Addiction is usually treated as a problem of the substance or, more recently, of trauma, yet in the people I see it is usually more than either.

At the centre is a refusal. The person cannot accept that they are powerless, meaning they cannot take a little without being pulled back into a lot. That is the loop, and around it grows a delusion, defended with lies to others and, more stubbornly, to themselves.

The defence is often built out of true material: a trauma that happened but is not the main thing driving the use, a pattern of self-sabotage, or relationships arranged almost by design to fail and hand the addiction its reason. It takes a certain confidence to go past all these things because they are real and may look like the whole story.

Underneath, there can be something less like a symptom than a shape the person has taken: a hardened second nature made of lying, unreliability, and selfishness, or a greed never quite satisfied, sitting oddly close to a deep self-hatred.

For some, what society would call a flawed character was there before the addiction. For many more, it is the other way round: years of using slowly eroded a character that had been perfectly sound. Often poor parenting or early harm laid the ground, and the addiction grew on it. Either way, by the time they reach me, the character has been warped.

Here is an example, perhaps not often talked about, that shows how insidious and cunning this can be. People often tell me they felt intense anxiety before using, and that their substance use was a simple ‘medicating anxiety’ story. This is where maybe a well-intentioned psychotherapist would then see an anxiety disorder and start a CBT protocol, or a psychiatrist might reach for the SSRIs.

Sometimes the anxiety would turn out to be about wanting the hedonistic experience of intoxication, a feeling of greed and selfishness. They would sit there with tears of shame streaming down their faces, telling me that they would lie to themselves and others, claiming their anxiety was standalone or trauma-based when, in reality, it stemmed from the guilt that their behaviour was in conflict with their values. A few go further and disclose that they intentionally lied about trauma and anxiety to justify their actions and to get people off their backs. Only then would they start recovering in a meaningful way and rebuilding a self they actually liked.

This is where I have to part company with the trauma-first account, which is now almost an orthodoxy, most associated with Gabor Maté. He is right about a great deal: much of addiction does grow from trauma and pain, and treating people as morally weak has only ever made things worse. I am not suggesting that anxiety isn’t a real condition or that it doesn’t often warrant CBT and medication.

Where I hesitate is with the idea that trauma is always the root cause of addiction. Many people I see have significant trauma that does not seem to be the engine of their addictions.

Sometimes their character was shaped by parenting that was not cruel but inconsistent, or so protective that the child never had to meet a consequence. Other times, the addiction itself did the shaping.

The same need for consequences runs through the present. For people with addiction, it is crucial to have boundaries that are completely inflexible: this or that, never both. The people who love them rarely manage it. Some are afraid, some are worn down by the hot and cold behaviour and the manipulation, and some bend from plain compassion, but every stretched boundary teaches the same lesson to them: that it’s possible to ‘have your cake and eat it’.

That lesson can form the delusion of addiction itself, the belief that this time using the substance will not feed the uncontrollable craving.

Yet, for people with addiction, it always does.

It is an immutable truth, not subject to pleading, bullying, or charming.

It sits there and patiently waits to be accepted as something unchangeable yet liberating.

It’s never too late.

Learn more or speak with Tom Maniatis on complex behavioral and substance dependencies.

Suggested reading:

• The fullest statement of the view that addiction grows from pain and early trauma, the perspective this piece both respects and argues past: Maté, G. In the Realm of Hungry Ghosts: Close Encounters with Addiction. Knopf Canada, 2008.
  
• A history of addiction by a psychiatrist in recovery, resisting every single-cause explanation and arguing for a more nuanced and humane view: Fisher, C. E. The Urge: Our History of Addiction. Penguin Press, 2022.
  
• A neuroscientist’s argument, told through case histories, that addiction is not a disease but a deeply learned habit of desire, which is why willpower alone so often fails and why change remains possible: Lewis, M. The Biology of Desire: Why Addiction Is Not a Disease. PublicAffairs, 2015.
  
• A philosopher’s case that addiction is neither simple disease nor simple choice but a habit that shapes character, putting the question of responsibility back without reverting to blame: Dunnington, K. Addiction and Virtue: Beyond the Models of Disease and Choice. IVP Academic, 2011.