Reading · Rat Park with Carl Erik Fisher

I recently went to Nantes, France, for a major conference on behavioral addictions. In the spirit of using this space for sharing work-in-progress and thinking out loud, here are some field notes, along with preliminary conclusions and practical implications for how we think about addiction today

I was mostly there for book research, coming in as a relative outsider trying to get a read on the most pressing questions: What do we really know? What are we getting wrong? What are the biggest debates? In practice, this looks like putting myself in the path of serendipity, eavesdropping, reading between the lines, watching for arguments, feeling out where the major divisions and disputes are.

What struck me was two very different conferences seemed to be happening under the same roof.

In one set of rooms, speakers talked about addictions as established “things,” as if workaholism, exercise addiction, or “social network use disorder” were already accepted conditions neatly separate from healthy normality, just waiting for official recognition in diagnostic manuals.

In other rooms, people were asking more fundamental questions: What actually qualifies something as a disorder? Does our traditional addiction model even fit these behaviors?

People in both camps were committed, passionate, and seemed to be helping people—even the overconfident therapists who were absolutely convinced that new approach had cracked the code. They were just starting from fundamentally different assumptions—and this became very clear when they started taking rhetorical shots at one another! From the outside, I could see these debates echoing a deeper question that runs through the whole addiction field: are addictions discrete diseases people “have,” or more like processes that take shape in various ways?

How we approach this question is absolutely central—it shapes who gets help, how, and when.

Let me focus on one of the major objections that I think has real teeth. There’s a common approach in behavioral addiction research that I'll call the "recycle-an-entity" approach.1 It takes the diagnostic criteria from substance use disorder and applies them directly to behaviors like gaming, social media use, food, sex, or exercise.

Under this approach, addiction to behaviors looks just like substance addiction; e.g., needing more time online equals tolerance, distress when offline equals withdrawal, and so on.

You may already see the problems here. When every ultramarathoner experiences something like "tolerance" and "withdrawal," does everyone with that hobby have exercise addiction—or no one? For gaming enthusiasts, social media users, or any other pursuit, where's the line between passion and pathology?

Critics within the behavioral addiction community put forward research to argue that these lists of symptoms wind up measuring things that don’t matter. When you drill down into the specific symptom-related data, hours spent gaming don't correlate well with actual distress or life problems. "Tolerance" is a real stretch for many behaviors that don’t have the physiological effects of substances. “Salience”—being preoccupied with your next gaming session is normal for enthusiastic players, including those without a problem.

I see a deeper problem too. The “recycle-an-entity” approach recycles a view of addiction that’s shaky to begin with—one that treats addiction as a fixed status caused by bad drugs that hijack the brain. I’ve written a lot on the problems of this view, including my book, so I won’t belabor the point. Suffice to say, we shouldn’t assume our current understanding of substance addiction is solid enough to copy wholesale.

Some of the behavioral addictions critics, such as Joël Billieux and his lab, call the “recycle-an-entity” approach the “confirmatory model” because it seeks to validate new addictions through mere resemblance to old ones.2 Researchers rephrase symptoms for a new behavior, create surveys and studies, and research proceeds from there without looking closely at the fundamental assumptions. This approach often skips the step of asking whether there’s actual clinical distress or real-life problems behind the symptoms.3 The result is a list of symptoms rather than a meaningful description of suffering, leading to potential overdiagnosis and general confusion.

And yet, at a certain level, this approach makes sense! There really are people who feel they suffer from behavioral addictions, just like traditional ones. It gives people an explanatory framework for understanding their pain. How to make sense of this discrepancy?

Pain was the constant theme throughout the conference. The “recycle-an-entity” people are trying to create tools for dealing with pain. The critics are largely arguing that the field is missing the pain that actually matters.

As I mingled at the coffee breaks, eating too many French mini-pastries, I was struck by how many clinicians from around the world were being pulled into creating “tech addiction” programs. These weren’t evangelists or profiteers. Often reluctantly, they were responding to families, schools, and communities in distress.

But there’s an odd disconnect: the public concern about technology is not really about addiction as a disorder or disease. People don’t typically show up to these clinical programs saying, “I’m Jacques, and I have an internet addiction.” And the broader concern is not so much about the subset of people contracting the condition of internet addiction but the effects of tech on all our lives. People are worried about fractured attention, seemingly unconscious habits, relationships under stress, persuasive technology, and a whole host of design features, economic incentives, and social factors that seem to be eroding our capacity for choice. People are looking for understanding and a way out.

So while conference attendees were debating the boundaries of narrow conditions like “problematic internet use” or “social network use disorder,” I couldn’t shake the feeling that they were largely missing the concerns people were grappling with outside those doors, a much broader concern about a perceived crisis in our attention and consciousness. So maybe the problem is that focusing too much on “dysfunction” makes us miss the addictive processes that are actually woven into all of our lives.

Like the critics, I am concerned that this field has moved too far toward treating behavioral addictions as categorical medical entities. More fundamentally, we’ve adopted assumptions about an overly medicalized view of addiction. There’s a need for questioning the purported binary between “addicted” and “normal.”

This issue isn’t unique to the addictions field. Many thoughtful therapeutic camps today now question our tendency to divide people into “sick” and “healthy” categories, as a necessary starting point for making sense of suffering and doing psychotherapeutic work. Acceptance and Commitment Therapy, for example, attacks the assumption of “healthy normality:” the misleading notion that some people are sick while everyone else enjoys health and happiness as the natural state of human life. This false assumption misses the ways that we are all destined to suffer, as part of our human legacy, often precisely because of natural human processes like verbal cognition and reasoning.

I don’t want to set up some sort of false dichotomy myself, implying that there’s only one right way to look at addiction. Some people do identify as addicted, and for them the label can be useful, even life-saving. Others have severe problems requiring intensive, specialized attention, within or without medicine. But in general, and in behavioral addictions in particular, a process-based perspective is a useful corrective to some of our fundamental assumptions. Rather than asking what condition we have, it’s good to build awareness and curiosity, asking why a behavior takes hold and what purpose it serves.

The binary that’s worth interrogating here is the one between healthy and normal. This recapitulates a deep, old question in addiction. Thirty years ago, after decades of research on the natural history of alcoholism, the psychiatrist George Valliant concluded by saying that addiction could be seen as both a condition and a spectrum: “Just as light can consist of both waves and particles, just so alcoholism can exist both as one end of a continuum of drinking problems and as a specific disorder.”4 Addiction is multivalent, complex, protean. As with many things, we have to hold a paradox:

Some severe cases fit the addiction model and need robust, specialized care, AND
Most people who struggle with addictive behaviors will be on the mild-to-moderate end of the spectrum—they won’t identify as having the condition of addictION, and that makes sense. But we can still describe addictIVE processes there.

This idea is still underappreciated within the substance addictions field. In behavioral addictions, amid moral panics and very young research, it’s even harder to hold the paradox.

Nantes is an interesting city. Historically Catholic and royalist, once a center of the slave trade, it was also more recently home to a famous radical occupation—the Zone à Défendre de Notre-Dame-des-Landes—where activists, environmentalists, and farmers occupied a huge swath of land and successfully resisted government attempts to build an unwanted airport.

Behavioral addictions are like that, I think. They carry multiple truths at once, fitting different models and understandings, depending on the human being at the center and the problems they’re facing.

For now, we’d do well to err a little more on the side of a process-based view. Holding too tightly to the entity model carries real risks: inflating prevalence rates, eroding trust, misdirecting treatment, prompting moral panics and policy overcorrections. But some people really do identify with and rely on the notion of addiction as a condition, and we should not be too quick to completely dismiss it. Perhaps we can find processes within these conditions, rather than see it as either-or.

To be concrete about all this, let me outline some specific ways a process-based view helps with suspected behavioral addictions:

Clinicians can screen for actual harm and dysfunction, rather than counting hours or filling out a checklist. And, they can try to address the function the behavior serves.
Parents and teachers can ask what a behavior is doing for someone, and what are the actual harms, before forcefully trying to regulate it.
People wondering about potentially addictive behaviors can ask what drives their behavior and in what ways it conflicts with their true aspirations for their lives, rather than rushing to labels.

These debates will continue, and they should. We are far from nailing down the mysterious phenomenon we call addiction. The field is messy and still taking shape. Just to ask better questions is already a massive step forward.

I’d love to hear your thoughts and reactions, whether you’re working on a specific behavior or just thinking about how loss of control works. How have you encountered behavioral addiction as a process vs a “thing?” Share your thoughts in the comments, or simply hit “reply” to this email.

Inside the Behavioral Addictions Debate – Conference Notes

Comments