Posted on

IHR Podcast #25: Skin cancer, present state awareness training, collective health decisions, technologies of isolation, and the meaning of anxiety

In this episode of the Integral Health Resources Podcast, I talk about my very recent experience with skin cancer surgery, then I ramble on about a variety of health-related topics that may or may not hang together in a coherent fashion.

Media, resources, and photos referenced:

Earlier this summer…
After Mohs surgery to remove two basal cell carcinomas
Posted on

The role of biology in problems of thinking, feeling, and behaving

Pissing in the wind

It’s a new year, and I find myself living in a “post-fact” world of “fake news” with catastrophic failures of critical thinking everywhere on display. Happy New Year everybody! What holds true–if anything holds true these days–in the realm of politics is not fundamentally different from what holds true in other areas of discourse, like say, behavioral health. And that true thing is this: our current capacity for critical thinking cannot seem to adequately process, evaluate, and analyze the constant flow of information that is being channeled through structures designed to further agendas rather than deepen knowledge and improve understanding. That was a mouthful, I know. I just can’t help wondering though, Has all this blogging been just pissing in the wind? Have I myself been duped, or been duping myself, into a false sense of certainty and self-righteousness? Maybe. But at least I’m trying. At least I care enough to ask questions.

The first Friday of every month I attend a continuing education training for mental health professionals. The training takes place in a local psychiatric hospital, and is conducted by various local leaders in the mental health profession. This last training was on the topic of addiction treatment, and I was expecting to get a heavy dose of twelve-step and brain disease dogmatism, and that’s just what happened. What took me by surprise was how starkly unscientific the presentation was–not a single reference to a single piece of research, and how uncritical the audience was as they nodded their heads to statements like “This disease wants you dead!” I felt like I was in a church listening to a sermon. I left the training deflated and discouraged. How can there be any hope of a sane, scientifically grounded approach to drug abuse (or any mental health problem for that matter) when the thought leaders, experts, and armies of professionals are all in lock-step headed in the wrong direction? Fortunately, there are dissident voices breaking through via the internet ether waves. But again, perhaps I have constructed my own cozy echo-chamber in this regard. You be the judge.

Johann Hari, he of “Chasing the Scream” and TED notoriety, wrote an interesting op-ed in the LA Times the other day called “What’s really causing the prescription drug crisis?” The piece pokes holes in the most well-subscribed narrative regarding the current opiate crisis in America, namely that Big Pharma has hooked everyone on irresistible drugs, and that what we need to do now is restrict access to these powerful life-ruining substances. The holes in this theory might not seem obvious. Even John Oliver, whose entertaining critiques usually strike the right tone, seems to have blown past them.

First of all, Hari points out that less than one percent of opiate prescriptions lead to addiction, and that super strong opiates (like diamorphine) are routinely administered in hospital settings in other countries without causing people to become addicted. So, then, the drugs themselves can’t be root of the problem, right? If it were the drugs themselves, then opiate addiction should be spread evenly across the country to match prescription rates. But it isn’t. Opiate addiction is concentrated in areas where times are the toughest, like in the Rust Belt. It’s the tough times–and their impact on people who may lack the resources (internal and external) to cope with them–that are more likely to be the root of the problem, rather than any specific numbing agent. Furthermore, how can stringent opiate restriction be the best response to the problem, when the vast majority of people who use the drugs to manage pain don’t show problematic use, and when cutting addicted folks off from their prescriptions so clearly leads them to black market heroin use? This “War on Drugs” mentality might be well-intentioned, but it’s just making things worse. In order to come up with a more effective solution, we need to fully understand the problem, which means taking into account all of the facts, which would lead us toward addressing root causes (like poverty, social isolation, poor coping skills) instead of restricting the latest, most available, most potent means of killing the associated pain.

Of course, addiction is just one category of so-called “mental illness,” and a broader argument can (and has) been made against viewing problems of thinking, feeling, and behaving, in general, as biologically driven processes best suited for physiologically focused interventions. I have been pissing in that wind for years as well, but I have not come across a more thorough critique of the predominant psychiatric paradigm than in this recent article by Phil Hickey called The Biological Evidence for “Mental Illness.” Hickey makes many of the points that I have made–ad nauseam–in previous posts (e.g., HERE), but he makes them far more meticulously and convincingly. He also grounds his arguments in research and years of clinical experience. Here are a few of Hickey’s ideas from this article that are well worth chewing on:

Depression, either mild or severe, transient or lasting, is not a pathological condition. It is the natural, appropriate, and adaptive response when a feeling-capable organism confronts an adverse event or circumstance. And the only sensible and effective way to ameliorate depression is to deal appropriately and constructively with the depressing situation. Misguided tampering with the person’s feeling apparatus is analogous to deliberately damaging a person’s hearing because he is upset by the noise pollution in his neighborhood, or damaging his eyesight because of complaints about litter in the street.

What psychiatry calls mental illnesses are actually nothing more than loose collections of vaguely-defined problems of thinking, feeling, and/or behaving. In most cases the “diagnosis” is polythetic (five out of nine, four out of six, etc.), so the labels aren’t coherent entities of any sort, let alone illnesses. But the problems set out in the so-called symptom lists are real problems. That’s not the issue. I refer to these labels as inventions, because of psychiatry’s assertion that the loose clusters of problems are real diseases. In reality, they are not genuine diseases; they are inventions. They are not discovered in nature, but rather are voted into existence by APA committees.

Both Hari and Hickey hit the nail on the head by pointing out what should be obvious, namely that addiction and other psychological problems are most often matters of adaptation, of learning, which are process that all healthy, normal brains participate in as they interact with their respective environments. How else could it be that the vast majority of people with such problems get better through such means as talking things out, rearranging their priorities, determination to change habits, and improving relationships? While it’s true–again, obviously–that every subjective human experience is grounded in some activity happening in the brain from moment to moment, it is sheer nonsense to assume that common problems faced by vast numbers of human beings are matters of hardware malfunction. This might be true for the very few. But it is only through misaligned incentives and misapplied critical thinking that the brain disease paradigm has become mental health dogma.

*Mic drop*

Posted on

IHR Podcast #6: Mindfulness in Schools

In this episode of the Integral Health Resources Podcast, I describe and explore the potential benefits, issues, and challenges involved in implementing mindfulness-based interventions with students in K-12 schools. Topics include:

  • Clinical applications of mindfulness
  • The use of mindfulness-based interventions (MBIs) with both adults and children
  • A review of the research on MBIs, with a focus on the use of MBIs with K-12 students

ia resources that may be helpful/relevant to this discussion:

mindfulschools

Posted on

IHR Podcast #5: Addiction and Connection

In this episode of the Integral Health Resources Podcast, I reflect on various views of addiction, specifically focusing on a recent article by Johann Hari, who has a new book out called Chasing the Scream:The First and Last Days of the War on Drugs. Topics include:

Summary:

    The most commonly held views of addiction in American society (e.g., the 12-step model and the NIMH’s “chronic relapsing brain disease” model) do not stand up to critical scrutiny, scientific evidence, or common sense, yet they continue to hold sway. Alternative (and, in my opinion, superior) perspectives have been put forth and deserve careful consideration.

Here are some other media resources that may be helpful/relevant to this discussion:

ratpark

Posted on

Book review: Impatient Rehab, by J. Larry Vaughan

impatient rehabJust like he did with his previous book, Tell Me How You Feel About That, Larry Vaughan has delivered another powerful, practical, gem of a little book about helping people. More precisely, it’s a book for people who need help, in this case with the problem of addiction.

Although Vaughan warns us up front about his “untrained” writing style, we realize within the first few sentences that this simple, straightforward, utterly-stripped-of-pretense mode of communication is something to be celebrated rather than apologized for. Reading Impatient Rehab feels like a sit-down with a cherished mentor, or an extended, wisdom-filled session with a master therapist. Vaughan speaks plainly and directly to his target audience—i.e., the person in pain who is struggling with a chemical problem. Refreshingly free of the jargon and narrow-mindedness that so often characterizes professional discourse about drug abuse and addiction, Impatient Rehab cuts right through to the human core of this complex issue, and does so with integrity, humor, and a profound respect for the reader.

As a counselor in training, it’s easy for me to imagine having several copies of Impatient Rehab in my future office, and handing them directly to clients who might be suffering from substance use/addiction problems. In fact, that’s exactly what I’m going to do. In the meantime, I recommend this book to any folks—mental health professionals, students in training, medical professionals, friends, family members—who work with or support people struggling with addiction. Most of all, I hope this book finds its way into the hands, heads, and hearts of people who are themselves looking for help to pull through their particular problem and onward toward a life of increased health and happiness.

Posted on

Substance-Related and Addictive Disorders in the DSM-5

IMG_0124Of all the changes from DSM-IV to DSM-5, I am most keenly interested in the reframing of substance-related disorders and the related inclusion of gambling disorder as an “addictive disorder.” I spent several years working on a chemical dependency unit in a psychiatric hospital, and my main role was providing psychoeducational groups to adolescent patients who were diagnosed with a substance-related disorder. I also accompanied the patients to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings several times per week. One of the more challenging aspects of the job was that these inquisitive young patients often questioned me and other staff members about the many contradictions they perceived between AA’s philosophy/approach, the information packets about chemical dependency provided by the hospital, and their own life experiences related to substance use and abuse. For instance, they might say something like the following:

“I personally know several people who used drugs heavily for years and then quit or cut down on their own, without any treatment centers or twelve step groups. So, why is everybody here telling me I can’t stop getting high on my own, that I’m powerless over the ‘disease of addiction’?”

I found it difficult to integrate the various perspectives about substance use problems in a way that made clear sense to these young patients (and to myself as well!). DSM-IV focused on the distinction between substance abuse and substance dependence; the twelve steps focused on admitting one’s powerlessness over the spiritual disease of addiction; the National Institute on Drug Abuse (NIDA) described addiction as a chronic, relapsing brain disease; and our hospital treated substance-related disorders from a psychosocial perspective, focusing on group therapy, family therapy, and community support for our patients.

In the years leading up to the publication of DSM-5, I read with interest many media reports about the proposed changes to the substance-related disorders diagnoses. For instance, DSM-IV Task Force chair Allen Frances (2010) lamented that DSM-5 changes would lead to increased mislabeling of people with mild substance abuse problems as “addicts.” Ian Urbina (2012) published a widely read article in the New York Times which claimed that the DSM-5 would reduce the number of symptoms required for a diagnosis of drug/alcohol addiction, which could lead to many more people being inappropriately diagnosed as drug addicts. I was highly sympathetic to these critiques of the DSM-5 changes, that is until I read the DSM-5 chapter on Substance-Related and Addictive Disorders for myself. I discovered that many of the widely publicized critiques regarding this particular change in the DSM-5 were simply inaccurate, at least as they relate to the final published version of the manual. For example, while it’s true that substance use disorder in DSM-5 more or less combines the DSM-IV categories of substance abuse and substance dependence into a single disorder (i.e., substance use disorder), the new manual does not apply the word “addiction” to this class of disorders. The DSM-5 (2013) clearly states that the word addiction, while commonly used by both clinicians and laypersons around the world,

“is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation” (p. 485).

Also, contrary to the often repeated charge that DSM-5’s general criteria for substance use disorders have been weakened by the combining of the previous categories of abuse and dependence, a strong case can be made that the new criteria have been strengthened:

“Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11” (American Psychiatric Association, 2013, para. 2).

Furthermore, the American Psychiatric Association (2013) makes the case that the previous DSM-IV category of “dependence” was problematic, as people often seemed to associate the concept of dependence with the concept of addiction, causing just the type of confusion I noted above when describing the young patients I worked with at the hospital.

At this early point in my knowledge of the new DSM-5 criteria, I am inclined to see the revised substance use disorder diagnoses — characterized by overarching criteria across substance classes and a severity continuum ranging from mild to severe — as a potentially useful advance in the conceptualization of substance-related disorders. I’m not sure, however, how I feel about the inclusion of gambling disorder in the new category of “addictive disorders.” While I understand the rationale behind this inclusion (i.e., the available research associating disordered gambling behavior with reward systems in the brain that are also linked to disordered substance use), I’m concerned that this linking of substance-related and nonsubstance-related disorders requires a far more extensive re-visioning of the concept of “addictive disorder” than is provided in DSM-5. Assuming that future research establishes and confirms the requisite connections between other “behavioral addictions” (e.g., those related to excessive internet use, sex, shopping, exercise, etc.) and specific reward systems in the brain, another major revision of this DSM chapter will likely be necessary, and that hard-to-define term “addiction” might become even more difficult to understand and talk about!

References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author.

American Psychiatric Association. (2013). Substance-related and addictive disorders (fact sheet). Retrieved October 30, 2013 from http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf

Frances, A. (2010, March 30). DSM5 “Addiction” Swallows Substance Abuse.
Psychiatric Times. Retrieved October 30, 2013 from
http://www.psychiatrictimes.com/articles/dsm5-addiction-swallows-substance-abuse

Urbina, I. (2012, May 12). Addiction diagnoses may rise under guideline changes. New
York Times. Retrieved October 30, 2013 from
http://www.nytimes.com/2012/05/12/us/dsm-revisions-may-sharply-increase-addiction-diagnoses.html

Posted on

Addictionally irrational

Go to the National Institute on Drug Abuse (NIDA) website right now and you’ll see brains. Pictures, graphics, scans — a colorful display. You’ll also see a photo of Nora Volkow, NIDA’s director, whose “work has been instrumental in demonstrating that drug addiction is a disease of the human brain.” This would be all well and good, if pictures (or any other representation or analysis) of what’s going on in a drug user’s brain actually demonstrated that addiction is a brain disease. But they don’t. How it is that “we have come to believe” this irrational notion, that it has become the accepted truth among both lay people and professional orthodoxy, is simply mind-boggling to me.

As Stanton Peele has pointed out again and again, including today on his Psychology Today blog, the brain disease model of addiction defies both common sense and a reasonable interpretation of scientific research:

The chronic brain disease model doesn’t explain the most fundamental things about addiction, like how the vast majority of people overcome it without treatment, that there are no measurable biological means to determine whether and when people are addicted and when they are not, nor is there any treatment that addresses the supposed dopamine-based nature of addiction. In fact, the best science and therapy both point towards an entirely opposite, real-world way of defining “recovery.”

Meanwhile, as the idea of addiction as a brain disease is imbedded in our culture, we simply get more and more examples of brain diseases as more and more things are understood as addictions, and as we spread the idea further and thinner than any possibly scientific explanation can be spread.

This idea is not an expression of science. It is, instead, a cultural myth, one that the best and the brightest are obligated to endorse to be recognized as mainstream thinkers.

Don’t get me wrong — I’m all for learning as much as possible about the physiological and neurological aspects of addiction, and of all other realms of human experience for that matter. Of course brains (our organism/physiology in general) are absolutely foundational to all that we experience. A baseball bat to the head is all the evidence needed to establish that fact. But how, pray tell, does the plainly evident and obvious fact that all human experience is grounded and reflected in wonderfully complex and interesting ways in the brain and body lead to the notion that so many of our life problems are therefore fundamentally diseases of the brain? Imagine Nora Volkow’s perfect scenario, that after years of research we have finally and perfectly mapped all the changes that happen in the brain over the complete course of drug use and addiction. Imagine that brain scan technology could yield perfect scans and that we understood and interpreted the images perfectly. To my mind that still wouldn’t lend a shred of evidence to the notion that addiction is a brain disease.

A quick thought experiment: You are hooked up to this hypothetical machine (a super scanner) which can perfectly record all changes in your body’s and brain’s physiology, demonstrating with perfect accuracy every deviation from healthy homeostasis. You are put in room. In through the door on the far end walks a tiger. Your body and brain begin to go haywire. Hormones and neurotransmitters are sloshing around and completely transform your state of existence from one of total health and relaxation to one of total stress. The super scanner perfectly records every change and quickly prints out a recipe for a drug that will re-balance your system, with minimal side effects. While your state of stress and imbalance is clearly and dramatically grounded and reflected in your physiology, isn’t it a bit shortsighted to think of your problem solely or even primarily in those terms? If someone were to drop a cage on the tiger, your physiology would quickly and naturally move back to homeostasis without any need for a drug or any other physiological intervention. Your problem was primarily the presence of the tiger, not the changes in your brain that the presence of the tiger inspired. The solution–i.e. the appropriate intervention–to the problem was primarily social and behavioral, not physiological. In fact, the information provided by the super scanner, interesting as it might be, was completely irrelevant in terms of the practical solution to the problem.

Drug use and abuse changes what’s going on in the brain. Yes. Everything we do and everything that happens to us changes what goes on in the brain. Yes. Therefore, deviations from healthy, homeostatic brain and body states are best thought of as diseases of the brain? Not so fast Dr. Volkow. Studying objective brain changes is one of many perspectives that are worthy of consideration, focus, and scrutiny. Taken together with subjective, relational, behavioral, social, and cultural perspectives, we might yet arrive at a truly comprehensive, rational, integral approach to helping those seeking health and well-being.

Posted on

Misunderstanding addiction: The beat goes on…

Stanton Peele
Back in May I wrote a post titled Understanding Addiction, throughout which I bemoaned the fact that the National Institutes of Health (NIH) — one of the most powerful voices on matters of health and well-being in our society — continues to perpetuate the misunderstanding that “Addiction is a chronic relapsing brain disease.” Taking a partial truth and stretching it — so that it seems far more significant than it actually is — is the modus operandi of huksters in every sphere, and it’s becoming an all-too-familiar gambit of mental health “experts” these days. Shockingly, my blog posts don’t seem to be helping matters much. Stanton Peele, however, continues to be a lonesome but powerful voice of reason, calling out to those of us with ears to listen. Earlier this month, Peele reminded us on his blog that the NIH’s own alcoholism experts (within The National Institute on Alcohol Abuse and Alcohol) recently concluded the following:

1. 20 years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.
2. About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.

These conclusions, based on the largest study of people’s life histories of alcohol use ever conducted (43,000 people), completely undercut the accepted wisdom that addiction (to alcohol, at the very least) is a “relapsing brain disease,” and they also bring into sharp relief the utter ineffectiveness of the most commonly utilized treatment programs. Beyond this study, the accepted wisdom regarding addiction also fails the tests of sound reasoning, common sense, and an honest appraisal of existing evidence — a case that Peele has been persuasively making for decades. And yet when Americans want the best available information and recommendations about addiction to alcohol and other drugs, we’re told by Dr. Drew, HBO, and the NIH that addicts have a relapsing brain disease, that they can never learn to moderate their drug use, and that their incurable diseases can be most effectively treated by checking into rehab and attending twelve-step meetings. Is it any wonder why our best efforts to help people with drug problems are so ineffective?

Sadly, if we instead look to the most renowned non-government authority on matters of mental health, the American Psychiatric Association, we’ll find only further confusion. In another blog post, Peele describes the APA’s latest attempts to redefine the concept of addiction for the latest version of the Diagnostic and Statistical Manual, DSM-5. Peele was an advisor for the substance abuse disorders section of the current version of the DSM, DSM-IV, so he understands the process well. The upshot is that the DSM-5 Substance-Related Disorders Work Group, chaired by University of Pennsylvania psychiatrist Charles O’Brien, is proposing some major changes, including ditching the term “dependence” in favor of “addiction” (a term not used in the DSM-IV to describe substance abuse problems). Beyond that, the group also wants to create a whole new category–Behavioral Addiction–to refer to pathological gambling. The rationale behind designating only pathological gambling as an addiction (but not pathological sex-having or video game playing or anything else) is that, according to O’Brien, “substantive research” indicates that “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system.” Peele, as he’s done his entire career, clearly shows the fallaciousness of O’Brien’s reasoning, which suffers from the same confusions and category errors that have been holding our understanding of addiction (and mental health, more broadly) hostage for decades:

O’Brien’s statement represents a rear-guard effort to frame addiction as a brain disease. There is, indeed, imaging research on the ways various drugs affect the brain. But that’s not the key to addiction. I designed and administer an addiction treatment program, and I can assure you that not one person is sent to our program—or any other program—because of a PET scan. People enter rehab because of regular, habitual screwups connected to substance use—compulsive involvement and continued use of a drug (or other involvements) despite chronic harm.

Indeed, as O’Brien points out, powerful experiences like gambling impact the same “neurological reward system” that drugs do. But so do many other rewarding activities. If there is some such higher level “neurological reward system,” then it can’t be said to exclude anything, from sex to food to gambling to video games.

Nor is O’Brien correct in suggesting that cocaine, nicotine, alcohol, and marijuana follow the same neurological pathways in the brain. Each substance has a very different chemical profile, including the timing of effects and the rewards people derive.

And if gambling affects the same brain reward system as substances, as O’Brien claims, why is it a “behavioral” addiction and not simply an addiction? DSM-5 further muddies understanding of addiction in its handling of two other non-drug appetites—“hypersexuality” and “binge-eating.” Neither is regarded as an addiction. Is this because they do not follow the same “neural reward pathways” as drugs and gambling? Binge-drinking can bring on addiction, but not binge-eating? How come? And is gambling really more neurologically, or intensely, rewarding than sex?

The problem with the DSM-5 approach is in viewing the nature of addiction as a characteristic of specific substances (now with the addition of a single activity). But think about obsessive-compulsive disorder (OCD): People are not diagnosed based on the specific habit they repeat—be it hand-washing or checking locked doors. They are diagnosed with OCD because of how life-disruptive and compulsive the habit is. Similarly, addictive disorders are about how badly a habit harms a person’s life. Whether people use OxyContin or alcohol, people aren’t addicted unless they experience a range of disruptive problems—no matter how addictive the same drug may be for others.

Unfortunately, misunderstanding and misinformation are becoming part and parcel in health education across-the-board in our society. As with our political system, the agencies and organizations responsible for informing the public about matters of health and well-being have been way too corrupted by special interest groups (particularly) and the profit motive (more generally). Moving toward a sensible, fact-based, integral understanding of health requires that we critically appraise and analyze all information that comes to us, not only from the media, but also from the “leading experts” themselves. I have no doubt that the vast majority of individuals working at the NIH, the APA, as well as the countless mental health professionals across the country serving people in need, have only the best of intentions and want above all else to make a positive difference in the world. The same can be said of the members of the United States Congress, but a system can become corrupt, broken, and ultimately ineffective (even destructive) despite the good intentions of most individuals within the system. Our current way of understanding and treating addiction — like the broader “war on drugs” we’ve been impotently waging for years — just isn’t cutting it. Stanton Peele may not have all the answers, but his approach makes a lot of sense to me.

Posted on

Understanding addiction

It seems reasonable to assume that if you want to know about a given topic, a good place to start is by checking out what the leading experts in the field have to say about it. For instance, if you google the word “addiction,” you pretty quickly are led to HBO’s Addiction Project site, which contains loads of information backed by such heavy-weights as the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). So what is addiction, according to the leading experts?

Addiction is a chronic relapsing brain disease. Brain imaging shows that addiction severely alters brain areas critical to decision-making, learning and memory, and behavior control, which may help to explain the compulsive and destructive behaviors of addiction.

Ah yes, the brain. The three pound hunk of tofu that is the ultimate source of all problems and all answers. (Deep, prolonged sigh.) Of course it’s true that any human behavior or experience can be understood in terms of neurobiology and brain states, and it’s also pretty clear that this understanding is valuable and worth pursuing. But it simply doesn’t follow—in theory or in practice—that therefore dysfunctional behaviors and experiences are neurobiological diseases. In our everyday lives, we take for granted that human life is complicated and plays out on many levels. And long before “neuroplasticity” became a buzz word, we already knew that what we do, how we use our attention, and how we relate to one another affects the quality of our lives (and the structure and function of our bodies/brains).

I worked on a chemical dependency unit in a psychiatric hospital for several years, and I’m fairly certain that most of the professional staff would accept information provided by NIDA (and most everything on the HBO site) uncritically, as I’m sure it fits seamlessly with what they learned in graduate school. But young people tend to question everything, and the patients I worked with were anywhere from 12 to 18 years old. Part of my job was to lead educational discussion groups with these kids several times a week. I also accompanied them to Alcoholics Anonymous and Narcotics Anonymous meetings several times a week. These kids constantly questioned staff members about all the contradictions they perceived between AA’s philosophy, the treatment center’s information packets, and their own life experiences. For the most part, the contradictions the kids brought up were crushed by the weight of authority, not cleared up by reasoned argument and explanation. I was quite often in the awkward position of covering for and/or attempting to recast the many misconceptions served up daily and repeatedly to patients, some of whom were desperate for accurate information. The kids (who were almost all cigarette smokers) would inevitably point out things like: “Nicotine is super addictive, right? Well, I personally know several people who quit smoking on their own, without any treatment centers or twelve step groups. So, why is everybody here telling me I can’t stop getting high on my own, that I’m powerless over the ‘disease of addiction’?”

As Stanton Peele (one of the few clear-thinking “leading experts” on addiction I’ve come across) has been pointing out for decades, addiction is and has always been politically and socially defined as much as it has been scientifically defined. Peele covers this ground thoroughly in his recent article The Fluid Concept of Smoking Addiction:

The neurobiological model of addiction is static. It is built on the difficulty – often stated as the near impossibility – of quitting or moderation. The model does not attempt to explain how (or, more accurately, why) people cease addictions – even though such cessation is more typical than not with every type drug. The neurobiological model really has nothing to say about why smokers quit (as a majority do), for example due to the pleading of a spouse or a child. In the terms of the model, cessation is unexpected, unexplained, unpredictable, and simply falls beyond its purview or boundaries.

I used an Integral Health framework to help my patients make sense of their substance abuse problems. In practice, our entire staff operated under the integral premise, i.e. that we must address every conceivable dimension of the patient’s life if we hope to make the most effective impact. Some patients, especially those who were heavy opiate users, were given (non-narcotic) drugs to deal with their withdrawal symptoms. Other than that, there was little about the treatment program that had anything to do with directly impacting brain chemistry. We helped patients become more aware of their thought patterns. We taught them healthy coping strategies to deal with the challenging situations and emotions that would inevitably continue to crop up in their lives. We brought their families in for counseling sessions. We contacted teachers, probation officers, judges—anyone who would be working with these kids once they were discharged back into their respective communities—and developed detailed aftercare plans. We covered all the bases, because we knew that substance abuse problems both develop and are potentially resolved in a multidimensional, bio-psycho-sociocultural context. Surely, most thoughtful people (including the folks at NIDA) know this to be true, and yet the “leading experts” continue to present their oversimplified, disingenuous “brain disease” model to the public (complete with brain scan images that often signify very little, and the obligatory lip-service footnote containing the term “biopsychosocial”). I confess, I’m not entirely sure why this is the case. I suspect it has something to do with how government and academic institutions secure their funds. The more influence the pharmaceutical industry has on research and policy processes, the more traction the brain disease model seems to get. And, of course, the public eats up (literally, in the case of pills) easy answers and quick-fix remedies that require as little life-style change and psychological work as possible.

So, although it may seem reasonable to rely on the opinions of leading experts in a given field, this doesn’t always hold true when it comes to the field of mental health. Integral and integrative understandings of addiction and other problems do exist, but they haven’t yet had the appeal and/or financial backing required to capture the imagination of either the leading experts or the general public.

On the bright side, I’m sure all this will change once I click the “Publish” button and everyone on the internet reads this blog post!