Addiction and Compassionate Pragmatism

Addiction and Compassionate Pragmatism

The simplest way to define addiction is as a compulsive behavior that continues despite negative consequences.  Of course, these compulsive behaviors are not limited to alcohol and other drugs; the internet, sex, shopping, gambling, eating, work, relationships – virtually all patterns of consumption are eligible. Yet the sheer scale of addiction compels us, both individuals and our wider society, to reconsider how we have been reacting this global dilemma.

Let’s begin by recognizing that addiction is not only about euphoria.

Maia Szalavitz, author of “Unbroken Brain,” shares her own personal experience with addiction, writing, “What heroin really did for me was make me feel safe and comfortable and let me stop thinking everybody hated me. But what really hooked me was just being able to feel OK.  It was a classic case of self-medication.” [1]

Keith Richards, the Rolling Stones guitarist, echoes a similar personal experience, marveling at “the contortions we go through just not to be ourselves for a few hours.” [2]

Chronic addiction has little to do with recklessly seeking euphoria; sufferers are simply responding to the unbearable conditions of their lives. Many actually believe they are doing something helpful to relieve their distress, even as they know it is ultimately self-harming. Kevin McCauley, M.D., an addiction specialist and Fellow at The Meadows, insists that “self-deception is a clinical feature of the midbrain downregulation that occurs with chronic substance misuse. They are not lying to themselves; they have been deceived by their own brains.” [3]

So how did we get here? To understand, let’s re-examine where addiction first blossoms: in context.

All behavior (compulsive, contorted, deceptive, or otherwise), occurs within, and is profoundly influenced by, context. There are two primary conditions that create our context: our setting and our mindset.

The first condition, setting, refers to our larger environment. This environment contains the collective historical, cultural, political, and geographical locations that shape our perception of reality. Also included within this larger reality are our family health histories and personal economics.

The second condition is our mindset, or worldview. We all have a worldview, a set of often-fuzzy expectations and probabilities designed to make sense of how the world around us is ordered (or should be), and to help us anticipate how that world will likely (or ought to), react to us.

These two powerful conditions operate silently as we choose behaviors that we believe will help us meet our fundamental needs. In Choice Theory, these fundamental needs are understood as Survival (Safety), Love and Belonging, Freedom, Power (Personal Significance), and Fun. It is important to recognize that while most behavior is viewed as purposeful and goal-directed to meet one or more of these needs, this does not mean our choices of engaging (or disengaging) with the world will be helpful, moral, legal, or even conscious.

The point here is that there are subtle limits to our individual control of our behavioral choices, though we like to tell ourselves otherwise. And these limits have names: Worldview and Environment.

For the past three years, at counseling conferences in Raleigh, Tampere (Finland), and Bogota (Colombia), I have refined this thinking as I presented and conducted workshops on “Worldview and Environment: The Relationship Before the Relationship.” These seminars were designed specifically for counselors, educators, and other helping professionals who were already literate in cognitive theories and developmental matrixes.


During this period, a larger realization startled me: Perhaps these very fine people were not the ones I really needed to reach.

More troubling, even as I cleverly sketched the largely academic and procedural nuances of “relating” while shielded by my own white male privilege and basking in my colleagues’ approval at exclusive hotels, I found myself wondering: What if there was a deeper, species-specific (human) psychopathology of self-violence within our worldview and environment (think of the Amazon fires, the water in Flint, the corporate cruelty that drove the still-unfolding pharmaceutical Opioid tragedy)? What if this kind of self-violence was a thread that connected our seemingly intractable sufferings: climate change, poverty, addiction, terrorism, prejudice, war, diabetes?

If this was so, what would I do about it, and who would I have to ask to help me? The unwelcome complexity of this thought drove me to simplify, and I turned to the Law of Threes: 1. Identify a shared goal that held relevance to most people’s experience; a goal that transcended cultural, economic, ideological, and geographical fault lines. 2. Provide realistic, inexpensive, and accessible concepts and tools to articulate to this shared goal. 3., Who exactly are the people I would need to respond with me?

Compared to number three, one and two are easy.

One. Our shared goal is re-imagining addiction. The sheer scale of addiction is cross cultural and transgenerational. By framing addiction as a profoundly human response to the conditions of our lives, addiction is no longer a shameful and criminalized moral failure of a single, weak individual, but a true reflection of our shared community mental health. By casting the global addiction dilemma as profoundly human, solvable, rooted in social justice, and interrelated to the conditions of our lives, we have identified our shared goal.

Two. The concept is Compassionate Pragmatism [4] and the tool is Harm Reduction. Compassionate Pragmatism re-humanizes the sufferer and devalues the idea that addiction is a problem isolated within a person’s biology, separate from their personal psychology, relationships, social, and economic contexts. Emphasizing values that view every life as sacred - and placing each person at the center of their own change, Harm Reduction begins by helping people live as safely as possible, meeting people where they are, affirming any positive change, removing barriers to support, and acknowledging abstinence as only one goal on a broad spectrum of solutions.

Three. The people we will need? Everybody who loves somebody who is suffering.

More on Compassionate Pragmatism and Harm Reduction here in the weeks ahead.


[1] Szalavitz, M. “Unbroken Brain,” 2017.

[2] Mate, Gabor. “What is Addiction?” 2015.

[3]  Personal Communication, March 20, 2019

[4] Compassionate Pragmatism is based on the work of Dr. Andrew Tatarsky, a leader in the treatment of problematic substance use and the architect of a psychobiosocial process model for understanding it. Compassionate Pragmatism embraces Integrative Harm Reduction Psychotherapy (IHRP) as an effective treatment for the full spectrum of substance use issues. He is founder and director of  the Center for Optimal Living in New York City, a treatment and professional training center based on this mode. He has specialized in the field of substance use treatment for over 35 years working as a counselor, psychologist, program director, trainer, advocate and author.