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It makes sense to experiment with rodents before trying ideas in humans. But it is a serious scientific error to generalize these results to humans unless they can be shown to apply to our species. Sadly, this is just the kind of very bad science that has taken over the addiction field. Neurobiological researchers have claimed for years that rat behavior to seek drugs is the same as human addiction, without the slightest awareness of how different that is from human addiction. Indeed, of all the ways one should not generalize from rats to people, complex behavior is the most obvious, since the one way that we are least like rats is that we have giant brains capable of human psychology, while rats have brains the size of a pea.
Of course, we know the "brain disease" theory is wrong for other reasons, since there are literally millions of examples of humans who have taken high doses of drugs like heroin and alcohol who never become addicts, something that should be impossible according to the "brain disease" theory.
The mistake of thinking human addiction is the same as rat stimulation is a cautionary tale. We all need to question what we hear, even from people who are supposed to know what they're talking about, until we have independent scientific review from scientists besides those invested in their own views.
Looking at consequences also induces guilt. It's understandable that those who have been hurt by addictive acts will confront those who have hurt them. But no good therapist would make this mistake. Over the past 40 years I've never encountered an addict who was not already sadly aware of the damage he or she was causing. People suffering with addictions are neither evil nor stupid, and adding to their guilt is simply pointless. If guilt could solve addiction there would be no addicts.
There are two other problems with focusing on consequences rather than causes. Since different addictive acts have different consequences, we have been misled into thinking they are different phenomena. Of course, this is not so, as we know from the fact that people regularly shift their addiction from one behavior to another. A variant of this misconception is that the dangerousness of the consequences matters to the cause of an addiction. I've heard people say that alcoholism couldn't possibly be basically the same as compulsive housecleaning, because alcoholism can kill you and housecleaning can't. But that's the result, not the cause, and in fact that very switch does occur (I wrote about one such case).
The closer we pay attention to the emotional reasons for the psychological symptom we call addiction, the closer we can get to mastering it. And in so doing, we save the time we would have wasted focusing on its consequences.
No, that's just being polite.
Nobody likes people who say "I'm right and you're not." We've all learned to be diplomatic, so nobody's feelings get hurt. Even when we're completely certain we're right, we realize it's good manners to say, "I'm sure there are ways you're right, too," or, "No doubt we both have something useful to contribute to this."
But science is different. The scientific enterprise is about getting closer to the truth, by discovering or creating new understandings, and discarding older ones that we know are misguided. In science, we cannot patiently accommodate mistaken ideas because it's good manners. Some people may still believe that the Earth is flat. Yet it would be very bad science to say, "Hey, no problem. We can both be right! Let's make a theory that the earth is round and also sometimes flat. Everyone will be happy."
Somehow in the field of addiction, "making nice" has managed to grab a powerful foothold. Ask nearly any psychiatrist about the nature of addiction, and she is likely to support the notion that it is a "biopsychosocial" phenomenon. This word, invented in the late 1970's, was intended to act as a sort of tepid catch-all which included every possible factor in the development of addiction: biological, psychological and social. Everyone's model got a seat at the table. Today the "biopsychosocial" explanation has become standard for virtually every psychiatric problem. And why shouldn't it be popular? "Biopsychosocial" may be the most diplomatic medical term ever invented.
But the goal of diplomacy is to smooth out disputes; the goal of science is to resolve them.
Biology, sociology and psychology represent three separate pathways to behavior. If a woman is exposed to rabies, she may begin acting aggressive and erratic, a pattern of behavior that is only biological. If a man lacks food and shelter, he may be more inclined to break the law to get what he needs to survive, a pattern of behavior that is fundamentally social. And if you keep responding to disappointments by drinking or gambling heavily, this pattern of behavior is only psychological.
The lines get blurred sometimes in the study of addiction because so many of these contextual factors appear in confounding lockstep: you are indeed more likely to be an alcoholic if your father was an alcoholic; you are indeed more likely to abuse drugs if your peer group does. But it is a fanciful leap to conclude from these correlations that a family pattern means that addiction is hereditary, or that a peer group can somehow make you an addict. After all, there are powerful emotional experiences at the heart of these circumstances as well.
Invoking the "biopsychosocial" label can obfuscate the explanation that hews most closely to what we know about how people work, namely, that addiction arises out of emotional factors which, when treated and understood, can evaporate the addiction for good.
Speaking personally rather than scientifically, I wish I could make friends with everyone and include biological and social factors in the understanding of human addiction. I happen to love biology: I was a biology major in college and did my honors thesis in embryology. In medical school, my favorite of the basic sciences was Histology: deciphering microscopic slides of different tissues.
But science isn't about what you love, or about being nice. And it's not about deciding that every field has an equal understanding of why we exhibit complex and meaningful behaviors. Sadly, "biopsychosocial" is doing more good for the theorists than for addicts.
When doctors don’t know the cause of an illness, they're stuck having to “diagnose” only its symptoms, not the source of the problem. That is just where we stand today with substance abuse, and it’s ruining our chance to treat it effectively.
For example, before we knew the cause of tuberculosis (a bacterial infection), it was named based on one of its symptoms: it was called Consumption because one of its main symptoms was weight loss. Naming the illness as a weight loss problem was not useful for either understanding or treating it. In fact, if doctors had tried to figure out the illness by looking into “weight loss” as the issue, they would never have discovered its true cause. The same thing happened with another commonplace “diagnosis” of the 19th century: Dropsy. This term referred to swelling, often of the ankles. There are several possible causes for this, one of the most common being congestive heart failure. But since doctors didn’t have a clue about this, they stroked their beards and sagely proclaimed that their patients had Dropsy. As with Consumption, the “diagnosis” was not just unhelpful, but thinking of the illness as a swelling problem could never have led to understanding it.
Today, addiction specialists and nearly everyone on the planet believes that there is something called “substance abuse disorder.” We are again naming a symptom as if it is the problem. Since the focus of an addiction can, and often does, change from one drug to the other, or to non-drug compulsive behaviors like gambling, eating or sex, “diagnosing” a “substance-abuse disorder” is both superficial and harmful. Like Consumption or Dropsy, it misleads us into believing that somehow the problem is about substances. Drugs in fact have absolutely nothing to do with the nature of addiction; they are just one common form of the problem. And like Consumption and Dropsy, use of this misleading term interferes with understanding and treating people suffering with it.
As readers of this blog or my books know, addiction is neither more nor less than a compulsive behavior, identical with other compulsions and understandable in psychological terms. (As always, I am not referring here to either physical addiction, or the biologic illness OCD.) It is certain that true addiction is not a “brain disorder” as I’ve discussed extensively elsewhere, and of course it is also not a moral/spiritual problem. We need to be appreciating addiction as the compulsive behavior it is, and treat people by helping them to understand its psychological roots so they can predict when their compulsive/addictive urges will next arise. With that awareness, and some psychological work, people can effectively manage and ultimately beat their addictions.
It’s hard to buck any entrenched system, but let’s try to keep in mind that people who compulsively use alcohol or any other drug are just like everybody else, just with this particular way of managing overwhelming feelings. They do not have a “substance abuse disorder” because there is no such thing.
If the world were a perfect place, our efforts to understand ourselves would be based on reason, experience, and evidence, and free of the poisoning influence of politics. Alas, the world of addiction is just as beholden to political tradewinds as other fields.
Recently I read Nobel laureate Paul Krugman’s book “End This Depression Now!” Before describing his views, I must make a disclaimer: my own education in economics began and ended with a single college course I took 40 years ago. So I’m not writing to endorse or refute Professor Krugman’s views, but to underline his description of his field. He writes that in recent decades, macroeconomics became divided into two great factions described as Keynesians and non-Keynesians (after the economist John Maynard Keynes). The non-Keynesians, he writes, “Soon got carried away, bringing to their project a sort of messianic zeal that would not take no for an answer… [a leader of this group predicted] in 1980 that participants in seminars would start to whisper and giggle whenever anyone presented Keynesian ideas. Keynes, and anyone who invoked Keynes, was banned from many classrooms and professional journals… [non-Keynesians developed] quasi-religious certainty that has only grown stronger as the evidence has challenged the One True Faith.”
The other powerful group is of course AA, and its 12-step brethren. Anyone who has tried to criticize the 12-step approach knows full well the hostile reception this produces from devoted members. In fact, because of my position as an independent voice in addiction, I have often heard from counselors working in addiction treatment programs around the country who tell me they are afraid to challenge the 12-step model for fear of losing their jobs.
Addiction deserves better. One online addiction website, The Fix, recently published my guest piece taking a critical look at both the official description of addiction in the new edition of the Psychiatry Diagnostic and Statistical Manual (DSM-5), and the brain chemistry people at NIDA. The Fix is a wide-ranging site that publishes a variety of views, some of which I don’t agree with, but that’s the point: like Psychology Today, it is a rare forum for contrasting ideas and discussion. We desperately need more open-minded resources like this, and a new national addiction conversation that doesn’t reflexively strangle dissent.