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.
The Meaning Dimension
The acute effects that drugs have on the brain are rewarding and become meaningful in relation to the whole person in his or her social context. People use drugs because they feel good and are reinforcing in some way. People who use drugs in problematic and addictive ways do so for reasons that feel vital to the user’s well being or survival. The pleasure, satisfaction, escape or high is always in relation to suffering and pain. There are several broad categories of suffering that render people vulnerable to problematic substance use.
Dr. Edward Khantzian of Harvard coined the “self-medication hypothesis” in 1985 to describe the use of substances as an adaptive attempt to heal or self-treat suffering. “Fixing” may actually refer to an attempt to fix something that feels broken inside. Depression, anxiety, stress, grief, boredom, despair, rage are common companions of problematic substance use. The turn to the substance may also reflect inadequate capacities to self-regulate feelings, soothe or comfort oneself such that feelings are experienced as overwhelming, confusing and frightening. In these cases the substance may feel necessary to one’s psychic survival and to maintain a sense of control of feelings and behavior.
- Rebelling against the Inner Critic
The release afforded by the drug effect is frequently a release from a generalized sense of inhibition, an inability to express one’s feelings, needs and vulnerability spontaneously in life such that one feels dead, cut off, disconnected and tense. The inhibition may be a response to a demanding, perfectionistic, self-critical personality style related to a harsh “inner critic.” The critic may not allow one to relax because one’s work is never done, one’s achievements are never good enough, one may be filled with anxiety about the threat of failure or depression over feeling that one has already failed. The substance is hard to give up if it is the only key to one’s liberation from the tyranny of the inner critic.
- Interpersonal Meaning
The reliance on a substance as a form of self-care frequently also reflects serious difficulties in interpersonal relating: profound mistrust of others, shame at expressing needs to others, and so on. Here the substance may become the more reliable parent, friend and lover. Drug use may also free people to express feelings and needs in the act of using that people are unable to express in words interpersonally, such as anger at feeling controlled by a boss or spouse that one feels too vulnerable or insecure to express directly. One patient said, “While I don’t feel safe enough to tell my partner that I resent the way he speaks to me when I drink too much, I can continue to drink too much to defy his efforts to control me and express my anger by killing him off in my mind when I am drinking.” Another patient said, “my drug use is my cry for help, the way I express my need to be cared for, my way of saying I am in agonizing emotional pain and never learned how to ask for help in the abusive family I grew up in. Please don’t reject me as my parents did, help me learn how to care for myself in a healthier way.”
- Social Meaning
The pleasure afforded by the substance may be particularly important in relation to a life in which there are few other sources of pleasure and satisfaction available such as lives of poverty, homelessness or increasingly common work lives in which the hours demanded leave little time for self-care and recreation. Mary is a 38-year-old attorney and mother of three young children. She is deeply dissatisfied with her husband in many ways, including sexually. She has great difficulty feeling and expressing anger and tends to direct anger and criticism toward herself. She has been injecting Oxycontin for the last year, originally as a way treat severe back pain, but increasingly to manage the stress of being a perfectionistic care taker of others, to quell her dissatisfaction and growing despair about her marriage and because she experiences the hit she gets when she injects in the following way, “the syringe is like my lover delivering the most perfect feeling like a wonderful orgasm.”
- Trauma and Dissociation
Sometimes the reasons for using are very much in the user’s awareness. However, in people who have experienced significant trauma early in life, substance use may become meaningful in ways that are outside the user’s awareness. If you ask these users why they use, they may not be able to say more than “I felt like getting high.” Trauma is typically coped with by dissociating, cutting off feelings and ridding oneself of parts of the self that threaten to bring about more trauma by overwhelming one’s capacity to function. Anger, sadness, grief, shame, humiliation, aliveness, curiosity all may become threatening and need to be suppressed and denied. These vital parts of the self may live in vague discomfort, just out of awareness, leaving the trauma survivor feeling tense, dead, tuned out, like a ghost, or “like Frankenstein” as one of my patients described himself. The substance use can provide the user a temporary experience of being able to connect with these parts and feel alive. In these people, excessive substance use is a meaningful reaction to trauma as an attempt to cope with what may otherwise be unmanageable pain.
When drugs carry and express important meanings for the user, the thought of giving the drug up or cutting back may be experienced as a threat to one’s psychic survival and capacity to function in the world. Trying to get someone to relinquish substance use without helping the person understand the role it served, and providing him with unique alternative coping strategies jointly discovered in treatment, is a recipe for failure. Unless the user has identified its meanings and discovered new healthier solutions, attempts to stop using will be met by understandable resistance. Psychotherapy is an essential ingredient in the treatment process. As the meanings and functions of the drug use are clarified it becomes possible to explore alternative less harmful routes of expression or satisfaction. Harm reduction strategies that minimize the risks associated with active substance use may be vital to the user’s health and safety. Some include using clean syringes, switching to safer substances and routes of administration, reducing amounts and intensity of use, not using alone, being attentive to general healthcare and nutrition. The harm reduction principles of meeting people where they are even if they are not ready, willing or able to embrace abstinence, and of accepting all positive changes in substance use as successes, allows users to begin the therapeutic process wherever they are in terms of their motivational stage and goals. This enables a collaborative exploration of the psychobiosocial variables that contribute to the addictive behavior. As the variables are identified it now becomes possible to bring together biological, psychological and social interventions to address them. Ignoring the powerful personal motives for using will subvert well-meaning efforts to support positive change.
Social Collusion with Addictive Dissociation
Might our culture’s tendency to neglect or ignore the multiple meanings of addictive behavior actually collude with and reinforce it? If addictive behavior expresses meaningful aspects of the self that the user disowns, might the cultural ignorance of the disowned meaning support the disowning of meaning in the user? The relatively greater national emphasis on punishing and incarcerating drug users and sellers and trying to get drugs off the street, an absurd and impossible fantasy, rather than emphasizing treatment and education reflects this ignoring of the meaning dimension. The “drug war”, against heroin in the 60s and 70s, crack in the 80s, crystal meth in the 90s, focused on the drug rather than the question of why are so many people drawn to these potentially devastating substances and other risky activities? I believe that in the minds and writings of addiction as brain disease advocates, their model does not preclude meaning but without an equally loud and clear proclamation that addictive behavior is meaningful activity, the brain disease statements can be interpreted to mean addictive behavior is a purely biological phenomenon that can be treated by purely biological methods: abstinence and medications.
So let’s remember that people use substances initially and throughout their using careers for multiple meaningful reasons that must be understood and respected so that they can be brought into treatment in ways that make new solutions and modes of expression possible. This renders substance use less appealing and vital to the user and supports an integrative treatment approach that addresses all aspects of the person involved with problematic substance use.
Andrew Tatarsky, PhD is the author of Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems. He is the Founder of The Center for Optimal Living, an addiction treatment center in NYC, and the Chairman of the Board of Moderation Management. He can be emailed at [email protected]