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Substance Abuse As SymptomReview - Substance Abuse As Symptom
A Psychoanalytic Critique of Treatment Approaches and the Cultural Beliefs That Sustain Them
by Louis S. Berger
Analytic Press, 1991
Review by Peter B. Raabe, Ph.D.
Dec 12th 2003 (Volume 7, Issue 50)

It's often the case that anyone who critiques any area of psychiatry, for whatever reason, is now referred to as writing "anti-psychiatry."  I find this very odd.  Imagine someone who wrote a critique of mechanistic Newtonian physics being referred to as having written "anti-physics;" or someone who has written a critique of dry academic philosophy as being guilty of "anti-philosophy."  We would surely consider this use of the term "anti-"  to be absurd, yet many individuals are quite content with calling the work of some authors "anti-psychiatry,"  even when those authors are themselves trained in psychiatry and diligently at work in that field.

Granted, there are authors who have said that the entire field of psychiatry is both nonsensical and harmful and ought to be disbanded, but Louis Berger is not one of them.  Still, his book Substance Abuse as Symptom will most likely be considered "anti-psychiatry" by some members of his own profession because he criticizes the authorized doctrine in mainstream psychiatry regarding the etiology of substance abuse.   Berger was at one time with the faculty of the Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine, and at the time of publication of this book (1991)  he was Staff Psychologist at Southwest Research Institute in San Antonio, Texas.  He takes psychiatry to task over its approach to substance abuse, not as an outsider would but from an internal perspective. 

Judging by the publication date, it may at first seem that this book is out of date.  But in fact many of the research conclusions about substance abuse and its treatment and prevention cited by Berger, although dated, have never been disproved or discredited;  they have simply been ignored by clinicians and obscured by so-called 'common knowledge' in conventional substance abuse programs.  This tunnel visioned, pseudo-scientific view of substance abuse is itself one of the topics dealt with in this book.

The book consists of two parts.  The first part contains five chapters in which Berger discusses what he calls the "mainstream substance abuse treatment industry."  Some of the major problems in dealing with substance abuse are created by the fact that it is dominated by the medical or disease model.  Not only does this model interfere with the psychoanalytic model of treatment and prevention--which Berger promotes in the second part of the book--it also creates paradoxical social conditions.   For example, Berger points out that, while the predominant position in North American society is that treatment and prevention of drug abuse ought to take place within a medical framework, drug use is still punished under the law; and while it is argued that legal deterrence is necessary due to the dangers of drug use, more people die every year from tobacco and alcohol use which are not illegal.  His main argument in this part is that research has repeatedly shown that the mainstream approach to substance use (prohibition), treatment (according to the disease model), and prevention (through education) is an utter disaster, yet it continues to flourish.  This is because of two factors:  first, there is a lot of money to be made in this 'industry,' and second, there is a complex underlying psychopathology in society.  According to Berger society suffers from the failings within education  (children are taught to work hard for external rewards;  education does not make better jobs available), consumerism  (the degradation of work;  ownership is the 'American dream'), politics and morality  ("we have a history of lawlessness in international matters;" "the leaders we elect are immoral and alienated from themselves"  [p. 67, 69]), and the environment  (a pervasive use of problem denial;  the alliance of government regulatory bodies and industry), leaving it at the level of a poorly functioning, self-centered one- to three-year-old.  This pervasive self-serving attitude is one of the factors which, according to Berger, maintains the incredibly profitable "war against drugs," and the lucrative but ineffective mainstream substance abuse industry.

Berger's main point is that the approach to substance abuse in North America has been superficial at best because it has avoided dealing adequately with what he sees as the "underlying cultural pathology, oedipal and preoedipal"  (99).   He argues that "if one wished to bring about sound, stable changes in the drug abuse situation, the basic pathology of our culture should be addressed"  (105).  But this will not and cannot happen by means of the conventional approaches because mainstream substance abuse counsellors are not sufficiently educated and trained to work at any but the most superficial levels.  Berger sees the lack of the psychoanalytic view of addiction, and the inability of mainstream addiction treatment workers to use a psychoanalytic therapies as the main obstacle to successful treatment. 

In the four chapters of the second part of the book Berger discusses both the limitations of non-analytic therapies and the benefits of analytic therapies in bringing compulsive drug users to a condition in which the drug is no longer desired.  Here his discussion is more philosophical than clinical in that he offers solidly reasoned arguments about, for example, the pragmatism, praxis, and phenomenology that are part of psychoanalysis.  This second part is very much a how-to section for practitioners, but discussion is still at an appropriately satisfying conceptual level.  This book is a broad and thorough treatment of the subject of substance abuse that is at once a criticism and a defense of the psychoanalytic perspective in treatment and prevention.  I see it as being of benefit to both practitioners and students of the history, anthropology, sociology, psychology, politics, economics, and philosophy of substance abuse.  And interestingly, while the book was published in 1991, Berger finishes it with the prophetic words that he doubts much progress would be made in the "war on drugs" as it was being fought in the pathological US society of the early 90's and that even if it were successful, "the current official 'enemy number one' would be succeeded and replaced by some other suitable 'enemy,' perhaps terrorism, nuclear war or other"  (208). 


© 2003 Peter B. Raabe

Peter B. Raabe teaches philosophy and has a private practice in philosophical counseling in North Vancouver, Canada. He is the author of the books Philosophical Counseling: Theory and Practice (Praeger, 2001) and Issues in Philosophical Counseling (Praeger, 2002).


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