Journalist Johann Hari is peddling a new book on addiction, promising a fresh new take – and yet it may not be all that fresh – and it may not follow from the evidence he cites.
Hari is smacking down the disease model of addiction, specifically the one that depends on pharmacology. And for making this smackdown in front of a wide audience, he deserves some kudos. So, definitely, let’s give him kudos. But he follows this up by presenting what’s supposed to be a surprising account of the cause of addiction, and essentially gives us the well worn underlying causes/self-medication model of addiction.
This view has been around in a major way since at least 1985 (Fetting, 2012) and probably goes back further – rehabs have been “treating underlying causes” forever – they’ve been seeing substance users as maladjusted forever.
The model goes like this: people’s lives are crummy – they lack opportunity, they are alone and isolated, they have depression, anxiety, loneliness, et cetera, and they turn to heavy drug and alcohol use to soothe this distress – they “self-medicate.” Hari seems to focus more on the circumstances/environment side than most supporters of the underlying causes theory, but it works on the same basic principle. In Hari’s presentation, people are still seen as pushed into heavy substance use by something out of their control.
One of the major pieces of evidence that he cites (and again, Kudos for getting it in front of such a wide audience) is Lee Robins’s famous study of Vietnam vets who were ‘addicted’ to heroin in Vietnam. It’s a landmark study, because, as Hari correctly states, most of them stopped swiftly upon returning home. Moreover, those who jumped right into treatment programs ended up having ongoing problems, while those who didn’t get treatment did quite well in resolving their problems long term.
In an interview with Democracy Now though, Hari puts the environmental underlying causes spin on this evidence:
What happened? All the evidence is the vast majority come home and just stop, because if you’re taken out of a hellish, pestilential jungle, where you don’t want to be and you could be killed at any moment, and you go back to your nice life in Wichita, Kansas, with your friends and your family and a purpose in life, it’s the equivalent of being taken from the first cage to the second cage. You go back to your connections.
The bit about cages is in reference to Rat Park (another important study that the public should know about, so again, kudos!). The “first cage” is the one in which most drug experiments are done on rats – they live in isolation in a tiny little cage where their only form of pleasure is the option to push a button sending a jolt of cocaine or morphine directly into their brain, and not surprisingly, they keep pushing the button, often until death. The “second cage” was what the Rat Park researchers tried – give the rats a giant cage with toys and other rats and things to do, as well as access to morphine, and see if they choose the drug when they have other options. Importantly, it was shown that the rats didn’t go overboard with drug use in this case.
Thus we see Hari’s conclusion – the soldiers were like rats in the small cage when they were in Vietnam: they were stressed, isolated, miserable, and turned to the drug for comfort. However, their return home was like entering Rat Park – a land of support and love and opportunity, and thus they no longer needed to turn to heroin. This is the underlying causes/self-medication model all over again. Hari clearly demonstrates this view here, stating that the driver/cause of addiction “is isolation, pain and distress” as well as “suffering.” He continues “We have created a society where huge numbers of our fellow citizens can’t bear to be present in their lives and have to medicate themselves to get through the day with these drugs.”
The thing is, Lee Robins, the prolific researcher who headed the Vietnam studies, tackled Hari’s supposedly new and surprising interpretation of her findings back in 1993. In a lecture published in the journal Addiction, she defends her research from what she believes to be some wrong interpretations by others, writing:
The argument that addiction in Vietnam was a response to war stress, and therefore remitted on exit from the Vietnam war theatre, is still frequently cited as though it were self-evident, because it sounds so plausible. Yet accepting this argument is difficult in the face of the facts. Heroin was so readily available in Vietnam that more than 80% were offered it, and usually within the week following arrival. Those who became addicted had typically begun use early in their Vietnam tour, before they were exposed to combat. Further, the dose response curve that is such a powerful causal argument did not apply: those who saw more active combat were not more likely to use than veterans who saw less, once one took into account their pre-service histories… Those with pre-service antisocial behavior both used more drugs and saw more combat…
…the greater the variety of drugs used before entering service, the greater the likelihood that narcotics would be used in Vietnam.
Now, to be fair to Hari, Robins also makes some comments that might be interpreted as supporting his model, but I can’t get over how directly this hits at the underlying causes/self-medication interpretation of her findings – and the fact that she wrote this back in 1993. She’s saying that the users were more likely users beforehand, and that the stress of war didn’t have anything to do with it.
I’ll also say this is an issue I’ve thought about quite a bit. We’ve been tackling it at the Saint Jude Program, because we see troubled people who’ve been taught in addiction treatment programs to conceive of their substance use as being caused by their childhood trauma, unfortunate life circumstances, and emotional/psychological problems. As a result their problems seem to become compounded, they leave treatment worse off, feeling triggered to use whenever anything in life doesn’t go their way.
But beyond the sad cases who’ve learned to default to substance use until their lives are perfectly balanced (an impossible task for anyone), I see too many people whose situations really aren’t that bad by the measures that Johann Hari and other social crusaders would use as their benchmarks. Remember, Hari’s hypothesis is that the Vietnam vets heroin use was caused by their painful environment. They were…
taken out of a hellish, pestilential jungle, where you don’t want to be and you could be killed at any moment, and you go back to your nice life in Wichita, Kansas, with your friends and your family and a purpose in life
…and voila! They stopped heroin because of their new opportunity and environment. External conditions caused the addiction, and external conditions caused the recovery, and thus we just need to provide everyone with a bunch of love and support and opportunity and they’ll be caused to change too. If only it were that simple.
I see nice people with nice lives and beautiful families from Wichita Kansas or Toledo Ohio, or millionaires who live in posh apartments in NYC and the whole range of people who’ve got plenty of love, support, and social connection and opportunity surrounding them in their lives. Many of them are involved in their communities, families, churches, and other organizations. And yet these people feel as if they must drink and use drugs every day. They feel lost and out of control. The circumstantial model always seems to make sense when we’re entertaining our cliches of people with substance use problems – the down and out street user, the guy at the bus station begging for money to buy another hit of crack, the children of broken homes and poverty – but it doesn’t hold up when we look at the full spectrum of troubled substance users. It doesn’t explain the celebs, the millionaires, or the average soccer moms, the immigrants with strong supportive family ties, or the suburban kids from middle class families, or especially the ones from upper middle class families like I once was. It doesn’t explain why someone like myself, who had every opportunity to build a life for himself, chose the crash and burn path of heavy substance use instead. Thus it doesn’t show that an impoverished/rough environment is a necessary “cause” of addiction (never mind the fact that those who become “addicted” in these circumstances are still a minority within said circumstances). There are plenty of people living in the big cage – and yet they still live as “addicts.”
Mere observation disproves the notion that addiction is caused by poor circumstances, as we’ve seen above. But there’s also more addiction in wealthier countries, and less in poorer/third world countries (except for some outliers in the former Soviet states where extreme drinking is deeply embedded in the culture). There’s also a boatload of research that calls the self-medication model into question. For example, the most recent and largest epidemiological study on addiction and other psychological conditions, NESARC, found that:
No association was observed between mood and anxiety disorders and dependence remission for any of the substances assessed [nicotine, cannabis, alcohol, and cocaine]
Mood disorders included DSM-IV primary major depressive disorder (MDD), dysthymia and bipolar disorders. Anxiety disorders included DSM-IV primary panic disorder (with and without agoraphobia), social anxiety disorder, specific phobias and generalized anxiety disorder.(Lopez-Quintero et al., 2011)
If these psychological problems are supposed to cause addiction, how is it that people manage to end their addictions while still leaving with these problems?
I’m happy to see Hari getting some of this classic research and other factsout to a wide audience, but I don’t agree with his conclusions, nor do I find them new, surprising, et cetera. They’re all well worn retreaded theories – self-medication, underlying causes, environmental causes – they’ve been around forever. Hari says we need social recovery and that love and a bunch of other touchy feely stuff is the cure. We’ve tried that for 75 years – it’s called support groups. It’s now “family programs” at rehabs that bring the whole family in to learn how to be supportive in recovery. It’s now a year or more of aftercare and every sort of therapy imaginable. It’s the recovery culture instructing people on how to host sober holiday parties so that their loved one with a substance use problem will feel welcome, supported, and safe. I’m all for love, but this external control approach doesn’t work– you can’t “cause” people to become un-addicted.
It doesn’t work because regardless of whether you use the word “disease” or not, you expose people to all of the same pitfalls of the disease model when you teach them that addiction is a thing that happens to them. Whether a disease is causing you to use substances, or poor circumstances and lack of meaningful connections is causing you to use substances, these are both things outside of yourself.
Addiction is not a disease – and in fact it’s not really a thing at all. Addiction is really just a social construct though which society defines certain behavior as deviant and attempts to control it by convincing drug and alcohol users that they can’t control themselves and need to turn themselves over to the medical establishment to have their lives managed.
Take away the judgment of deviance, and what you see is a strong preference and a habit. If it was a preference for healthy cooking, we wouldn’t call it an addiction, yet it would operate on all the same principles. People develop strong preferences for drug and alcohol use the same way they cultivate and develop other interests in life – and if we’d stop misleading them into thinking that addiction happens to them, then maybe they’d thoroughly re-evaluate and change these preferences for the better. Or maybe them would keep doing lots of drugs and alcohol, and we could just accept that as their life choice instead of declaring them addicted and endlessly trying to make them conform to our view of how a life should be lived.
Here is the surprising news about the “cause” of addiction: there are no causes of addiction because addiction doesn’t exist. It is free human behavior. It is caused by the individual’s perspective on the relative benefits of drugs and alcohol as compared to their other perceived life options. Thus you can have all the options in the world, and yet if you don’t personally see them as providing a better life than heavy substance use, then they will lose to heavy substance use. You can dangle whatever you want in front of people, but it’s up to them to see that thing as attractive. Human behavior has reasons – not causes.
For a person to “self-medicate”, they must first see their drug of choice as a medication for their woes – they must reason their way to that choice. But the term “self-medicate” is inaccurate and misleading itself – drugs and alcohol do not pharmacologically medicate stress, trauma, depression, etc – and they certainly don’t pharmacologically catapult someone out of poverty or into loving relationships. They provide a physical sensation that can be interpreted as pleasurable. They are not so meaningful as our culture believes them to be – and the self-medication theorists only convince people to see drugs and alcohol as more and more meaningful when they credit them as answers to emotional suffering. They also convince troubled substance users to see themselves as weak and cornered into heavy substance use. This mindset disables them (I was once there).
If you don’t fully get what I’m saying here, you can check my article on “How to stop self-medicating” (hint – understand it’s not your medicine). Stress, anxiety, depression, and life’s curveballs can and will happen to everyone – and unfortunately these problems randomly hit some people more than others. While it’s great to try to reduce these problems, the answer isn’t to insure that they never occur again…. or else you’ll “relapse.” The answer is to mentally sever the mental connection between these problems and heavy substance use – dump the disabling beliefs!
If you don’t get why I’m saying the whole construct is disabling, then I think you may learn it by analogy. Listen to the story of the Batman on NPR’s This American Life. It’s about blindness, and how the blind are inadvertently hobbled by their helpers. I guarantee you’ll find it enlightening.
Fetting, M. (2012). Perspectives on Addiction. Sage Publications. Retrieved from http://www.sagepub.com/books/Book235147?prodId=Book235147&ct_p=toc
Robins, L. N. (1993). The sixth Thomas James Okey Memorial Lecture. Vietnam veterans’ rapid recovery from heroin addiction: a fluke or normal expectation? Addiction (Abingdon, England), 88(8), 1041–1054.
Lopez-Quintero, C., Hasin, D. S., de los Cobos, J. P., Pines, A., Wang, S., Grant, B. F., & Blanco, C. (2011). Probability and predictors of remission from lifetime nicotine, alcohol, cannabis, or cocaine dependence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction (Abingdon, England), 106(3), 657–669.