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.
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 disorder and post-traumatic stress disorder (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, I'd be out there lookin’ for him and I'd be goin’ out there getting’ high, too.
Many participants who described Punctuated Equilibrium
spoke of making deals with themselves, vows to quit that crumbled when mental illness or another comorbidity flared. Paige, a housewife in her fifties, spoke about her pattern of abuse and the bargaining process:
I had a blackout, don't remember, ended up in the hospital...then I got out of the hospital after three days and swore I would never drink again. And within two weeks I was having wine again. I told myself it was just wine, it couldn't do any damage. So, yeah. And it just spiraled down and I was very, very depressed and constantly hopeless...I have emotional triggers that are problematic.
Paige also described her addiction as a disease. For her, understanding alcoholism as a disease in need of treatment, just like her depression needed treatment, stripped away the moral judgment. She used the biological understanding of addiction as a helpful construct that “takes away guilt and shame processes that we go through and [that are] hard to carry that around and get into recovery.” Thinking of addiction as a natural condition to balance around a normal value, just like diabetics learn to monitor and adjust their blood glucose within normal limits, helped reduce for her the stigma of seeking treatment for addiction.
Chip, a mid-forties janitor, said, “I kinda think that mental illness is a part of my genes, you know. I didn't just pick that up randomly, and I sometimes smoke like right now, I'm a little depressed so I smoked to kind of balance it.” He did not consider his substance use to be a genetic trait, but he did think he had a biological problem, depression, that he could treat with cigarettes.
When speaking of “emotional triggers,” the transitions in and out of addictive behaviors were sometimes subtle. Natasha Dow Schüll describes the challenge of discerning successful addiction treatment for gambling addicts because the treatment programs available so much resembled the repetitive habits they sought to treat. How different was “the zone” of playing video poker, from the zone of going several times a week to small group therapy meetings, from the zone of filling out self-assessment forms in treatment? The rituals of gambling treatment were eerily similar to the rituals of video-gaming. To illustrate her theory of a “modulating self,” Schüll uses a reflection upon addiction from one of her interviewees, Rocky, “The idea I've been fiddling with—that certain behaviors balance out other behaviors in some complicated way—is an equilibrium concept. Being a chemist and a nuclear scientist, I have a feel for different kinds of equilibria” (Schüll 2006
Similarly, the demanding work of scrutinizing self-management processes among those who described the Punctuated Equilibrium
theme, such as the administration of a salving substance, a drug to fight cravings, the pursuit of meetings, counseling appointments, vigilance to avoid environments where the substance is offered, or intensive treatment to control the substance use, could provoke enough anxiety itself to trigger a relapse. To what extent did treatment provoke anxiety or emotional stress that could only be relieved by substance use, and then to what extent did substance use cause anxiety and stress that could only be relieved by going to treatment? For this subset of participants, in particular smokers, this dilemma was termed “the vicious cycle.” Jack, a 50-something salesman, said
I thought after treatment I could control my drinking, but as soon as I got out and I started drinking and I just was back in the same cycle again. . . I fought with that, the first time I went to treatment because I thought I didn't believe the whole thing that with alcoholism you can't control it. I didn't really buy into that. I thought a lot of people were using that as a crutch.
Triggers that were more easily discerned were negative circumstances, specific events in time that offset equilibrium. Whereas the plot and time narrative components of emotional states are not so easily discerned or recalled, these triggers, as concrete events, could be literally placed in one's history, allowing the addict to “move on” past that place. Jerry, an aircraft mechanic, described his unprecedented abuse of alcohol within the last year as a result of an unfortunate series of events:
This whole past [year] was nothing but a joke in my life ‘cause I lost my brother, two weeks after that, I worked for [company], they fired me...And then we lost the house to bankruptcy. My dad has health problems... I wanna be able to drink with my friends in a bar...use it as a recreational tool, not like it's been overpowering my life like it has been.
Jerry believed that there was a place, a context, for healthy use of the substance, and had confidence that he would be able to return to that state. Alcoholism, he thought, was an episodic anomaly created by circumstances, like a rude and unexpected episode of unbridled speciation to a stable ecosystem. Equilibrium would reestablish itself, with time. Alcohol use was not a part of his innate character, nor would it be something he had to constantly manage in the future. Jerry did not consider himself an alcoholic but someone who had experienced a bout of alcoholism as one might experience a bout of the flu.
Like a car coasting out of its lane, these participants described an awareness of addiction similar to drifting onto the warning track. After bumps and jostles, as Joe described in the encounter with his wife, he eventually straightened out and achieved equilibrium. The drifting and realigning, as Rocky might predict, would all balance out in the end following the law of conservation. What seemed most harrowing about this narrative type was the struggle to maintain self-awareness of where one was on the continuum of illness and treatment. Self evaluation could be as difficult as driving in fog.
Julia, a student in her twenties, described herself as a “chronic relapser” for whom social stress was the trigger for alcohol use.
I always felt out of place. I always felt like I didn't fit into my skin. I was so afraid of people and of the world and I had horrible social anxiety and all I ever really wanted was to like, be a part of something, to have friends and to be comfortable with people, and I couldn't do it sober. And when I had my first drink it was like, Wow, this is what I've been looking for all of my life!
In the context of Julia's “social anxiety,” (in which the very use of a pharmaceutical industry advertisement-constructed term bespeaks the influence the media has to deliver diagnoses that individuals can choose on their own to adopt and regulate (Dumit 2006
)) the use of alcohol seemed to level the playing field with her peers. She used alcohol as self-medication to regulate what seemed a more distressing disorder, social anxiety. She felt more equal terms with others when intoxicated. This might be considered, for some, nothing more than a cultural ritual, and a positive one at that, but Julia goes on to discuss why, for her, it was a problem:
I remember that there was a line that I crossed where I suddenly realized that I had to keep drinking even when everybody else was done until I blacked out or passed out. But, I remember thinking to myself, I am only happy if I have a drink in my hand.
For Julia, the warning track on the road was the line between being satisfied by the company of friends with whom she felt comfortable (a feeling enabled by the substance) and being satisfied by the comfort of the drink itself, with no regard for those in company.
The narrative of disequilibrium caused by a deficiency, whether it be comfort, interest, or love, has some overlap with Hanninen and Koski-Jannes’ Love Story, where addiction was a compensation or a substitute for a sense of emptiness, unfulfilled desire, or lack of love. Dawn mentioned that she felt like she had “no self control, no self worth, you know, and then so, when the drug is there and you go use the drug, it fulfills those empty, that emptiness.” The substance, then, is compensation for what is lacking. Its use is merely an attempt to realign or reestablish what is perceived to be better “balance” or fullness. As Joy deftly noted: “If I'm bored or lonely, or hungry, or tired, I found is when I smoke a lot. Then, I don't feel so lonely, I don't feel so sad, I don't feel so bored, and I don't feel as hungry.”
Punctuated Equilibrium narrators were keenly aware of their “fullness” status, and yet, they also had insight about when they were pushing the limits of healthy. The existence of guardrails like insight, self-awareness and concern, are strong evidence against the claim that addicts have “no control” over their substance use—that they are void of agency and powerless to addiction.