When I began researching grassroots responses to crack-cocaine I found myself—albeit naively—both surprised and confused by heavy-handed, aggressive calls for more policing and harsher sentencing from working and middle class black urbanites. Was this unique to the period? Did this represent a specific and different response to the marketing invention of crack? Moreover, I found myself asking: What motivated calls to stigmatize and scapegoat members of their own local communities? Why would local leaders deliberately attract negative attention to their already beleaguered districts, thereby further perpetuating negative stereotypes regarding the debasement of inner-city culture? Where were the progressive voices calling for moderate, rational, public health responses?
“Rational”? Pretty condescending. It’s not to difficult to imagine this being a very rational response when trying, against great odds, to build and maintain strong, upwardly mobile minority communities in cities and neighborhoods that are constantly on the edge of disaster.
In spite of that, it’s a worthwhile read.
As, I’ve pointed out in previous posts, while policies like the crack sentencing guidelines have had horribly racist effects, the policy was supported by the Congressional Black Caucus.
Cabinet Magazine has an article on the bizarre history of Synanon from beginning to end:
Soon the number of people wanting to join Dederich’s after-hours sessions grew too big for his living quarters. This was largely due to an influx of drug addicts who had heard of Dederich’s ability to keep people straight. For the addicts, Dederich offered their only chance of salvation. AA didn’t want them and the state offered only hospitalization or prison. Sympathetic to their need, Dederich scraped together some cash and rented an old store on whose front he painted the letters TLC, short for “Tender Loving Care.”
The store was a safe place in which drugs, alcohol, and violence were forbidden. But the reason for going there was Dederich himself. Following the LSD experiment, he had become an awesome presence. He held seminars now in which he would talk for hours on end, weaving psychological and philosophical insights together and ridiculing, cajoling, teasing, and harrying the addicts who surrounded him. And most amazingly, it seemed to be working. When one addict slurred the wordsseminar and symposium together, Dederich suddenly had a name for his project—Synanon. It was a word redolent of “sin,” “Zion,” and, of course, “Alcoholics Anonymous.”
“I knew something,” remembered Dederich, “and I wanted to transmit this to other people. I had the feeling I could really make people more comfortable.” He would choose to do this by making them profoundly uncomfortable. Combining AA’s teachings with the cursory knowledge he had of psychiatry and a heavy dose of Ralph Waldo Emerson’s 1841 essay “Self-Reliance,” Dederich took his natural loquacity and love of rhetorical combat and created a sort of moonshine therapy, a form of treatment that would live on long after Synanon was destroyed and Dederich was disgraced. It was known as the Game.
So much for the frequently asserted but bogus argument that 90%+ of treatment providers in the US are one-true-way 12 steppers:
The researchers surveyed 913 members of the National Association of Alcoholism and Drug Addiction Counselors from across the United States. About 50 percent of the respondents said it would be acceptable if some of their clients who abused alcohol wanted to limit their drinking but not totally give up alcohol. In the earlier survey published in 1994, about 25 percent of the responding administrators of substance abuse treatment agencies found moderate drinking acceptable for some of their clients.
When asked about treating clients who abuse drugs, about half the counselors in the new study accepted moderate drug use as an intermediate goal and one-third as a final goal — this is about the same as it was in a similar survey 10 years ago.
It isn’t true and it hasn’t been true for a long time.
In September, when Tennessee-based Acadia Healthcare Company paid $90 million for Timberline Knolls, a 122-bed inpatient treatment program in Chicago, treatment providers wondered if their programs were worth that kind of money, bed for bed. Other deals in recent months, including Foundations Recovery Network’s acquisition in early October by Nick Pritzker Capital Management for an undisclosed amount, point to the possibility that addiction treatment — at least in the commercial (non-Medicaid, nonpublic) sector — is a profitable enterprise.
This made me recall a mind blowing article by Bill White about the emergence and decline of 19th century addiction treatment. Profit seeking prevailing over mission was no small factor.
A weakened field found itself unable to respond to these environmental threats. Several factors contributed to the field’s professional and political impotence. The field’s public reputation had been wounded by highly publicized breaches of ethical conduct. Newspaper exposés charged incompetence and fraud in the field’s clinical and business practices. Allegations abounded of inadequate care, patient abuses, sleazy marketing practices, and the financial exploitation of patients and families. Muckraking investigations of the bottled addiction cures exposed products secretly loaded with alcohol, opium, morphine, and cocaine.
Because 19th century treatment institutions catered mostly to an affluent population, they had done little to ease the burden indigent alcoholics were placing on jails and community hospitals. Many institutions became viewed not as agencies that served their communities but as places where the rich went to dry out and escape the consequences of their drinking behavior. As a result, there were few community leaders who came to the defense of inebriate institutions during their time of most critical need.
All this money in treatment brings unanticipated problems for families seeking treatment. We see this all the time.
One of the biggest concerns — some people think one closely related to profits – is Internet marketing. “Rehab” and “addiction” are valuable Google search terms, so there is great interest in how the Internet is helping addiction treatment businesses grow.
Sometimes treatment centers advertise online as if they are an independent referral service when they are actually funded by a treatment program.
“For consumers, it’s the Wild West,” said Rhodes, who has worked with people who have gone on the Internet to try to find treatment. Call centers may try to place people in programs that are inappropriate, said Rhodes. “It’s potentially dangerous, and there’s no regulation,” he told ADAW.
For example, Narconon programs, which are run by the Church of Scientology, have a “very major web presence,” said Rhodes. “If you start looking for treatment on the Internet, sooner or later you will end up at Scientology,” he said. Many patients don’t even know that Narconon is Scientology, he said.
In 1834 — with a population under 5,000 — 100 people were licensed dealers selling liquor in Detroit; there was no estimate of the unlicensed. It was said there was a bar for every 13 families.
A traveler from New Hampshire with a strong Puritanical eye, a Mr. Parker, noted in 1834: “The streets [of Detroit] near the water are dirty, generally having mean buildings, rather too many grog shops among them, and a good deal too much noise and dissipation. The taverns are not generally under the best regulations, although they were crowded to overflowing. I stopped at the Steamboat Hotel, and I thought enough grog was sold at that bar to satisfy any reasonable demand for the whole village.”
However, saloons and bars were not the entire picture. Pharmacies did substantial business packaging and selling liquor for medicinal purposes.
Throughout Detroit, but especially in Corktown and Germantown, whiskey also was sold through groceries to such an extent that many grocers distilled their own whiskey and had sit-down bars in their stores. The term “grocery” became synonymous with “saloon.”
Records of temperance groups of the day show the desire to “reduce the number of groceries in the city.” At the time, whiskey was sold in barrels, smaller kegs, or demijohns (jugs ranging anywhere from five gallons to half a gallon.)
Keep in mind that this is during the period of our “national binge”.
In 1825 the annual consumption of pure alcohol was 7 gallons per person over the age of 15. Today it’s 2.49 gallons annually, nearly two-thirds less.
An antique collector has a new book about collecting opium smoking paraphernalia. Collector’s Weekly has an interview with the author:
What drew you to antique opium paraphernalia?
Steven Martin: There was something dark about it. People collect all sorts of weird things, like old torture mechanisms, just bizarre stuff. I think this falls into the same category. It had this outlaw-chic thing about it that attracted me right away.
This reminded me of Bill White’s line, “I can’t tell you what will be the next major drug of misuse will be, but I can tell you that it’s already here and someone will develop a new way to use it.”
What are the origins of opium smoking?
Martin: The interesting thing about opium is that until the Chinese invented this system for vaporization—sometime in the 18th century—there was no pleasurable way to ingest opium. People were eating it. People were smoking it, mixed with tobacco. But eating it causes really bad side effects, the worst being constipation for weeks. And burning it destroys certain alkaloids in the opium that make the intoxication enjoyable.
Then a Chinese inventor whose name is completely lost to history came up with a system for vaporizing it. That invention opened the door for opium to become a recreational drug. Suddenly, all the bad side effects were lessened. Vaporizing opium takes out a lot of the morphine content, which is the thing that makes you feel stupefied and out of it. Good-quality opium, smoked with the proper accoutrements, is energizing. It doesn’t put you on the floor. Well, you’re lying on the floor to do the actual smoking, but that’s just because it’s the most comfortable position to hold the pipe over the lamp. That’s the only reason the old photographs of opium dens show people lying down. It wasn’t because it made them so stoned they couldn’t stand up.
McLeans has an interesting interview with George Vaillant about, “the surprising things you find out about people if you follow them for long enough.”
What’s so different and interesting about this study is that it followed the subjects for decades from a pretty young age. Their subjects were college sophomores when the study began and their selection was not based on any problems or characteristics. So, they studied them before, during and after their active alcoholism.
Here are a few of the better bits.
On alcoholism and recovery:
Q: What, then, are the great lessons to be drawn from the study?
A: Some of the most important ones involved alcoholism. About 50 per cent of alcoholics recover, but a remarkable percentage of those do so with AA. The fact that this study followed up with these men on 60 different occasions with regard to their alcoholism over a period of 50 years did allow us to identify what made a difference.
You’ll have to read the Natural History of Alcoholism, because he didn’t expound on that in the interview.
On childhood unhappiness and alcoholism:
Q: A lot of long-held theories flew out the window over the decades thanks to your work.
A: One of the simplest examples was the notion that unhappy childhoods cause alcoholism. What a study like this shows is that, first, lots of alcoholics invent an unhappy childhood to justify their drinking. Second: if an alcoholic’s childhood is miserable, it’s because a blood relative has alcoholism. If the unhappy childhood is the result of an alcoholic step-parent, the person doesn’t drink to relieve the misery. So it’s the genetic component of alcoholism that matters.
On alcoholism’s toll (Too bad these lessons need to be re-learned!):
Q: You argue that alcohol abuse is the most ignored causal factor in modern social science. Why?
A: Because it’s much more fun to pay mind to nice people than to angry, passive-aggressive people, and the disease of alcoholism makes people angry and dishonest. If you look at the major books on marriage, alcoholism is mentioned nowhere in the index as a cause of unhappiness. Yet 57 per cent of all the divorces in the Harvard sample occurred when one or other spouse were drinking alcoholically. The alcohol abuse almost always preceded the trouble in the men’s life. Another dramatic example: depression does not lead to alcoholism, whereas alcoholism leads to depression. If you take 100 cases, you can find two or three exceptions, but that’s all. People didn’t really know that before the Grant study.
“Once I became my diagnosis, there was no one left to recover.”
Yesterday’s Pat Deegan post led me to Dr. Daniel Fisher’s work on mental illness recovery. He promotes an “empowerment” model of recovery that he contrasts with a “rehabilitation” model of recovery.
According to this vision, one is capable of recovering from the mental illness itself, not merely regaining functioning while remaining mentally ill. … We realize that the idea that people can recover from mental illness will create more work on the part of entitlement programs. Instead of a single, once-in-a-lifetime determination of disability, episodic periods of disability will need to be supported.
In this model, treatment is part of self-managed care. The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society. The primary goal of treatment should not be to control the person’s behavior. The use of medication does not itself mean that a person has not recovered from mental illness. It depends upon the degree to which the person and those around them see the medication as constantly needed. Ideally, each person should learn to take medication on an as-needed basis, after having learned to self-monitor. Many people also embrace holistic health as an alternative to medication.
Not surprisingly, many researchers have concluded that medication alone is best for the treatment for mental illness. Despite recent convincing research showing the usefulness of psychotherapy in treating schizophrenia, psychiatric trainees are still told “you can’t talk to a disease.” This is why psychiatrists today spend more time prescribing drugs than getting to know the people taking them.
I, too, used to believe in the biological model of mental illness. Thirty-one years ago, as a Ph.D. biochemist with the National Institute of Mental Health, I researched and wrote papers on neurotransmitters such as serotonin and dopamine. Then I was diagnosed with schizophrenia — and my experience taught me that our feelings and dreams cannot be analyzed under a microscope.
Schizophrenia is more often due to a loss of dreams than a loss of dopamine. At the NEC, we try to reach out across the chasm of chaos. I know there are many people who feel they have done all they can, have struggled against mental illness to no avail, and we understand their pain. Yet we believe that recovery is eventually possible for everyone — although it can take a long time to undo the negative messages of past treatments. We can offer hope from first-hand experience.
Another post identifies common factors in these recovery experiences. I’ve summarized them. It’s worth noting that that author reports that people achieving recovery reported that traditional psychiatric treatment was a barrier to achieving these factors.
Factor #1: Hope in the possibility of real recovery. All participants in all three of my research studies expressed that in order to even begin the journey towards real recovery, they first had to believe that such recovery is actually possible.
Factor #2: Arriving at an understanding of their psychosis alternative to the brain disease theory. Every participant went through a process of developing a more hopeful understanding of their psychotic experiences, generally coming to see their psychosis as a natural though very risky and haphazard process initiated by their psyche in an attempt to cope and/or heal from a way of being in the world that was simply no longer sustainable for them.
Factor #3: Finding meaning. All participants expressed how important it was for them to connect with meaningful goals/activities that made their life worth living—that provided them with some motivation to greet each new day with open arms and to channel their energy productively.
Factor #4: Connecting with their aliveness. All participants reported how important it was for them to connect more deeply with themselves—particularly with their feelings, needs, and sense of self agency.
Factor #5: Dealing with their relationships. All participants expressed the importance of healing and/or distancing themselves from unhealthy relationships and cultivating healthy ones.
It seems that the biggest objection to the disease model is that mental health consumers experience this model as something that puts them in a passive position, waiting for someone or something to come along and hopefully mend their broken brain just enough to allow them to get through life with something less than full personhood.
This article in Friday’s Wall Street Journal gets at the same thing with respect to much less severe mental illness as experienced by young people.
When I first began to take antidepressants, I understood that doing so meant I had a chemical imbalance in my brain. I knew that, arguably, I should find that comforting—it meant that what I was going through wasn’t my fault—but instead it made me feel out of control. I wanted my feelings to mean something. The idea that my deepest emotions were actually random emanations from my malfunctioning brain didn’t uplift me; it just further demoralized me.
In my 20s, I sought out talk therapy, partly to deal with the questions that using antidepressants raised for me and partly because the effects of the drugs, spectacular in the short term, had waned over time, leaving plenty of real-world problems in their wake. Only then did I begin to notice just how nonrandom my feelings were and how predictably they followed some simple rules of cause and effect.
Looking back, it seems remarkable that I had to work so hard to absorb an elementary lesson: Some things make me feel happy, other things make me feel sad. But for a long time antidepressants were giving me the opposite lesson. If I was suffering because of a glitch in my brain, it didn’t make much difference what I did. For me, antidepressants had promoted a kind of emotional illiteracy. They had prevented me from noticing the reasons that I felt bad when I did and from appreciating the effects of my own choices.
What’s so interesting about this is that people with addictions have a completely different experience. Within the context of addiction recovery, discovering that one has the illness of addiction means that one has a lot of work to do and a lot of responsibility for their recovery. This model is not without its limitations, but it’s amazing how many people find an admission of powerlessness to be so empowering.
I have two thoughts.
First, there seems to be a parallel here. People band together in response to the failure of existing institutions and, together, find an alternative path to recovery. The institutions use their size, wealth, connections, research and publications to de-legitimize this path to recovery. It’s probably a very good thing that PhRMA didn’t have a stake in addiction treatment in 1935.
Second, as the Affordable Care Act is implemented and we need to start really grappling with the cost of chronic diseases, this empowerment model of recovery fits very well with a lifestyle medicine approach. Unfortunately, our medical system is not structured (staffing, reimbursement, monitoring, research, etc.) to support this approach.
I think mental health and addiction treatment have a lot to learn from lifestyle medicine, but I also think addiction and mental illness recovery movements have a lot to teach lifestyle medicine about how patients can maintain wellness over decades.
NOTE: Dawn Farm is not anti-medication, though we do have concerns about the way they are used. More information here.
There are a lot of generalizations about LGBT communities and treatment, but this is an interesting commentary on the place of addiction and recovery in the queer health agenda:
As early as 1970, gay activists in recovery began to challenge AA in the flurry of queer-positive activity that followed Stonewall, petitioning AA for the right to establish “special interests” gay AA groups. This piece of history, largely unknown to the overall queer community, preceded the 1973 removal of homosexuality as a mental disorder in the DSM-II by the American Psychological Association (APA). Advocates pioneered what was to become a current network of “Gay AA” meetings across the country, arguing that it was important to create a safe and openly identifiable recovery space in which queers could explore the nature of their addiction and sexuality in a supporting and understanding community of peers. This has resulted in a strong, sober queer community that is a subset of the larger community. It has also created an overall acceptance of queer experience in many mainstream factions of AA and 12-step culture in general.
Many queers today express discomfort with the notion of disclosing their recovery within the queer community. As in other oppressed communities in which substance use is a social norm, there is often a reverse stigma and harsh judgment placed on people in recovery who no longer share common activities that center around the use of substances. Further, oppressed communities tend to shy away from addressing addiction as a social problem in their specific communities, fearing that it will bring further negative attention and blame upon them by the dominant culture. Because of these variables, it is important for us to tease out the issue of addiction in our community from the separate but related issue of the “right to use,” and the historic role of substance use in subcultures promoting sexual liberation. Thoughtful dialogue can direct us to recovery solutions that include not only those who practice abstinence from substances as a means to generate their recovery from addiction, but also those who chose to use substances in a way that promotes informed choice, awareness, and acknowledgment of risks, while reducing harm.
Queers who are successful in completing addiction treatment often return to their communities unsure of their footings and confused about how to find safe places and people who will support their recovery. Linking to new sober friendship networks and community spaces and engaging in activities that do not involve the use of substances are key elements in stabilizing their early recovery.
As we go about making a queer politics more inclusive of the experience of all queers, let us not forget that doing so will involve a commitment to supporting community responses to substance use, addiction, and recovery. If we approach this subject with a sense of our own power and authority, a complex understanding of the multiple reasons for substance use, and genuine solidarity between recreational drug users, nonusers, those struggling with addiction, and those who have achieved long-term recovery, we can only strengthen the broad and diverse community that we are.
It took me a few reads, but Alan Brody suggests that addiction is a combination of impaired will and impaired evaluative faculties that lead to poor choices in how to exert our will. Then again, I’m not sure I know where he stands. He guides through some philosophical musings about addiction and will.
He presents Socrates’ view:
When faced with a choice, Socrates tells us, human nature means we want to do what we think is best. So, he argues, if we believe we know what the good (the best) thing to do is, and it is accessible to us, we will do the good. However, says Socrates, things which tempt us can have the power to alter our perception or understanding of their value, making them deceptively appear to be what is best. Consequently, we choose the temptation as the best thing to do. The experience of going along with temptation is not, Socrates argues, one in which the person protests or fights against its unreasonableness while being dragged along into gratifying it. For Socrates, ‘yielding to temptation’ is not being unwillingly overpowered, but is the experience of being a willing participant choosing what is at that moment wrongly thought to be best.
Aristotle offers another take:
Aristotle thought that by asserting that when we gratify our desires for what tempts we are still doing what we think best, Socrates was denying the existence of akrasia – ‘weakness of will’, or a failure of self-restraint. The denial of both compulsivity and of weakness of will in explaining addiction has resulted in a willingness model commonly referred to as the moral model of addiction. On this view, what the addict does can be explained in terms of Socrates’ willingness model and an addict’s immoral character: ie, they want to do it, and care more about satisfying their addiction than the consequences of doing so. The addict’s moral deficits reside in their motivations, as illustrated in the accusation: “If you cared more about peoples’ safety than drinking, you wouldn’t drink and drive.” Here, the individual is judged to be morally deficient for not prioritizing peoples’ safety over their own desire to drink.
He rebuts the willingness model with this story:
One day in Hell the Devil approached a man who loved the drinking parties there. The Devil told the man that as long as he was willing to quit drinking he could immediately go to Heaven, where he would forever have a better time. The man replied that although Hell wasn’t so bad, and the parties were great, he preferred Heaven, and was willing to go there right now. The Devil told him that if he wanted he could have a great send-off party now, and go to Heaven tomorrow. The man thought it seemed a good idea to have the best of both worlds, so he accepted the deal. The next day the man was reminiscing about how great the send-off party was when the Devil approached him and said he could have another terrific party right then, and go to Heaven the next day. Of course the man accepted. Each day the Devil made the same offer, and each day the man accepted the party, replying, “I’ll quit drinking tomorrow.” Well, the Devil knew that the man didn’t have what it takes to ever refuse a great party.
In order for our well-being not to be undermined, we need to be able to be motivated by certain preferences. The protagonist of our story would prefer to get out of Hell, but he also needs the ability to be motivated by that preference – and he doesn’t have what it takes to do that. His desire to drink trumps his preference to do what he would prefer to be able to do, thereby undermining the kind of self-regulation he would prefer to have. The willingness model fails to capture the presence, nature, and significance of these kinds of self-regulatory failures, but this kind of dynamic is what addiction is built upon. … This is called ‘clear-eyed akrasia (failure of self-restraint).
He also meanders back to Socrates teachings on “self-mastery”, which is rooted in self-knowledge and offers these thoughts:
Addiction is not just a condition made up of a bunch of weak-willed acts. Addiction undermines the person’s self-regulation, true. But it also undermines their ability to accurately assess their problem’s seriousness as it repetitively generates a willingness or motivation for acting in violation of their most important preferences, even knowingly. Moreover, those who follow addiction’s callings do not simply act from their own sanctioned desires; they have become the enchanted followers of yearnings arising from a metastasized love. The ability to recover often has to develop as a result of experiencing addiction’s deep hardships. Addicts often talk about how it took a lot of destructiveness, danger and ‘craziness’ before they could realize how ‘insane’ they had become.
When thinking how misfortune has deprived someone of what is needed for doing better, we sometimes respond compassionately by communicating that the person would have done better at controlling their over-eating/smoking/alcoholism/other temptations if they could have. When we realize that luck is required to put into place what was needed in order to have what would have enabled us to have done better, more compassion might arise towards ourselves and others, as we see how the trouble we bring about is also what fortune sets up for us.
My problem is that, while rebutting these moral models, it feels like he never strays very far from talking about a flaw in character. This is why, to me, the hijacked brain metaphor is so helpful.