Thoughts on The Overdose Death of a Young Woman

By Joe Nowinski 06/18/15

What it teaches us about a holistic view of addiction.


As we continue to explore the etiology and underpinnings of addiction, a variety of divergent theories of both cause and treatment are under investigation. Dr. Joe Nowinski, in reflecting on his work with a troubled young woman, looks at the limitations of the behavioral paradigm of addiction and argues for a more holistic view of etiology and treatment that includes long-term participation in a fellowship program….Richard Juman


“Ellie,” at 22, came to see me at her parents’ behest after signing out AMA from her second residential rehab, having spent barely a week in each. I was not the first therapist that Ellie had seen; she’d been in therapy since age 14—and always, I learned, to placate her parents. The youngest of three children, Ellie’s older brother was gainfully employed as an engineer and had recently married. Her older sister, meanwhile, was in the process of completing her education to become a physical therapist, like Ellie’s mother. Her father was a successful financial advisor. 

Ellie’s drug of choice was heroin, although she also smoked pot quite often and got drunk on occasion. Living with her parents, she would sneak out in the middle of the night—sometimes stealing money and taking one of their cars, at other times walking some distance to meet a friend. She, or they, would then drive half an hour or more to score some heroin.

Over time I came to think of Ellie as a sort of female James Dean—a rebel indeed, but one without a discernible cause. Her choice in clothing, in jewelry, in makeup, all screamed it. Through our conversations, I learned that she first began to become what she called “unconventional” at around age 13. While her sibs excelled in school—and although she struck me as very intelligent—Ellie more or less cruised through high school, with no set goals. The peers she chose to hang out with were all like her. She referred to them, with a hint of a smile, as “the aliens.”  

Viewed from a behavioral perspective, there was no reason why Ellie—like the vast majority of teens who abuse and become addicted to prescription opioids and heroin today—should have had an affinity for any drug. She came from a supportive, nurturing home. Growing up she enjoyed all the same resources as her siblings. Neither her sibs nor her parents had an affinity for anything more than what we think of as low-risk or “social” drinking. Yet there she was, stealing money and stealing away to get high. 

Ellie met with me on and off—more off than on—for about eight months, at which point she simply stopped showing up and did not respond to the voice and email messages I left her. My suggestions during that time included going to some AA or NA meetings and just listening. They also included spending more time with non-using friends (“I don’t have any these days.”) and thinking about how to say no to an offer to get high. (“I don’t really want to say no.”) And when I suggested seeing a psychiatrist to consider medications, she once again demurred.

Six months after her last no-show, I listened to a voicemail message from her mother telling me that Ellie had died of an overdose.

When I offered to meet with Ellie’s parents, I found two people who were both grief-stricken and baffled. Her mother said, “I don’t know why she stopped seeing you. She said she liked talking to you.” Hearing that, I confess, I felt my eyes sting. My response may not have been wholly satisfying, but I explained that my opinion was that Ellie had formed an identity—for better or worse—as she moved through adolescence, that set her apart from everyone else in the family. Part of that identity, unfortunately, was as someone who was not part of mainstream society, who liked to get high, and who had an affinity for others who liked to get high. Ellie knew from our work together that I was an advocate of 12-step recovery and of involvement in a 12-step fellowship as an alternative to her chosen peer group. I enjoyed talking to Ellie as well; but she would have none of what I was suggesting to her.

The Recovery Paradigm

Should we take the example of Ellie to mean that addiction is somehow fated? Not at all. That said, we clinicians must recognize that when we speak of the “biological” versus “environmental” causes of addiction, that environment is a complex psychosocial one for humans, one element of which is identity. Among teens in particular, identities such as “druggie,” “loser,” “outcast,” (and perhaps “alien”) are very real. Once crystallized, these identities play a role in determining one’s view of one’s self in relation to the world, one’s expectations, and consequently one’s behavior. Changing such identities is not easy. From my experience creating programs for addicted teens, though, I believe it is possible, if we are able to intervene early enough and comprehensively. Unfortunately, larger social influences operative today can eclipse the influence of family, which was once dominant.

The Limitations of the Behavioral Paradigm of Addiction

In a recent thought piece on The Fix, Dr. Bruce Alexander cites early experiments using an apparatus called “the rat box” as a paradigm for understanding the roots of addiction and, presumably, its treatment. He accurately cites studies which, in summary, demonstrated that rats who were housed in a “reasonable social environment” (i.e., with other rats) demonstrated less affinity for morphine than rats who were housed in solitary wire cages. Based on these findings he concludes that addiction in humans is not a brain disease but rather a disorder whose etiology is largely social.

As a means of demonstrating that the social environment can play a role in understanding addiction, the rat box paradigm is useful. However, as a paradigm for understanding and treating addiction in humans, I would argue that it is decidedly limited.

Behaviorists are famous for overextending the utility of their paradigm, with the most famous of these being, of course, B.F. Skinner. Skinner believed that human free will was an illusion, and that all behavior was determined by its immediate consequences—reward, punishment, or extinction. This in turn led Skinner and other behaviorists to anthropomorphize from their experiments with rats and begin to think of humans as operating in the same way. This form of thinking led Skinner to write a book, Beyond Freedom and Dignity, in which he argued that one could effectively create a humane society through the application of behavioral principles on a grand scale. Skinner exerted his influence on his graduate students, including Ogden Lindsley, who coined the term behavior therapy to refer to the application of behavioral principles to clinical problems. At its zenith, behavior therapy associated such things as the implementation of token economies in treatment centers (as well as classrooms) in an effort to “shape” both academic and social behavior, and Lindsley’s Precision Teaching which utilized a simple counting technique to reinforce positive behaviors and extinguish negative ones.

But are the mechanisms that drive human behavior the same as those that drive the behavior of rats? What constitutes a nurturing environment—versus one that might contribute to addiction—for a human? Do rats experience emotions such as guilt, grief, or shame that often sow the seeds of addiction in humans? Does a rat have an identity, like the one that Erik Erikson wrote of in his seminal book, Identity: Youth and Crisis, that becomes a template for the direction its life will take? Do rats have a sense of self at all? Do they have a sense of style, or what is trendy in the rat world? Do they respond to peer pressure? Can they contemplate a God or higher power? Can they be altruistic?

The point of all this is simple: the environment does play a role in addiction—but in humans that environment is a complex bio-psycho-social one. Dr. Alexander rightly empathizes with parents who are baffled and scared when their child turns to alcohol or drugs (or cutting or anorexia) despite their best efforts to create a nurturing and supportive family. I agree that too many in turn blame themselves, thinking they somehow have failed. Dr. Alexander argues that promoting a view of addiction as a brain disease—one that results from an innate vulnerability or what he calls “the demon drug”—offers a false sense of solace to these parents. 

A Holistic View of Addiction

An alternative to viewing addiction as having its roots solely in the social environment, and/or that it is driven strictly by behavioral principles, would be to regard it as a disorder whose etiology is bio-psycho-social in nature and therefore complex. This alternate paradigm might not satisfy those who seek a simple answer (and therefore a simple solution), but it more accurately reflects human (as opposed to rat) behavior. Addiction, for example, may not be simply a brain disease. That said, research informs us that alcoholism and drug addiction do affect the brain, perhaps more so in some than others. Some of us, therefore, may indeed be more vulnerable to “the demon drug,” in which the effects of substance use on the brain may lead to a vicious cycle of craving and tolerance.

For others, substance abuse and addiction may have its origins in this complex psychosocial environment that characterizes human development. It may have its roots in a dysfunctional adolescent identity (which parents cannot completely control despite their best efforts). It may be driven by unresolved guilt, shame, anger. It may be the legacy of loneliness, alienation or isolation. Stress may play a role, as well as grief. And to be sure, the social network we operate within plays a role. Here is an example:

If we accept the holistic view of addiction, then treatment becomes a complex challenge. In a recent book—If You Work It, It Works: The Science Behind Twelve Step RecoveryI organized and presented two-plus decades of rigorous research into the 12-step model of recovery from alcoholism and addiction. Although not perfect, that research clearly demonstrates that those who elect to become involved in a fellowship such as AA (and most likely others, such as Women for Sobriety) that offers ongoing social support for abstinence, offers significant benefit, even when compared to other options. Why is that? In my opinion, it has a lot to do with the fact that a fellowship is not treatment. Treatment (or rehab) begins and ends. Outpatient treatment typically relies on a single person—the therapist—as the agent of change. A fellowship, in contrast, is there for as long as an individual chooses to avail him or herself of it.

Fellowships offer ongoing support and caring. The agent of change here is a collection of individuals (actually, many collections of individuals) who may come from a diversity of backgrounds and experiences, but who share a common goal. They can be a solution to loneliness and isolation. They offer opportunities for long-term, communicative relationships, within which issues such as shame and guilt can be shared and healed. And they are venues for exploring spirituality and meaning as opposed to alienation. For some they offer an opportunity, through openness and honesty, to re-evaluate identity and set a new course in life. In 12-step parlance this is referred to as a “spiritual awakening” that alters the course of one’s life. All in all, as an agent of change and a solution for the complex problem of addiction, fellowships represent a much richer option than what we commonly think of as treatment. 

Joe Nowinski, Ph.D. is also the author of  The Identity Trap: Saving Our Teens from Themselves. He last wrote about why AA is OK.

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Joseph Nowinski, Ph.D. is an internationally recognized clinical psychologist and author of . If You Work It, It Works: The Science Behind Twelve Step Recovery. He has written articles for the Huffington Post, TheFix, and Psychology Today.. He has held positions as Assistant Professor of Psychiatry at the University of California San Francisco School of Medicine, and Associate Adjunct Professor of Psychology at the University of Connecticut. After retiring from the University of Connecticut Dr. Nowinski accepted a position as Assistant Professor at the Hazelden Betty Ford Graduate School of Addiction Studies, where he teaches Advanced Twelve Step Facilitation. He is currently in independent practice in Tolland Connecticut. You can also find Dr. Nowinski on Linkedin or follow him on Twitter.