So I got the manuscript back from my main editor (who works for the publisher), and to my horror the right margin was swarming with little purple boxes containing suggested revisions. This was only for Chapter 9, mind you. Everything else was pristine by now. Still, I really thought there would be little left to do…and I was just starting to sink into a warm pool of mindless oblivion. (yes, I know how that sounds)
Besides little phrasing issues, there was one serious omission, in her eyes: I had not identified the implications of “my model” for treatment. Duh. She had a point. Shouldn’t that have been the grand finale?
So I dragged my ass back to my computer and immediately sent cries of distress to Matt and Cathy, my two informal (but brilliant) editors, and then thought about it for awhile, and this is what I came up with. No, this is what we came up with —
(I’ll quote the relevant sections in two installments. Here’s the first:)
Part 1. What’s wrong with conventional treatment — i.e., treatment that fits the accepted definition of addiction as a disease?
The medicalization of addiction has provided certain benefits. Foremost among them has been the development of pharmaceutical agents that can diminish withdrawal symptoms and ease cravings. Even if these are temporary measures, they can make a real difference during the darkest of times. The disease model has also led Medicine and society to a more enlightened view of addiction, as a very human phenomenon with clear biological underpinnings, while encouraging humane treatment for those who suffer. But treatment approaches based on the disease model are too often ineffective. Addicts continue to suffer. Medicines that help people cope with symptoms do not ignite the desire to change or light up new pathways for life beyond addiction. And worse, rigid, cookie-cutter methods and institutional and monetary self-interests too often turn “treatment” into a dead end or a revolving door for people who seek help. The premise of this book is that medicalization and the disease model have outlived their usefulness.
To bring the drawbacks of medicalization to a point, consider my claim that addiction can only be beaten by the alignment of desire with personally derived future goals. Does medically-based treatment help with that agenda? On the contrary, such treatment is almost always institutional treatment, and institutions are famous for eroding the self-direction that addicts may have mustered to get them to the door. Typically, those seeking treatment are 
told to call back, unless they are ordered into treatment by the legal system, which obviously trounces self-direction from the outset. Then they are given a date to come in for an assessment. And any delay can be easily justified: “We want to make sure you’re really ready.” Finally they’re scheduled to begin treatment, weeks later. That is, if they’re lucky enough to bypass the notoriously-long waiting 
lists for state-sponsored care or afford the swank offerings of a private setting. They are assigned a bed. Ironically, their beds are the hallmark of their claim for help, but beds are where people sleep and where sick people lie when they can’t walk around; they are hardly platforms for initiative and empowerment. Then, if the waiting time for service delivery hasn’t completely undermined their incentive to change, the philosophy of medical care may do so. Addicts become patients, and patients do not participate in decisions about their care. Patients follow the regimens of authority figures who understand the workings of their disease far better than they do. So personal intention has no place in the cure.
If you think this depiction is too extreme, you need only listen to addicts who have been through institutional care (or read Inside Rehab by Anne Fletcher). They often feel overwhelmed by the weight of depersonalization, 
passivity, and submission to authority, the disinterest of staff in their personal views, and their e
xclusion from evaluations of how they’re doing, what they’re doing, and when they’ve had enough. At the outset they are told, “We’ll have to break you down so we can build you back up again”—a phrase commonly heard in institutional settings, according to Matt Robert, a friend, former addict, and group facilitator in both institutional and community-based programs. It’s not that such policies are borne of ill intent. It’s just that they’re wrong-headed. Disease model advocates like David Sack despair that “a large portion of addicts continue to use in the years following treatment regardless of the particular drug involved.” They view this as evidence that the disease of addiction is terribly serious and needs all the ammunition society can muster—which often translates to more money and more institutional beds. Yet the obvious conclusion is that mainstream treatment for addiction just doesn’t work. And since it is founded on the disease model, that model is likely to be flawed.
Note that many of these conclusions derive from the sincere and sometimes devastating stories shared by you, dear readers.
Part 2 — what’s the alternative? — coming up next post.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Here’s my comment on my own post. Couldn’t sleep, got up, looked at mail, and opened an email from rehabs.com, a big site for rehab info in the U.S.. Curious about costs so went to the appropriate page (http://www.rehabs.com/about/frequently-asked-questions-about-addiction-rehabilitation/#how-much-does-rehab-cost) and this is what I found:
“Some low-cost rehab options may charge as little as $7,500 per month, whereas high-end luxury programs can cost as much as $120,000 per month. A good amount of evidence-based, high-quality options exist in the $18,000 to $35,000 per month range.”
So their middle ground price range (per month) is way beyond most Americans’ expendable annual income. Too bad they almost never cite success rates, because you might have to go back a few times. And “evidence-based” means essentially f___all.
Now I really can’t sleep.
Hi Marc…
Though I agree with many of your comments around the disease model of addiction, I’m a bit hesitant to buy into any particular model. The way in which “rehab” has been described in the US doesn’t mean its the same everywhere. My experience, regarding treatment, 27 years ago, was absolutely uplifting, enlightening and spiritual. Perhaps being from a small town makes a difference.
However, my perspective, in helping those to help themselves, isn’t defined by any particular model and ought to be self-directed by the client in conjuction with all other supports. It isn’t as importance for a client to understand my “map-of-the-world” as much as it is for me to appreciate where they are and perhaps where they want to be.
I have to admit, right from the beginning, I never liked to think I was afflicted with a “disease”. It was easier for me to look at it from another view which made it easier for me to accept. “Dis-ease” was much more accepting for me seeing that my life was less than “easy”. However, it was my thinking that got me into trouble and it was my thinking that also got me out of trouble. A person with a problem is also a person with a solution but they need some help or assistance in order to gain enough insight for change to occur.
Again…I do agree with many of your statements and that if institutions function on the premise of a, “Cookie-Cutter” mantality, and that “we” know better than “you” as to what you need it leaves one feeling more and more helpless and perhaps hopeless. It is vital, in my opinion, to help empower an individual so they can embrace thier true nature and strength. As I have stated many times “Change Is An Inside Job” and “I” do not have the power to change another only myself!~
Hi Gary, thank you, your post was a relief to read!
I haven’t been involved in a rehab environment myself, other than attending a few weekly sessions after years of attending a 12 step fellowship and indulging in a few months of occasional drinking (other substances are my bag), So,I offer no opinion on that topic. However, your post resonated positively with my own experience of feeling the “dis-ease”, self direction, the person with the problem also has the solution etc.
In my experience, after letting go of my reliance on drugs to fill the void with some kind of “ease”, participating in life was (and still can be) challenging. I do find though, that the solution to any issues that arise are often very simple, if I am able to slow my thinking down long enough to become aware of it.
The thought of having a “disease” or being a patient that cannot participate in my own life/recovery from addiction, is, to me, as scarey as addiction itself.
Thanks again Gary.
Jo.
Gary,
You say “I’m a bit hesitant to buy into any particular model. The way in which “rehab” has been described in the US doesn’t mean its the same everywhere.” …as though we’re not in agreement. But actually we are.
I don’t advocate any particular treatment orientation. You’ll see that more clearly in Part 2. It’s precisely the one-size-fits-all approach of mainstream rehab/treatment that I’m criticizing. I also strongly agree that “the treater” has to meet the client, not only where the client is but WHEN the client is. My biological arguments highlight a brain that changes rapidly in reward focus and anticipation — very rapidly, — due to the sudden impact of dopamine on receptors that mediate desire as well as attentional focus. When using becomes repellant and abstinence feels like freedom, even for a few hours, that’s when treatment needs to begin. Right then.
For the details, you’ll have to read the book. But the conclusion is plain as day.
Hi Marc,
I have to totally agree with your statement from a biological perspective, I mean, that’s a given!~ If not for the “reward system” whats the point? I mean if the brain didn’t respond and/or change accordingly then repeat behaviour wouldn’t be so important.
The basic mechanisms in the brain that respond to drug intake was what I wanted, enjoyed and then became dependent upon. Due to the neuroplasticity of the brain its able to change. The deeper the “ditch’ the harder for change to occur.
In closing, I just want to add that I don’t dispute your perspectives as well as I don’t make claim that my opinions are truths. However, I do appreciate being able to have this dialogue openly and freely without rigidity in any one direction. In fact, you inspire me to question and for that I thank you!~
And for that I thank you. One thing I’m learning during all this is that my own perspective continues to adjust itself and, I hope, become more realistic, the more I question it and the more I expose it to debate with others.
Hi Marc.. So looking forward to your book… And thank you for keeping this going! 🙂
Jo.
Hi Jo,
Glad that you were able to related and/or appreciate my post!~
I’m known to speak not “the truth” just “my truth” because I don’t know what “the truth” really is!~
Gary
Hey Marc
The disease model is fraught with problems when it comes to implications for treatment, and mostly it has served as a major distraction. All Volkow’s brain studies and those MRi scans that are searching for the mysterious “brain disease” component. The search for vaccines, some of which block the effects of the drug only to result in increased drug use in vain attempts to overcome the blockade or a migration to another drug, are pointless when one conceptualises addictions correctly. Of course, if we could find a means to prevent addiction across all substances we would be medicating against being human. Ablative surgery has shown how damaging such an attempt can be.
Another major problem with the NIDA disease model is that it has distanced the research from being clinically relevant. How often do we see animal studies and pre-clinical trials that any good social scientist could tell you are doomed to failure or are not representative of the addicted population. Also, by defining it as a disease there is the misconception that “addicts are different” – some alien species who have this strange behaviour called denial and are somehow incapable of rational decision making!
We also need to note that the NIDA model and the 12 step model of addiction as a disease are different (as Scott Kellogg often points out). The 12-step model emphasises stigma – once an addict always an addict, join us or the only outcome is jails institutions or death! It is one of stasis and the “addict personality” etc etc
While Leshner’s original article “Addiction is a brain disease and it matters” may have jolted people into seeing addiction as requiring medical intervention (in some cases) it has done more harm than good. The billions of dollars poured into pointless research and being fleeced from unsuspecting families could have been far better spent on things that make a difference – education, employment, better urban environments, developing better drug policies etc etc.
Hi Shaun. Thanks for filling in the gaps…and then some. I particularly like what you said:
“How often do we see animal studies and pre-clinical trials that any good social scientist could tell you are doomed to failure…”
That’s precisely it. Imagine if someone addicted to money (and I just spent four months in L.A.– I know whereof I speak) could take a drug that would quash acquisitive urges. I suppose they might be happy for a little while. What a relief. Until they notice all the nice things money can buy which they can no longer enjoy. Without that acquisitive urge, what would they DO with themselves?
It makes no sense to spend money finding more effective ways to constrain addicts’ urges for peace, pleasure, relief, and excitement, even a sense of belonging — which translate to opioid and dopamine metabolism…Rather, as you suggest, money spent on upgrading social environments would help them to find those rewards without going to so much trouble.
Rat Park really does say it all.
Two thoughts:
I’ve found it difficult to ground my research in so much of what’s “hot” right now because the entire conversation seems part of a surreal alternate reality. Like with the push to implement evidence-based practices, there’s little acknowledgment that most treatments are only modestly efficacious, and even less effective in “real world” settings. And most people who might be experiencing problems with drugs will never walk through a treatment center’s doors. But instead of asking whether treatments aren’t more effective because they haven’t addressed larger social issues, or whether people don’t get treatment because they will get better on their own, we show 12-step-based counselors a powerpoint with a bunch of brain scans and technical language. And, well, that’s SCIENCE, so you can’t challenge it, meaning raising social issues is a non-starter – even among clinicians who know that’s where the answer often lies. It’s like they’re lying to themselves.
Re stigma, I read a 2014 study (Pescosolido was an author) looking at how portraying schizophrenia, depression, and 2 types of addiction as treatable health conditions affected stigma. Reading a vignette portraying a person with the conditions increased stigma, but if the person got treatment stigma decreased, though stigma (toward people with addiction) was still upwards of 70-80%. The treatment for all disorders, including addiction, was a medication that was keeping symptoms under control. Leaving aside that unlikely scenario, I had to wonder if a fuller picture of “recovery” would have made a greater difference in the attitudes. This depiction reinforced the idea that someone never really gets better, and didn’t seem consonant with how people who’ve been addicted describe their journey.
Ok, so here, after some thought, is why I think that the disease model is dangerous when it comes to treatment: When we conceptualise addiction as a disease, as a brain disease, then the treatment is simple: Stop using drugs. Anything that helps us stop using drugs becomes good, and anything that prolongs drug use is bad. Any sort of drugs, because the disease is addiction. Drugs are the problem. On an individual level and on a macro level, this is very unhelpful.
When we realise that drugs are not the primary problem, when we realise that problematic drug use is a lot more than the result of pharmacology acting on or causing a diseased brain which suffers from this thing called addiction, we are then beginning to see that all problematic drug use and addictive behaviour is the result of a confluence of often confounding factors.
While abstinence may give us the space to look deeper and identify those issues, abstinence is not the end in itself. Unfortunately most treatment modalities don’t embrace this way of thinking.
There has been some attempt to address this by calling it a bio-psycho-social disease, but really that means nothing much more than “I don’t know”!
Hi Shaun, I just read this over, and I do like your synopsis. Although we both see a lot of complexity in the cause-effect relationship, I think the other crucially important issue is that of empowerment. You just can’t be a patient and at the same time a discoverer and determiner (if those are words) of who you need to be.
Great comment Erin. This trials of interventions seem to be un-implimentable in many cases. Or, even when they are, they are often ignored. I saw a great study on brief problem solving therapy for people with SUDs who had been admitted to ER. It used the window of opportunity and the interventions were conducted over 4 sessions and did not specifically target drug use. But guess what? People started to better deal with their problems and drug use decreased….. This makes sense to me, it is practical and relatively cheap, but has it been implemented? Nope.
Fascinating, Erin. Thank you. The term “evidence-based” has been our ticket to get papers published in clinical journals, and now it’s being used by treatment centers to get people in the door. But it becomes completely meaningless when held up against tests including the need for replication, placebo effects, and, as you stress, real-world settings. In Anne Fletcher’s book she mentions how Hazelden recently reported optimistic outcome stats: after a year out, former residents reported using considerably less. What the report didn’t mention was that the sample of respondents had dropped to roughly half. Hmmm….wonder how things were going for that other half.
It’s like Shaun said: to get rid of what leads us to addiction would be getting rid of what makes us human. So getting rid of something is the wrong approach. Rather we have to accept what we are and move forward.
The stigma issue you mention gets back to the topic of choice. If you choose to get treatment you’re trying, right? If only it were so simple.
The revolving door of treatment programs is set up by these programs. The programs are so disempowering that using is a no brainer after leaving one for the relief of dehumanization that occurs day after day for the duration of the stay. There are still to few support groups or treatment programs that encourage empowered change and the courts still favor 12 step programs or the MN model of treatment. The change in how abuse of a substance is viewed has to include the legal and political structure. I am not saying this can be accomplished in one book but I do think the outlook has to be considered as an end goal. It is a matter of setting someone up to fail by tearing them down and asking that they summit to another rather than getting in touch and aligned with the empowered part of themselves that can be trusted. Getting in touch and aligned with the empowered part of themselves that can be trusted and building on that has to be the goal of any treatment or it will fail more often than not. At that point the person, family and community is left with an underpowered, uninspired therefore misdirected being playing out the very few choice available to the imagination, which is the state of mind the treatment/legal system left them in. Nobody wins here which is why prisons are overcrowded. Your book, Marc, is important in changing the direction of where many that abuse substances end up. Perhaps that is what your editor was pointing to.
Yes, that’s exactly what she was pointing to, and I hadn’t seen the forest through the trees until she, Matt Robert (from this blog) and his partner Cathy led me by the hand.
Your points are very well taken. I just watched The Anonymous People (https://vimeo.com/ondemand/theanonymouspeople), on Matt’s insistence. The issue of empowerment is hugely important.
Which is why I was particularly moved by the often-heard quote, again provided by Matt: ““We’ll have to break you down so we can build you back up again.” And I included that picture of the smiling doctor in my post. I get chills just looking at it.
WHOA!!!! here Marc. I rarely disagree with you but I sure do here . Big time . YOu have described the worst of the worst . The only thing wrong with the disease model and medicalization is it is incomplete. And has the huge benefit of money for research and improved compassionate treatment .
What needs to change is not that approach but the treatment system and the doctors who practice where they will see such patients – changing the docs will not be easy but easier than changing any other social system . Compassionate care by primary care physicians who have learned the basics , the pharm, and enough of the psychology to know when to refer to a psych expert . And refer to appropriate mutual support groups for continuity . And sensitive to environmental forces . And finally the background to understand the good science that will move treatment forward.
Recovery is all about motivation to change and the helpers can do this by facilitating it that motivation .
That enough to focus your attention for a bit??
I love Rat Park– for rats !!
BillA ( MD.)
Hi Bill. We sure do disagree here. Medical doctors have a place in rehab/treatment, but why should it be the central role? Why should doctors be referring addicts to a psych expert or support group rather than the other way around?
I see addiction as a psychological problem. Maybe you see it as a medical problem, but I’d sure like to hear how that makes sense. I mean, we all know that withdrawal symptoms are a tiny fraction of the struggle to get and STAY clean. And many substances, not to mention behavioural addictions, don’t produce withdrawal symptoms at all. Most of us agree that “psychological addiction” — viz craving, etc — is the real barrier to abstinence. So why oh why should doctors be the front line?
I think you’re implying that the medical profession is best poised, given the society we live in, to work with addicts. Really? Doctors are paid by insurers who are notorious for calling the shots entirely on the basis of profit. Insurers would be foolish to pay for medical addiction treatment on a large scale — primarily because it’s ineffective.
Doctors need to deal with medical problems. Do they have time to spend an hour or two or three per week with an addict going through the psychological gyrations of quitting? At what cost? And who pays?
My brother is an MD — I have great respect for doctors, but they need to know their place. The fact that Medicine has a great deal of control over the money and power needed to deal with serious social issues does not indicate, in my view, that doctors should control addiction treatment. On the contrary, so much of that money and power has been wasted; maybe it’s time to turn over the authority to others. Like psychologists, psychotherapists, social workers, support group facilitators — or how about a whole new brand of addiction specialists, which seems to be springing up everywhere? Training is needed, of course. But only a fraction of that is medical training.
Severe personal and social problems are not necessarily medical problems. We don’t send victims of abuse, or racism, or family discord, or broken homes or broken hearts to doctors….we send them to someone who has the time and expertise to listen, not prescribe, and to help. And even depression, which doctors like to call an illness, has been dismally handled by Medicine and Pharmacy. I’m sure you know about the meta-analyses showing that treatment with SSRIs is sketchy at best.
When your stomach hurts, you need a doctor. But when your soul hurts, you need something else.
We probably arent as far apart as it seems. And Ill await to learn your approach before further comment.
We do agree that it is NOT a disease and is a malaptive coping strategy – yes with learning and desire in the mix .
YOur approach is from the pure science side, mine is the pragmatic
Cheers
Fair enough, Bill. I should also mention that I appreciate hearing your views, all the more if they’re discrepant from my own. This is a good place for debate as well as consensus.
Also, I don’t claim that “my approach” is all that amazing. In fact, I don’t really have an approach, per se. But having thought for a long time about fitting the neurobiology to the experience of addiction and recovery, I think I at least got some perspective on what’s most likely to work and what’s least likely to work — and why — across the panoply of treatment options that are already out there. With the help of Matt and Cathy, who know the treatment world intimately. Plus some thoughts about where new approaches can help fill the gaps.
So, in the famous words of the gay director in Mel Brooks’ The Producer (the original version), “Be cruel!”
I’m confused–a model for why addiction occurs or the model that’s useful in treatment?
I’m thinking about Scott Stossel’s strategy in his marvelous book about anxiety–that anxiety is a complicated mess of factors genetic, environmental and attitudinal–that all the models have holes in them and that building resilience is possible no matter what model we ultimately settle on. I went around yesterday buoyed by that idea–yeah, I’m a part-time alcoholic and full-time dysthymic but I’m more resilient, by God, through trying out all kinds of interventions and skill-building.
So why not punt? Say an ultimate model for why it occurs is not settled but that we don’t need an absolutely correct model to get people in off the ledge and no matter what model, we can build resiliency to any mental health challenge, whether it comes from addiction or just plain old life. I’ve got a young friend who hates the 12-step model of treatment–so I just tell him that it’s important to just be doing SOMETHING–kinda no matter what but start with the obvious stuff to help himself–it’ll add up and he may just find the model that works for him.
Then have fun showing the holes in some commonly accepted models, what they don’t explain very well and some practical pitfalls and horror stories of being too attached to one model for right now.
Seems like your editor wants something too black and white from you, like, what, you should settle the question conclusively for everybody? If only Freud had been modest enough to say it ain’t settled but that his model explains some things well.
Hope I’m helping. 🙂 Thank you for your hard work and honesty in the face of confusion and the chance to contribute.
Hi Tom. Very interesting comment. So if Freud had been satisfied modeling neurosis and never come up with psychoanalysis, would we be farther ahead? I don’t think so. But like you said, if I get you correctly, let’s punt. You don’t need to have a perfect model before you can get some yardage viz treatment.
I told my editor: Look, I don’t know much about treatment. It’s not my place to prognosticate. Etc, etc. She said: Look, understanding is only so interesting unless that understanding leads to helping.
Indeed, I did have fun knocking down the disease model for awhile, and sure, “my model” is incomplete, and I agree that a lot of the best guidance re treatment comes from common sense or at least intuition and a creative take on what’s available. Still, I think I found something to add as a finale for the book that links other people’s intuitions with my scientific breakdown. That feels like a good landing because it provides something for both worlds, gift wraps it in one package, and thus helps people in each world connect with the other one. To put it differently, trying to explain WHY something works may be almost as useful as figuring out WHAT that thing is.
I sure do agree with you that no one something is the answer. My conclusions are more about how things are timed.
Thinking about your reply, I hope that the neurology of it all is the ground that any other model has to respect. I often wished in AA to ask: “Wait–what’s the biology of that? What’s the brain science that informs that?” So I don’t believe in a toss-up between models, like the philosopher Feyerabend advocated, sorry I wrote it that way. Your hard-won knowledge of the brain is a powerful way to clear away or modify treatment models that don’t respect it.
Thanks, Tom. Yes I think the body is the ground. In my academic life we called it “embodied cognition.” Tonight I hugged my 8-year-old twins so tight, I felt the blood and sap that connects us,and saw it from a different perspective — the body is the shared ground, and the better we understand it, the more integrated our treatment models will become.
Wonderful, well-said. I don’t think a “model” will ever be able to contain the entire field of possibilities in recovery. But if we can punt or gain a couple of yards here and there it can be a life changer. Thanks, Tom for the wise words.
I commented on this idea of a model further down in this blog. Thank you everyone…. I know we are making a difference.
Thanks Tom, for bringing up the issue of resilience. It’s obvious that anyone who makes it out the other side of addiction and thrives, has it. But how do we identify, develop and support it in the lives of those vulnerable to addiction, without them having to go through it?
Wow!! What incredible insights from so many people who have thoroughly and agonizingly studied this. This should be published somewhere.
Oh, wait. It already is…:)
I find myself agreeing with everything. This has to tell us something, about how to get this moving, just like the internet exploded exponentially ( they even have in-patient for that “addiction” now). Open source everything.
Medicalization, criminalization and stigmatization haven’t worked out so well in treating and preventing addiciton. Treating it as a disease, an ethical failing, or somethiing that needs to be hidden away somewhere only turns our focus away from potentially productive avenues. Viewing it as a normal element of human development gone awry may shine the light in a more useful direction.. Looking at it in the shadows with a flashlight, maybe not so much. This’ll persist as long as we continue to regulate ourselves with unhelpful methods. I know, I know…old news, right? We need tools to lean into the challenge as humans have always done. And our ability to flood the world with media appears to be a pretty potent one It lays out options, and options are what we lose as addicts.
Okay, now somebody kick this soapbox out from under me before I hurt myself.
Nah, that was good. You can preach here any time. Even if we are, by and large, the converted.
…but it starts to feel like I’m a whiny old person wagging my finger from my rocking chair… oh wait..
Hi Marc,
Your proposed paras hit some deserving targets, but the are some gaps in this answer, thus far.
“Treatment” in hospitals and facilities is often disempowering. Heck, even for broken ribs, I was somewhat reduced to ‘do as you’re told.’ That does not mean that broken ribs are not a real injury.
What you come close to saying, but might put more directly is that for psychological problems, e.g. ‘depression’ any ‘treatment’–for a whole lot of cases– must involve a social approach. Many depressed people are isolated, for example. Some hospitals, with their social work staff do try to help. Yet obviously “doctors know best” may interfere with social approaches (“We’ve done what we can; Ms. Jones relations with family is not our concern.”)
Note that many of these points apply generally to ‘psychological disorders’ or ‘psychosocial problems.’ They are not peculiar to addictions, so called.
That being said, your general point is that *narrowing focus*, esp. in the current ultra narrowing to ‘brain states’ that supposedly show ‘brain disease’ is the opposite of the way one wants to go. I have just finished reading a fine chapter
about cocaine and medical approaches to it (summarizing the rat research).
They make the point you’re making rather eloquently:
http://www.druglibrary.org/schaffer/cocaine/crack.htm
The Social Pharmacology of Smokeable Cocaine:
Not All It’s Cracked Up to Be
John P. Morgan and Lynn Zimmer
Chapter 7 of Crack in America: Demon Drugs and Social Justice
Craig Reinarman and Harry G. Levine, editors
©1997 by The Regents of the University of California, ISBN 0-520-20241-4
When animals are allowed to interact socially, their drug consumption also tends to decrease. In one series of studies, rats were trained to drink a morphine solution but then permitted access to an open area populated with other rats and scattered with objects for inspection and play. These opportunities for exercise, play, and socializing markedly decreased their consumption of morphine (Alexander et al., 1981).[35] Environmental factors also affect the trainability of rats for cocaine injection-for example Schenk et al. (1987) found that rats reared in groups were less likely to self-administer cocaine than were rats reared in isolation
// Studies of drug self-administration by rodents, dogs, and even primates have garnered much attention but have not contributed much to understanding cocaine use in humans. This is true because the conditions used in most animal studies are so extreme, so unlike the conditions of ordinary human life. In fact, experimental conditions are expressly designed to maximize animals’ self-injection of cocaine. For example, test animals are raised in isolation or removed from social interaction with others of their kind. They are outfitted for solitary life and implanted with an IV injection apparatus. They are often starved to prepare them for their lives as cocaine “addicts” and almost always denied all opposing reinforcers—even sweetened water. And experimenters make unlimited supplies of cocaine constantly available. Thus, it is not surprising that researchers can train “nine out of ten laboratory rats” to inject themselves with lethal doses of cocaine (Bozarth and Wise, 1985). Such studies are then cited as scientific “proof” of cocaine’s extreme addictiveness—implying that what is true for rats is also true for humans. This is the clear message in the Partnership for a Drug-Free America’s “Dead Rat” video, which has been shown frequently on television.[36]
The National Institute on Drug Abuse has paid for much of this animal research and continues to do so—now defining as a prime objective the discovery of a cocaine “antagonist” that will block or counter cocaine’s effects and be useful for “treating” cocaine and crack addiction in humans (Leary, 1993; McNeil, 1992). This effort is premised on the idea that current “cocaine addicts” cannot stop using the drug—an idea that is continuously reinforced by the animal self-administration studies. However, the accumulated data on human cocaine use show that most users do not become addicted to the drug, and, of those who do, most eventually stop or greatly reduce their use. //
HI NN. A couple of points.
Treating injuries can work fine without empowerment, as you imply. That doesn’t mean that anything being treated without empowerment is, ergo, an injury. You and I agree that addiction is part of a class of “psychosocial problems” that are not best approached as medical conditions or diseases. And sure, depression is in the same class.
But my point is a bit different from the “let’s break away from neuroscience” approach — also embodied in Sally Satel’s recent book. As far as I’m concerned, let’s do the neuroscience until we turn blue. It won’t lead to a disease model. It will lead to a developmental model.
I’ll have to get back to the chapter you linked later. But if the point is about crack culture, then fine with me. The same brain that processes cocaine molecules also processes culture. In my world, you just can’t get away from the brain — nor would you want to, because it’s just a gateway, not a destination.
Thanks for your articulate and moving review of how and why animals get addicted in laboratory studies. I usually summarize this point under the heading of the Rat Park studies conducted by Bruce Alexander, which you also refer to. And I agree with everything you say about the “causes” of addiction in these cases. Note also that, even though the establishment has kinda missed the point here, others have not. Carl Hart’s work shows clearly that cocaine/crack/meth “addiction” is governed by environmental conditions. See also Alexander’s 2010 book, The Globalization of Addiction — http://www.amazon.ca/Globalization-Addiction-Study-Poverty-Spirit/dp/0199588716/ref
What’s wrong with treating the “disease” of addiction?
It doesn’t work?
That’s pretty much straight to the point, isn’t it. I’ll get back to you on your longer post soon….
Marc: I haven’t posted a comment for quite a while, but I’ve been following your blog pretty closely since the book was released in Canada.
You are right on. “A desire to change, aligned with personally derived goals” seems to be the nut of it. I’ve often noticed that it takes a very smart person to distill a complex problem down to it’s essence.
The disease model fails to address the fact that the “desire” is often fleeting. One moment there is a strong desire, but it often doesn’t last long, which leaves a narrow window to start treatment.
If a program can catch someone at the peak of their desire, the treatment itself is really as simple as providing the tools for an individual to identify and work towards new, healthy life goals. That’s really all there is to it. Hospitals and similar institutions are probably not be the best place for that. Depending on the addictive substance, pharmaceuticals might help with physical symptoms.
I can’t help but think that we really need about as many treatment options as there are “personalities” especially if the goals must be personally derived, which I agree they must be.
Looking forward to your next post.
Peter
HI Peter. I would reply “precisely” to everything you say, except that this would be immodest about what a smart person I am. And it’s probably more luck and even artistry more than smarts that helped me reach that conclusion. Oh, and having very insightful others to talk with. A good book, poem, paragraph, thesis or article ought to end up referring to whatever it started out with. So, yeah, the biology of desire….it never goes away. Never.
And it is ever-present, and mercurial, and it is especially mercurial in addiction, because of the influence of dopamine on “delay discounting”…which I call “now appeal”. Strike while the iron is hot or forget it.
And by the way, this brilliant conclusion also occurred to my friend and former addict Peter Sheath, who just started a very well-funded program to get help IMMEDIATELY to addicts who badly want to quit…right when they want to quit. No biology needed. Probably what helps most of all is having been there oneself.
More in a few days…
I would just like to say NO WAY! Did Mark just say “Part 2 — what’s the alternative? — coming up next post.” ??? Cliff hanger, really? wow – so not right : )
You should be happy. You have to pay for that with TV.
Dear Marc/Contributors:
Thank you all for reminding me why I visit/contribute to this amazingly thoughtful forum! My first and foremost thought is why must addiction be defined/understood in such binary terms?? There are surely enough studies to suggest it is both a choice and a disease (depending on where you look). So, Marc: back to to your editor’s comment about implications for treatment….
Isn’t that putting the cart before the proverbial horse? How can one (i.e. you 😉 even suggest implications for treatment when treatment is still (mostly) in it’s rudimentary stages???
I struggled like heck to find appropriate support, and have a strong background in research/mental health etc. Even still, I can’t begin to explicate the flaws I found in the “system/s,” which are most often shaped by social, political, economic and other factors (to name a few).;
Hopefully, the theory/research will be more informed by – and follow – the practical realities.
Jasmine
HI Jasmine. It is a thoughtful forum, isn’t it. I see what you’re saying about implications for treatment. The political and economic realities are becoming increasingly clear to me. While medicalization is far in the lead when it comes to defining treatment, the actuality doesn’t follow. The disease model has become deeply merged with 12-step methods in a vast majority of treatment/detox centers. That’s such a weird marriage! And it falls out into two vastly different worlds: state-run (free) rehabs that are generally terrible in every way and private rehabs that are way too expensive for most people. The latter have a chance of working, but not because of disease thinking or 12-step principles. As far as I can see, they work mostly because people have a chance to relax in the country, ride horses, swim, or whatever, and feel good doing non-drug things. But there’s just no rationale to connect these “cures” with mainstream thinking about addiction. What a mess!
Let’s see, we’ve got somebody engaging in a behavior that’s wrecking her life and that, if continued, will end her in hospital, institution, or dead, that continues to worsen in spite of the consequences, and that requires some sort of major intervention, epiphany, or treatment to remedy, and she’s not sick?
And there are psychological addictions that are not reflected and underlaid by brain states?
Implications for treatment? She’d better do something different, behaviorally long term, something that sticks the same way the addiction did, and provides some quality of life worth having. Improvements in treatment would entail helping people break through denial and helping prevent (especially early) relapse.
Are there bad and stupid treatments out there? Absolutely, but guess what? Some folk have gotten sober through them. Are their many paths to recovery? Absolutely. Is there one right path for everyone? Probably not. The key to recovery lies in the addict, not in the treatment. The blind don’t need light; they need eyes. One of the major implications for treatment is that mindfulness meditation is good for addicts.
And what’s this about dissing animal studies and pre-clinical trials? Talk about throwing out the baby with the bath water.
OK. Off the soapbox, Nick
Nick, I’m delighted that you pitched in. Though slightly nervous. You should stay on that soap box and let me have it.
I’ll try to come up with a more textured response soon…….
Nick,
You distill points well. You clarify the issues. I have some exceptions to take, but offer them in an friendly way, respecting your point of view and experience.
NR: //Let’s see, we’ve got somebody engaging in a behavior that’s wrecking her life and that, if continued, will end her in hospital, institution, or dead, that continues to worsen in spite of the consequences, and that requires some sort of major intervention, epiphany, or treatment to remedy, and she’s not sick?//
She does not have a disease, no. Her behavior may become a problem for her in the same way as for one who enters cemeteries repeatedly, and defaces Jewish headstones. (Arrest, etc.) Her behavior may bother others, but there’s less chance of this if she’s well off (drunk on her own private estate).
[…]
NR: //Implications for treatment? She’d better do something different, behaviorally long term, something that sticks the same way the addiction did, and provides some quality of life worth having. Improvements in treatment would entail helping people break through denial and helping prevent (especially early) relapse.//
Well, a judge can say, “No more vandalism, else jail time!” It might work. But let’s assume for the sake of argument, your first point. She’s sick; she has a disease. Then “better do something different” rings rather hollow, doesn’t it? For a real, full-on, disease like major clinical depression, do you say, “Better do something different”? “Get out more often”?
//helping people break through denial// I think perhaps this has been overemphasized, esp. in those who’ve been around the treatment block as few times–e.g. Philip Seymour Hoffman. These addicts are often quite aware of consequences. There is a general issue of ‘denial’ that holds in those
causing problems or discomfort in others, e.g. narcissistic personality disorder.
(“Your reactions are not MY problem!”)
To conclude: It’s true that the things you mention need to happen, just as the poor need better schools. Who’s providing for this ‘treatment’ is one question.
What options does a person have in accepting/refusing it, is another. But it’s not logical to go from “Something should be done” to “We have a disease on our hands and we’d better find a treatment for it.”
Great to hear your ideas!
Well said.
Hi Nick. I read this again. I’m reading along and pretty much agreeing with most of it…and thinking, ok, he doesn’t like that I don’t like the term “sick”….well, whatever. And then you say something like “the key to recovery lies in the addict, not the treatment.” Wait a minute. If that’s what you think, then the sick/disease model isn’t doing it for you either. What sort of medical thinking could endorse the logic that the “cure” is not in the treatment? And since we both agree about the value of self-motivation and empowerment, I think there’s little that we differ on, except your weird attraction to the “disease” label.
And of course there are brain processes underlying every psychological process, including behavioural addictions. I’ve recently written two books claiming exactly that. What’s the point? If there is a brain process involved, then addiction is a disease? Then so is thought, emotion, memory, learning, hell, life itself.
It seems we disagree on very little except matters of definition. But we already knew that.
Marc, you know how much I enjoy our discussions. If I didn’t respect your thinking I wouldn’t bother. It’s pretty weird that we agree about so much and disagree about what’s wrong with these people. I think that how we frame it up and what we call it matters because it drives our strategies for intervention.
Let’s go back to OCD and addiction. I think we agree that the behavior begets the behavior. I’m not sure that the defacer of Jewish cemeteries is the same. I suppose he could be obsessively anti Semitic the way Ted Nugent is obsessively anti gun control and the obsession drives behavior but in a more scattershot way: swastikas on temple walls, nasty comments on Twitter, burning dreidels, etc. anything that provides fuel for the fire. But it stays intentional in ways that addiction doesn’t. Addiction has that Pavlovian conditioning that divorces the behavior from both intent and result. The knot is tied tighter in addiction.
On a larger scale, increased polarization and hardening of belief systems in society leads to more lock-stepped conformity. So to fit in you have to be anti gay marriage, anti climate change, anti immigration reform, anti environmental protections, anti abortion, pro capital punishment upfront, and be initiates of the coded misogyeny and racism, and operate out of fight/flight; and you have to toe the line completely; any deviation is apostasy, any hint of compromise treason. At what point is being caught up in the mutually reinforcing thoughts and feelings sick? Is unhealthy necessarily sick? Is emphasizing what to think instead of how to think ok? Are Nazis sick MF’s or products of overlearning? Do we tell those afflicted with addictions that they’re sick or that they have an overlearning issue?
Do addicts in sustained recovery see their former selves as having been sick? Obviously I think that devolution is sickening. Which, BTW, is why I asked earlier if mindful detachment is the opposite of addiction. Gimme some of that PFC and ACC!
Nicolas,
That’s an insightful and thoughtful contribution about the self reinforcing world
of the addict.
There’s a very thorough and careful review of mindfulness studies related to addiction, online:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800788/
Subst Abus. Author manuscript; available in PMC Oct 1, 2010.
Published in final edited form as:
Subst Abus. 2009 Oct–Dec; 30(4): 266–294.
doi: 10.1080/08897070903250019
PMCID: PMC2800788
NIHMSID: NIHMS150897
Mindfulness Meditation for Substance Use Disorders: A Systematic Review
Aleksandra Zgierska, MD, PhD,* David Rabago, MD,* Neharika Chawla, MS,** Kenneth Kushner, PhD,* Robert Koehler, MLS,*** and Allan Marlatt, PhD**
I read this after replying to your previous comment. Well we both agree on one thing: that we agree on almost everything except what to call it.
I’m truly not sure what you’re saying here. Your dystopian view of society (not surprising, given that you live in the US) is one thing. But are you saying addiction is or is not a part of this condensing wrongness? Or you don’t know? Bruce Alexander sees addiction as precisely part of the alienation caused by current cultural trends. But I think you’re saying that these are very different. That addiction is more like OCD (self-perpetuating and uncontrollable) than it’s like the bad things people do because….they’re angry or stupid or misinformed. Have I got that right?
If so, I still partially disagree: defacing synagogues or mosques or, for that matter, picking up a gun and killing in the name of religion, still seems to me partly compulsive. Not that people who do these things shouldn’t be punished. But overlearned thinking and behaviour naturally gravitates toward compulsion. This happens psychologically as activation and synaptic change move “northward” along the striatum, from the ventral Nucleus Accumbens to the dorsal striatum. I know, I know, I’m sorry to get technical. But I’ve been learning all this stuff from the neuro literature. And it’s really important.
I am all for the neuroscience since I believe it underlies the conditioning of addiction. What I am talking about in the larger sense is closed systems whether biological (kindled seizures), psychological (fanatical beliefs), behavioral (addictions), or social (cults). I think that we agree that the shift from ventral (NAcc) to dorsal striatum reflects a devolution in function, impulsive to compulsive. I think that we also agree that kindling is relevant to addiction and OCD. The loss of self-regulation is reflected in the reduced D2 receptors in the PFC and we sometimes describe the loss of control in addictions as like a car with no brakes: once in motion it can’t stop itself (“Once I started drinking I couldn’t stop”). What stops it? A crash, hitting bottom, something from without, a revelation perhaps, the self is the recipient, not the agent. “There’s a crack in everything: that’s how the light gets in” as Leonard Cohen says. The dysfunction of delusion is malfunction. Ron Siegel says that the brain evolved to create difficulties for itself. If malfunction of other organs is disease, why not of the brain?
My son got better after he got a “real” disease. AIDS. This brought him off the streets, into truly therapeudic settings with doctors and caregivers, services, friends and family. He stopped using drugs, stopped going through the endless cycles of rehabs,clinics, jails, homelessness, lies, and brokeness. He stopped behaving like an addict.
He formed relationships with his doctors and built a network of support.
In the past, we were unable to “cure” his addiction no matter what anyone tried. As it took a back seat to his health crisis, and he began to care for himself, we saw healing that previously was unimaginable in circumstances we had not anticipated. He lived in a shed with a rescued puppy for the first months of his recovery and walked to his doctors offices. He got services from an AIDS organization and got some transportation and meals and other support. He moved into an abandoned house with the permission of the owner and fixed it up for himself and his dog. He took his medicines and stayed away from other drug addicts. He protected himself. He planted a small garden. Someone gave him a few baby chicks. I started to bring him food and we rebuilt our relationship.
Just like his fall into addiction, his rise from it had many many components. I know there is not one model for what creates an addict and I believe there is not one model for the cure. If we can accept that there is not one model for cure… then we can open our hearts and our minds and keep the light on. It may very well show us things we had not imagined.
Never did I think that AIDS would give me back my son, that we would reunite in a shed with him 40 lbs underweight but more alive than he had been in years.
Healing comes in ways we do not fully understand. It can’t be bought or sold or, sadly, even duplicated.
We are on the right track in knowing that it can’t be admisistered across the board according to one formula.
It is a shared journey.
This is a very important perspective. Anyone who reads this should look at Janet’s “guest memoir” here: https://www.memoirsofanaddictedbrain.com/guest-memoir/immortal-pain-loving-an-addict/ It’s another feature of this website, and by the way please contribute something if you wish. Shifting from Janet’s Memoir to her present comment reveals a very moving before-and-after story of addiction and recovery.
Thanks again for sharing this remarkable saga.
Hi Marc
I await Part 2 with interest
As someone who works in a high end 12 Step treatment centre – I feel we can offer our clients more than telling them they have a disease and giving them step work
I enjoyed your first book and am curious as to how therapists such as myself can work alongside the latest research and insight from Neuroscience and apply to a clinical setting
Richard
Hi Richard. That’s good to hear. You sent this in before I replied to “jasmine” above. If you look at my comment you’ll see a pretty pessimistic view of things, including high-end rehabs. I’ve gotten more pessimistic about treatment by tuning into what’s going on in the lives of so many addicts, reading Anne Fletcher’s book, and scanning the offerings of treatment centers, their price tags, and their muddled outcome reports. But I’d sure like to hear more about what DOES work.
We should talk more…and maybe the upcoming book will offer some suggestions. I’ll post Part 2 shortly.
Hi Marc
You’re preaching to the converted! I work at my current facility as part of my clinical placement and am not a 12 Step convert by any means. Having been through that particular treatment model myself -I came to see the language and labels as both restricting and self-perpetuating. My main concern with what I see on a daily basis with clients is them being given labels and the negative attribution that comes with that and being given assignments that I had in treatment over 17 years ago ! A new paradigm in treatment is needed. I am impressed with the work that CMC are doing in New York (without knowing their outcomes) An ongoing dialogue with yourself would be really beneficial , as a therapist I keep coming back to the same questions – such as how can I intergrate the latest addiction research from people like yourself into effective clinical practice without having to go and study neuroscience ! ?
Richard
Very insightful article and sounds like a great book “Chasing the Scream”
http://www.huffingtonpost.com/johann-hari/the-real-cause-of-addicti_b_6506936.html
Yes, this has gotten a lot of publicity lately. A book about the failure of the War on Drugs sounds very timely and important. I haven’t read the book yet, just the blogs/articles about it. But I hope Hari realizes that social variables like isolation and disenfranchisement have been studied quite a bit since Alexander’s breakthrough Rat Park studies in the 80s/90s.
Greetings Marc/Contributors:
Just came across this interesting article that calls into question the “causes” of addiction. I know a great deal has been written/researched on attachment theory, though I can’t help but wonder if this article is all that overly simplistic?…
http://www.the-open-mind.com/the-likely-cause-of-addiction-has-been-discovered-and-it-is-not-what-you-think/
I hope you all enjoy the read,
Jasmine
Hi Jasmine. This is the same book as linked above by Cheryl. Good find.