Exercises — Chapter 33: Addiction, Compulsion, and Recovery

Part A: Understanding the Mechanisms

Exercise 1 — The Reward System in Your Own Experience

Before applying the addiction framework clinically or to others, it is useful to understand the reward mechanisms in your own experience with compelling behaviors.

Choose one behavior you engage in regularly that has at least some compulsive quality — not necessarily addictive, but something you do more than you explicitly planned, return to for relief, or find difficult to stop once started. Common examples: social media scrolling, phone checking, coffee consumption, snacking in certain emotional states, streaming episodes past your intended stopping point, exercise when it becomes rigid rather than flexible.

Answer the following:

1. The trigger: What typically precedes the behavior? What emotional state, situation, or context?
2. The reward: What does the behavior provide? Relief from something (anxiety, boredom, loneliness)? Pleasure? Stimulation?
3. The tolerance question: Has the amount, frequency, or intensity of the behavior changed over time to produce the same effect?
4. The stopping question: When you try to stop mid-behavior (e.g., put down the phone, stop the episode, close the app), what happens? Is it easy, difficult, or somewhere in between?
5. The consequence question: Has the behavior ever produced consequences you regret? Has it ever crowded out something more important?

Reflection: You are not diagnosing yourself with addiction. You are developing familiarity with how the reinforcement loop works — because the same loop operates in addiction, just at higher intensity, with neurobiological changes that make it more powerful.

Exercise 2 — Reward System Sensitization vs. Tolerance

The chapter describes a paradox in addiction: the brain becomes sensitized to the addictive stimulus (wanting more intensely, reacting more strongly to cues) while simultaneously becoming desensitized to natural rewards (finding ordinary pleasures less satisfying).

1. Explain in your own words why this combination — intensified wanting + blunted liking — makes addiction self-maintaining even when the substance no longer produces genuine pleasure.

2. The chapter describes dopamine as more closely related to "wanting" than to "pleasure." How does the distinction between wanting and liking change the conventional picture of addiction as pure pleasure-seeking?

3. A person with severe alcohol use disorder says: "I don't even enjoy drinking anymore. I feel sick afterward. I don't know why I keep doing it." Using the neuroscience from the chapter, how would you explain this to them in non-technical language?

Exercise 3 — The ACE Connection

The chapter cites data showing that people with ACE scores of 6 or higher have approximately 5000% higher rates of intravenous drug use than people with ACE scores of 0. Vincent Felitti observed: "The question is not why the addiction, but why the pain?"

1. If addiction often begins as a solution to the problem of unbearable emotional states — anxiety, depression, trauma — what does this suggest about why willpower-based approaches to treatment frequently fail?

2. Translate the Felitti reframe — "why the pain?" — into a non-judgmental explanation of addiction that you could give to someone who had a family member with severe substance use disorder and was struggling to understand how it happened.

3. Consider the implication for prevention: if ACE history is a major risk factor for addiction, what prevention strategies would target the upstream causes rather than the downstream behaviors?

Part B: Recognizing Problematic Patterns

Exercise 4 — Applying the SUD Criteria

The DSM-5 Substance Use Disorder criteria organize into four domains: impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal). For general educational understanding (not diagnostic purposes), apply this framework to a hypothetical case:

Case: Alex, 31, drinks alcohol most evenings — typically three to four drinks, sometimes more on weekends. Alex has told friends several times that they're going to cut back; these attempts have lasted a few days each time. Alex sometimes drinks in the morning on weekends to relieve hangover symptoms. Alex recently missed an important work deadline because they were too tired after a late drinking night. Alex's partner has expressed concern; Alex responds that the concern is overblown and that work stress is the real issue.

Using the four domains, identify which DSM-5 criteria Alex appears to meet. Based on the number of criteria, what severity would this presentation suggest?

Exercise 5 — Denial and Motivated Reasoning

The chapter describes denial in addiction as more than dishonesty — a combination of neurologically impaired self-assessment, psychological self-protection, and motivated reasoning.

For each of the following statements, identify which component(s) of denial are operating and explain why challenging the statement with evidence is likely to be ineffective:

a) "I've never missed a day of work. How can I have a drinking problem?"

b) "I know plenty of people who drink more than I do."

c) "I only use on weekends. I have complete control over this."

d) "My wife exaggerates. She doesn't understand the stress I'm under."

Reflection: Given that evidence-based confrontation is generally ineffective for denial, what approach does motivational interviewing suggest instead?

Exercise 6 — Compulsive Behavior Audit

The chapter describes behavioral addictions and near-neighbor compulsive behaviors that share the neurobiological substrate of substance addiction. This exercise is a structured audit of your own relationship with behaviors that can develop compulsive qualities.

For each behavior below, rate your relationship with it on a 0–4 scale: - 0 = Not part of my life - 1 = Part of my life, no concerning features - 2 = Some features that give me pause (I do it more than I intend; stopping is harder than expected) - 3 = Significant concern (it's affecting my functioning or relationships; I've tried to cut back and struggled) - 4 = Clear problem that I haven't fully addressed

Reflection: For any behavior you rated 2 or above, apply the behavioral observation from Exercise 1 (trigger, reward, tolerance, stopping difficulty, consequences). Is there a pattern worth examining?

Part C: Recovery and Treatment

Exercise 7 — Medication-Assisted Treatment: Stigma Examination

The chapter notes that stigma against medication-assisted treatment (MAT) for opioid use disorder — the idea that medication-maintained recovery is not "real" recovery — is not evidence-based and costs lives.

1. What arguments do you anticipate someone might make against MAT as "real" recovery? List two or three.

2. Counter each argument with the evidence from the chapter.

3. The MAT stigma often reflects a moral framework (addiction as choice, recovery as willpower) rather than a medical framework (addiction as brain disease, recovery as treatment). What does accepting the brain disease model imply about our obligations — as a society, as families, as individuals — toward people with addiction?

Exercise 8 — Stages of Change in Practice

The Transtheoretical Model (discussed in Chapter 29) maps stages of change: precontemplation, contemplation, preparation, action, maintenance. Motivational interviewing is designed for the ambivalence of contemplation. This exercise applies stage-matching to addiction presentations.

For each of the following brief descriptions, identify the probable stage and describe the most appropriate treatment approach:

Person A: "I don't have a problem. My friends are overreacting."

Person B: "I know I should cut back. I've tried a few times. Part of me wants to stop and part of me really doesn't want to give it up."

Person C: "I've made my decision. I want to quit. I'm ready to do whatever it takes. Where do I start?"

Person D: "I stopped three months ago. Some days are easy; some days the craving is intense. I'm worried I won't be able to keep it up."

Exercise 9 — Writing a Support Letter

A central insight of this chapter is that shame drives addiction deeper, while compassion and connection support recovery. Motivational interviewing teaches us to work with ambivalence rather than confront it.

Choose either: (a) A person in your life (real or imagined) who is struggling with addiction or compulsive behavior (b) Yourself, regarding a behavior you identified in the audit above

Write a short letter (one page or less) that: - Acknowledges the person's full humanity without minimizing the problem - Names what you've observed with care rather than judgment - Expresses your investment in the relationship, not just the behavior - Avoids ultimatums, lectures, or lists of consequences - Asks what the person needs rather than telling them what to do

Reflection: How does this letter differ from a confrontational approach? What makes it harder to write? What might make it more likely to be heard?

Part D: Impact on Families and Communities

Exercise 10 — The Family System Under Stress

The chapter describes how families reorganize around addiction — with the enabling patterns, excessive responsibility, and emotional enmeshment often called codependency.

Case for reflection: A parent has been sober for six months after ten years of severe alcohol use disorder. Their adult child, who grew up managing the family's household and emotional climate from age 11, is now having difficulty adjusting to the parent's recovery. The adult child feels anxious when the parent seems stable; the vigilance that protected them for years has not resolved.

1. What role does the adult child's early experience of living with active addiction play in their current response to the parent's recovery?

2. The chapter cites the CRAFT approach as evidence-based for family members. CRAFT recognizes that family members can influence the probability of treatment engagement without controlling the person's addiction. What is the psychological distinction between influence and control, and why does it matter for families?

3. What form of support might the adult child benefit from, independent of the parent's recovery status?

Exercise 11 — Reduction vs. Abstinence

A contested question in addiction treatment: should the goal be abstinence (complete cessation) or harm reduction (safer use, reduced use, reduced harms without requiring complete cessation)?

Arguments for abstinence: - Neurobiological changes make controlled use unreliable for many people - Abstinence provides clear criteria for success - Social support communities (12-step) often require abstinence

Arguments for harm reduction: - Many people who won't pursue abstinence will pursue harm reduction - A person who reduces from daily heavy use to twice-weekly moderate use has improved their health, even if not abstinent - Harm reduction approaches reach more people and reduce mortality even before abstinence is achieved

1. How do you evaluate these arguments? Is there a population where abstinence is clearly necessary? Is there a population where harm reduction is clearly more appropriate?

2. Needle exchange programs (providing clean needles to people who inject drugs) have been shown to reduce HIV transmission without increasing drug use. What does this evidence suggest about the harm reduction philosophy more broadly?

3. The "no wrong door" principle in addiction treatment holds that any contact with the treatment system — even brief, harm-reduction-focused — is an opportunity to build the therapeutic relationship that may eventually support abstinence if that becomes the person's goal. How does this principle change how you think about success in addiction treatment?

Reflection Journal Prompts

Prompt 1 — The Felitti Reframe "The question is not why the addiction, but why the pain?" How does this reframe change your understanding of addiction in someone you know or have known? How does it change your understanding of your own relationship with substances or behaviors — even subclinically?

Prompt 2 — Connection as Medicine The Johann Hari/Alexander "rat park" argument proposes that addiction is, in part, about the absence of connection and meaningful engagement. Consider your own life: are there periods when you were more prone to compulsive behavior that correlated with loneliness, meaninglessness, or disconnection? What does this suggest about the conditions that make you vulnerable?

Prompt 3 — The Stigma You Carry About Addiction Before reading this chapter, what was your implicit framework for understanding addiction — moral failing, disease, choice, or something else? Has the chapter changed that framework? What remains difficult to release?

Prompt 4 — The Compulsive Edge Jordan recognizes in himself patterns that share features with addiction — the compulsive edge of his work behavior — without meeting clinical criteria for addiction. This is not uncommon. Where in your own life do you recognize the compulsive logic (relief-seeking, tolerance-like escalation, harder-to-stop-than-expected)? What is the behavior managing?

End of Chapter 33 Exercises