The most recent entries in this blog appear first. For earlier posts please scroll down the page.
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.
What’s missing from the project are the firsthand accounts of how people with addictions feel about their own experiences in 12-step recovery. That’s where I hope to have help from readers of this blog: If you would like to describe your honest and open account of personal experiences in AA and/or rehab, I’d like to hear it. Please note that both positive and negative experiences are welcome. If you don’t have a story to tell but know someone who might want to share, I would appreciate if you could pass this request along to them. If I receive enough accounts, I intend to publish many of them verbatim in the forthcoming book.
No identifying information will be published, including any information about individual counselors, treaters or sponsors. (I.e., it’s fine to say “I was treated at Betty Ford Treatment Center” but not “I was treated by John Smith, a counselor at Betty Ford.”)
If you’d like to participate in this project, please contact me directly firstname.lastname@example.org. Let me know in the email how you’d like to be contacted, and whether you would prefer to conduct a phone interview or simply send your written thoughts. Thank you, and I look forward to hearing from you.
We've been stuck for a long time.
Published on February 24, 2013
Recently, someone told me he thought that when people relapsed to their addiction after many years, it was a different phenomenon from people who relapse quickly. He had decided that different factors might be at work when it comes to relapsing after long-term sobriety – perhaps some social reason, or inability to stand success, or forgetting the consequences of returning to addictive behavior. He felt the need to come up with these hypotheses because he had found an inexplicable problem: The folks who relapsed after a long time had been successfully abstinent through their involvement in 12-step programs. That they should relapse after so much time seemed strange to him; it did not square with his understanding of addiction. Therefore he reasoned that, since these people had truly “gotten” the 12-step method, he would need to think of a new explanation for their relapses. His idea reminded me of a basic fact in science.
Whenever we humans don’t know the cause or nature of a phenomenon, we instinctually generate many possibilities to explain it. Multiple hypotheses are themselves a good and healthy thing, of course: More ideas mean more things that we can test against experience or experiment. The downside to the many-hypotheses state of knowledge, though, is that before answers are actually understood, people often become attached to their views, whether they are correct or not. For thousands of years, many fervently believed that the earth was the center of the universe. That was a reasonable hypothesis if one didn’t understand the motion of the celestial bodies. But even when presented with overwhelming evidence to the contrary, the people of the 17th century clung to their outdated beliefs. Galileo was imprisoned in his house for the rest of his life for daring to dispute that ancient earth-centric idea. Today many millions of people are still waging already settled debates about issues like evolution.
Hostility to new ideas arises in addiction as well. Treatments for addiction that have arisen from old ideas have become especially “stuck” because of the investment by those who have benefitted from them. When a person is helped, it is understandable that he or she will feel their own experience “proves” the rightness of the approach. New ideas are especially hard for the therapists and counselors who provide treatment according to an old model. If all they know is that old formula, they may well fight to the (professional) death to defend it, since their jobs and professional identities are at stake.
This is what has happened with much of the addiction treatment industry today. Despite the now enormous body of evidence that 12-step programs are effective for only a very small minority of those who attend them, its defenders are commonly unswayed. This “stuck” system is cemented in place by the large financial interests of 12-step based addiction rehabilitation centers, who need to have people believe that their programs are sound in order to justify their often enormous expense.
One of the common byproducts of clinging to an outdated idea is the need to invent ever more elaborate “work-arounds” to account for new information and contradictory evidence. The model grows more and more complex, and the arguments more byzantine, as adherents struggle to incorporate the total tonnage of countermanding evidence. This man's ideas about relapse to addiction are a good example.
If one understands the psychological nature of addiction, there is no need to hypothesize new and distinct factors depending on when the relapse occurs. It is characteristic of every psychological symptom that it may occur at any point in a person’s life. Symptoms don’t die off with age (though their form may change); their reappearance depends on whether the factors which produce them are present. A woman who is meek in every circumstance, and drinks to reverse the sense of utter helplessness this creates, may marry a man who treats her well despite her need to capitulate. Her symptom may disappear. But whether it is six months or six years later, if she finds herself back in that old helpless position, she will be at high risk of drinking again. The psychology behind addiction doesn’t change when the drinking stops.
The best treatment for her would be psychotherapy to help her understand the connection between her meekness and her drinking, to see the ways she has unconsciously recreated her helplessness in her life, and ultimately to work out the roots of her need to be submissive. With this work done, she would have the best chance to avoid relapses forever. 12 Step programs work for a small number of people for reasons that are more complex than they perhaps even know, but such programs are not designed to do any of this work.
Unfortunately, at the present moment, referring everyone with an addiction to 12-step treatments has become routine in our culture. If this is going to change, then both those who have benefitted from the 12-step approach and those who rely on it to treat people will have to let go of some of their old and cherished beliefs.
Published on December 3, 2012 by Lance Dodes, M.D. in The Heart of Addiction
Legalization of marijuana has been opposed for several reasons:
• It has been believed to be immoral to use drugs
Proponents of legalization point to reasons of their own:
• The failure of the “War on Drugs” to reduce drug use or the problems it causes
Understanding addiction as a psychological symptom allows us to do something that is rarely done in this discussion: separate the drug from its use, and its use from addiction.
Addiction is addiction no matter which substance or activity comprises its “narcotic” – alcohol, other drugs, shopping and eating can all act in the same functional way. This is the reason that so many addicts switch throughout their lives from one drug to another, or even from a drug to a non-drug addiction like gambling. It is nonsensical to speak of such people as being “dually addicted” or even being multiply addicted; the inner engine of addiction—its meaning—is consistent for each individual, namely an effort to relieve feelings of being trapped or helpless and to establish a sense of control. “I may not be able to tell off my boss,” is a common example, “But by God I’m going to have a drink or have a joint, and nobody is going to stop me.”
All compulsive or addictive behaviors are substitutions, or displacements, for a direct action that is felt in some sense to be impossible or forbidden. The particular form this substitute action takes can be almost anything. The “War on Drugs” is not just a misnomer; it reflects a real failure to understand that addiction lies in the individual psychology of each person – why he uses the drug – and not in the nature of any, or all, drugs. (Of course, one can develop physical dependency through the heavy use of certain drugs, but as I have described before, physical addiction has little to do with the problem of addiction. Likewise, the notion that drugs cause brain changes which produce addiction in humans has been amply disproved.)
Naturally, increasing the availability of any drug will increase its use and will increase the problems arising from that use, with or without addiction. If marijuana were more widely used, for instance, some people will drive while intoxicated on marijuana exactly as people do now with alcohol. From this standpoint it makes as much sense to criminalize alcohol as marijuana.
And yes, if more people have access to marijuana, then a portion of them will also use it addictively or compulsively, again like alcohol. But will this increase the total number of people with addictions? For that to happen there would have to be individuals who begin compulsively using marijuana but who have no prior addiction. While some people might shift to marijuana from other addictive focuses, there is little reason to think that people without any emotional need for addictive behavior would develop that need because of availability of marijuana.
Okay, but what about the “gateway” idea? This notion assumes that once people use marijuana they will seek a more potent drug. But recreational use of any drug, as with alcohol, does not create a need to move on to other drugs. There should be no surprise here; the psychological purpose of the addiction may be completely satisfied by marijuana. In fact, there is no reason to think that heroin would do a better job, and it could well do a worse job if people experience the drug effect as disempowering. (“I need to get some relief so I drink or smoke pot, but no way do I want to be a junkie”). Part of the confusion is that many people who use harder drugs started with marijuana, but this is simply the well-known “post hoc ergo propter hoc” fallacy: just because B follows A does not mean A caused B. Saying that earlier use of marijuana led to later use of heroin is like saying that since 90% of bankers had tricycles as a child, tricycles lead to banking. In fact, a recent study in the American Journal of Psychiatry following a group of young boys into adulthood found no basis for the idea that marijuana was a “gateway” to later drug use, fitting with what we would expect from a psychological perspective.
If marijuana ever became completely legal, then it is likely that more people would use it. It is also likely that some ill effects would occur from that use. There may be a few more people who use marijuana addictively, but it is unlikely to catalyze a major shift away from current addictive use of alcohol or other compulsive behaviors, and it is unlikely that the total number of people with addictions will rise significantly. There is also little reason to fear that it will lead to increased use of more potent drugs. Parents and teachers would need to counsel their children about marijuana use just as they now do about alcohol, but those kids will develop in more or less the same world we occupy today with alcohol.
And we could save some of the estimated 75 billion dollars we spend yearly on the War on Drugs and put that money into replacing a failed and outmoded drug treatment industry with a more sophisticated psychological approach.