modal approach to treatment of adolescent gamblers. Paper in preparation.

Jacobs, D.F. (1989). A general theory of addictions: Rationale and evidence supporting a new approach for understanding and treating addictive behaviors. In H. Shifter et all (eds) Compulsive Gambling: Theory Research And Practice. Lexington Books, MA.

Kuley, N.B. & Jacobs, D.F. (1988). The relationship between dissociative-like experiences and sensation seeking among social and problem gamblers. Journal of Gambling Behavior 4 (3).