We Don't Treat Brains, We Treat People
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The US government estimates there are 80,000,000 Americans with diagnoses of substance abuse, dependence or binge patterns, and we treat a tiny, tiny fraction of them effectively. We spend billions on the war on drugs, on research and on treatment and yet have little overall impact on the epidemic. As Dr. Richard Juman and others have noted, when you look at the repertoire of addictive behaviors evidenced by Americans, we have become a “nation of addicts.” Is addiction untreatable or are we simply going about it the wrong way?
The American Society of Addiction Medicine has re-affirmed what several NIDA directors previously declared, namely that “addiction is a brain disease.” This is a sophisticated and evidence-based restatement of Jellinek’s Disease Concept of Addiction, which has organized the field for over half a century. The idea that addiction is a brain disease relieves the addicted person of some responsibility for the negative consequences of his or her behavior and helps with the crippling shame and guilt commonly felt. This idea also suggests that greater understanding of the brain aspects of addiction will lead to advances in the medical aspects of treatment and, in fact, we are seeing an increasing number of medications that show some promise of helping in the treatment of addiction.
On the other hand, we don’t treat brains—we treat people. And, while there is no doubt that the brain is involved in addictive behavior more and more as an addiction intensifies over time, these proclamations can be misleading and make it easy to lose sight of the individual into whose life the “brain illness” has intruded. As examples, many addiction treatment programs throw people out of treatment if they don’t quickly stop manifesting the very behavior—substance use—that brought them in. They refuse to work on critical psychic and interpersonal issues, insisting that the patient is “not ready” to begin understanding his own existential position. Then, when the patient drops out of treatment because his needs are not being met and because he feels shamed and punished by the provider, the program tells him (and itself) that he has to “hit bottom” before he’s ready to be helped. What other specialty healthcare profession systematically operates in such a patently absurd and ineffective way?
Without addressing the meaning of addiction for the unique patient, as Stanton Peele suggested in 1985, attempts to resolve these problems are doomed to fail with most people.
The Psychobiosocial Model
Accumulating data and clinical experience support a “psychobiosocial” model in which biology and behavior intersect with meaning and social context in complex ways that are unique to each person and give rise to the problematic and addictive behavior. Alongside the brain changes associated with acute and chronic use, and the powerful conditioning of habits that accompanies them, the multiple personal and social meanings that substances carry and express are powerful motives for continued use in the face of negative consequences. From a dynamic/meaning perspective, the “addictive process” may be understood as an experiential behavioral syndrome that both expresses and, in some cases, disguises multiple aspects of the person: feelings, wishes, needs. Without addressing the meaning of addiction for the unique patient, as Stanton Peele suggested in 1985, attempts to resolve these problems are doomed to fail with most people.
To the extent that these factors are operative, the resolution of the addictive process requires that they are identified, brought into awareness and integrated into one’s life such that new less harmful, more satisfying modes of expression and satisfaction can be discovered. We don’t have the science to determine in advance with each patient how much each factor contributes. This must be determined over time in treatment with a deepening collaborative assessment between the clinician and patient. An appreciation of the meaningful reasons people use, the personal, subjective, often hidden dimension of drug use, is critical to every aspect of treatment: engagement, therapeutic alliance, assessment, diagnosis, treatment planning and successful outcomes for the entire spectrum of substance use problems. A treatment approach that integrates psychotherapy and biological and social interventions can dramatically increase our ability to help people with substance use problems heal, grow and create positive change in their lives. Failure to adequately appreciate this is a key contributor to treatment’s poor success.