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The disease of addiction first jumped in front of me during my second year of residency training. On my first all-night call alone, I admitted a woman in her fifties into the intensive-care unit. She had drunk so much over such a long period of time that her blood wouldn’t clot. Because of the back pressure caused by liver disease, she had esophageal varices, which are varicose veins in the esophagus, and she had a Sengstaken tube to compress the varices so they wouldn’t bleed. During the night, she coded. We had to remove her Sengstasken tube to artificially breathe her, and her varices opened up. I still remember—vividly—standing over her, blood everywhere, wondering, Why? Why? I started sobbing. She was the first patient who had died in my care. One of the nurses put her arms around me. “She drank herself to death. You did all you could do.”

The next day I skimmed through the volumes of her medical record. Her chart was almost two feet tall, nearly all of it related to alcoholism. “Patient understands dangers of continuing EtOH [alcohol],” it read, and sometimes “Patient placed on Antabuse.” Multiple entries of the same comments.

Why? I still wondered. Why do we continue self-destructive behavior? What causes addiction? How do we change?

I met Ethlie, author of Love Addict: Sex, Romance, and Other Dangerous Drugs, when we were both undergraduates at the University of California at Santa Barbara. I was exercising rich people’s polo ponies to put myself through school, not quite making the rent on a two-bedroom Craftsman house just below the Santa Barbara Riviera. I didn’t want to move. I needed a roommate.

A high-energy redhead wearing hot pants answered the ad. Ethlie. She was a student in the College of Creative Studies, full of ideas and smarts and with long curly hair she’d blow-dry straight. Her mother lived in England with the third of what became four or five husbands. Ethlie had gone to school abroad and acquired an English rock-star boyfriend. She spoke French and had the insouciance of someone who’s been there, done that. I had never been farther afield than Colorado, and my boyfriends were all homegrown.

In those days, there were “good” girls and “bad” girls. Good girls didn’t, or at least they didn’t, admit it. Bad girls were captivating…like Ethlie. In those days, we believed in kismet, in finding Mr. Right and living happily ever after.

Various young men marched through our little house to the copper-colored satin sheets on Ethlie’s waterbed. A succession of pretty boys, all with the same long hair, skinny legs, and dimples. Ethlie seemed to lead a thrilling life while I worked, studied, and focused on getting into medical school. She invited me to a few parties. I tagged along as her wing woman, usually leaving with someone Ethlie asked to take me home.

Hey, I met this cool guy. You don’t mind if I leave you, do you? I asked Joe (or Michael or David) to give you a ride.

I’d endure another ride home in silence, my hands clasped in my lap.

She and I wanted the same things as anyone else: Love. Romance. Commitment. She wanted these NOW. I wanted to wait until I was finished with medical school.

Uh, hi,” I remember saying more than once to a guy I met in the tiny hallway between our bedrooms, just outside the only bathroom.

I learned to wear robes on Saturday and Sunday mornings.

Ethlie seemed to be looking for something, but I was never quite sure what it was. I thought she was wise beyond her years. Decades later, I learned she was nearly as naïve as I was, but she dove into guys. She was a kid in a penny candy store with a ten dollar bill, buying one of everything.

No, that wasn’t it. What else do you have? No, that wasn’t it. What else do you have? No, that wasn’t it…” Nothing satisfied the restless, nameless hunger, and I never saw most of these guys again.

We had both started out pre-med at the University, and Ethlie quickly moved to more artistic endeavors. After graduation, we lost touch. I went on to UCLA, earning a Master’s in Public Health, and then to Baylor College of Medicine in Houston. When we renewed contact, I was amazed to learn where Ethlie’s “thrilling” life had taken her.

She had a few marriages under her belt. She had been an exotic dancer and was a convicted felon. She worked at an insurance company. She had a chronic sniffle.

Allergies, I thought.

She went to the bathroom more times than I did, and always alone. Had I been more observant, and she less careful, I might have seen some white powder around her nostrils. But I wasn’t and she wasn’t and anyway it wouldn’t have made any difference.

When Ethlie finally got sober, I remember her calling me up to say she was sorry for making chocolate chip cookies with me and encouraging me to join her in eating the dough. Part of staying clean, she said, was cleaning up the past.

Cookie dough?” I laughed.

I have since come to understand that, from a medical point of view, cookie dough is indeed an addiction for some and is neither better nor worse than any other.

Our brains are wired for us to repeat behaviors that contribute to our survival, such as eating or having sex, or give us pleasure, such as drinking or having sex. We do more, we get more pleasure, and we repeat the behavior. How many of us have eaten that extra cookie, or had that extra glass of wine because it will feel good in the immediate future?

I brought these questions and more with me when I sat around a kitchen table in Denver, Colorado, talking health policy with the wife of a dark-horse presidential candidate. When Bill Clinton won the election, I became the first physician appointed as Mountain States Regional Director of the U.S. Department of Health and Human Services. I traveled and spoke around the country and in England, New Zealand, and China. I worked on Indian reservations and in rural America. As I worked on each project, I wondered why change is so difficult. Why do people continue irrational behavior in light of negative consequences?

My search for motivation has brought me to a career in leadership development. I coach physicians to be more effective leaders and design physician leadership development workshops. I am particularly interested in behavior and neuroscience. Why do we do what we do? What is the physiological basis for our behavior? Why is change so difficult?

Until the nineteenth century, mental illness, mental retardation, and physical disabilities were lumped together and given essentially the same treatment. Exorcism to get rid of demons was popular. People with psychiatric problems were locked up in prison-like asylums, chained into dunking chairs, burned at the stake, or subjected to experimental medical treatments.

Treatment for addictions focused on religion and morality. That alcoholism, for example, could be caused by brain chemistry was as preposterous as the idea that bacteria could cause ulcers. “Everyone knew” that ulcers were a lifestyle problem, the result of a spicy diet and job stress.

In 1982, two Australian researchers discovered ulcers were actually caused by the Helicobacter pylori bacterium. They could not convince their colleagues even to try antibiotics as treatment. In 1984, one of the researchers, Dr. Barry Marshall, drank a Petri dish of Helicobacter pylori to induce a stomach ulcer and then cured himself with antibiotics. Finally, in 1994, the National Institutes of Health advocated antibiotic treatment for ulcers. In 2005, the researchers won the Nobel Prize in Medicine.

What we thought we knew about addiction is changing as well. We now believe that addiction—the compulsive use of x, despite negative consequences—is a disease of both behavior and brain. We know some of the biological and environmental factors contributing to addictive behavior, and we’re on the cusp of understanding the genetics underneath it.

Recent research suggests there are even more complex interactions between Nature and Nurture than we realize. Epigenetics is an emerging field that examines “inheritable alterations in gene expression in which DNA doesn’t change, but is affected by mechanisms that prevent gene expression.” What that means is behavior can actually trigger changes in your body at the cellular level, and it is possible your children will inherit those same tendencies.

This is not far off the evolutionary theories of Jean-Baptiste Lamarck, who said in the early 1800s, that acquired characteristics could be inherited. Lamarck was laughed out of consideration and died a pauper, his belongings sold and his body dumped into a lime pit.

It may be of some consolation to Lamarck that we have genes that sit outside the nucleus of the cell, which are activated by the environment. These genes can migrate into the cell to be inherited by future generations. It is indeed possible that acquired characteristics can be inherited. Epigenetics is an exciting field, the surface of which has barely been scratched.

Is love addiction a disease, a psychiatric diagnosis, or a myth? Someday, medical technology will make psychiatric diagnoses as definitive as diagnosing ulcers. Until the data are in, my bets are on some combination of neurotransmitters primed to keep the good times coming (physiology), our lives growing up (environment), our inherited genes, and the activation of epigenes sitting outside our cells, just waiting for something from the environment to say, “Come on in!”

Are addictions good or bad? Yes. No. It depends. My observation is any addiction that becomes an obsession may close your mind to possibilities and narrow your outlook, thus stunting your life experience. Ethlie has loved too much, too many, and too often for her own good. Intellectually, she’s one of the smartest people I know. Emotionally and developmentally, she got stuck somewhere in her teens—for a long, painful time. As I read Love Addict and learned more about her life, I developed even greater respect for where she is today and what it took to get there.

Ethlie has been clean and sober now for twenty-five years, and we have been friends for more years than she will allow me to commit to print. It’s been a long, experience-packed road for each of us. We are finally at a point in our lives where we both eat in moderation (even cookie dough), exercise in moderation, and moderate in moderation. Ethlie, thanks to the genetic/environmental/behavioral/mysterious factors that made her an addict, needed a lot more support to get there than most of us. If anyone’s story can get you, or your patients, unstuck from love addiction and move to self-acceptance and recovery, it’s this one. It may take some time, and you may have some lapses. You can get there from here.

Author’s Note: This was rewritten from my foreword to Love Addict.
Margaret Cary, MD, MBA, MPH
Maggi is a family doctor and leadership coach who engages her audiences in highly interactive presentations. Maggi is a doctor’s doctor with a physician’s mind and a friend’s heart. As an executive coach, she blends a scientist’s thinking with empathy. She is a constant learner and serial focuser with a lifelong passion for sharing what she’s learned. She is an inspirational motivator, occasional humorist, and excellent listener and storyteller. She translates the latest research in leadership development into her coaching process and into entertaining and highly interactive presentations. She is an author, trainer, facilitator, and teacher (Georgetown University School of Medicine). Her authenticity and ability to communicate and connect emotionally with her audience through storytelling—combined with just enough humor—result in rave reviews and standing ovations. She embodies a warm, sincere approach in sharing lessons learned as she guides you in creating your own Leadership Expedition. Email Dr. Cary at to learn more.


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