Kyle Keegan became a heroin addict as a young adult and messed up his life, at the same time as repeatedly lying to his parents, breaking his promises, stealing, and even totaling his mother's car. He went into detox and rehab many times, and relapsed nearly as many, but eventually he recovered. His story ends with him married with a baby and a life full of promise. In Chasing the High, with the help of psychiatrist Howard Moss, he sets out his experience in the context of the modern scientific understanding of addiction. It has the standard views one would expect: addiction is a brain disease; some people have a genetic predisposition to addiction; the risk of addiction is increased by some social circumstances; addiction is sometimes associated with other mental disorders such as depression or bipolar disorder; addiction is a livelong disease for which there is no cure; addicts need to get treatment, and are unable to end their self-destructive behavior on their own. At the end of the book, Keegan explains in broad terms the different kinds of available treatment, and there is a list of frequently asked questions with answers at the end of the book.
The sorts of views Keegan advocates are very similar to those promulgated by US government agencies, especially the National Institute on Drug Abuse, (NIDA) and as those set out in the HBO Addiction series. Yet they are problematic in their rhetoric and for what they leave out. The most jarring piece of rhetoric is the repeated appeal to the term "brain disease." The term brings to mind conditions such as brain cancer, Alzheimer's, Parkinson's, and neurosyphilis, but of course if one is an addict, one does not make an appointment with a neurologist. Addiction is associated with changes in the brain (as shown in the publications of NIDA), and it is certainly true that long term drug use can cause brain damage. It does not follow from this, however, that addiction is itself a brain disease. Indeed, if addiction is a brain disease, why is it not listed in standard lists of brain disorders? (For example, look at the US Department of Health and Human Services list of Brain Diseases or the Australian Brain Foundation's A-Z of Brain Disorders.)
Why indeed does this view insist on using the word disease, when the American Psychiatric Association's classification manual (the DSM) is a list of disorders? The definitions of both these words are not clear, and there's no real way to draw a distinction between them, but disease sounds more serious than disorder. Mental disorders include all sorts of conditions, including depression, anxiety, cognitive developmental delays, personality disorders, and pedophilia. So the motivation in calling a mental disorder a disease is to say "this is really a medical condition, not just a psychological problem or a form of deviancy."
The problem with this sort of special pleading is that it undermines its own message, because it looks like propaganda. Keegan says he was unable to change his behavior before he was in recovery, and gives many examples of incredibly self-destructive behavior. But then he says he made a decision to change, and this led to his recovery. This contradiction is at the heart of all such narratives of addiction depicted as involuntary behavior: it leaves utterly unexplained why the previous resolutions to change did not work, and the final successful one did work, and it makes it a mystery why acts of will to end one's addiction are ineffective at one point, but are effective later.
Furthermore, despite the allegiance to science in this series from the Annenberg Foundation, there is no mention of the success rates of different forms of treatment compared to the recovery rates of people who never go for treatment. At the end of the chapter on "Trying to Get Help," Keegan says "I know from my own experience that effective treatment can get you free of drugs and start teaching you the skills you'll need for the ride that comes next: living your life -- hopefully, the rest of your life -- in recovery." This from a man who went into treatment many times with no success at all. But the more important point is that no testimonial can count as evidence for the effectiveness of treatment. A recent survey of treatments for substance abuse reported, "Many widely practiced methods remain unsupported by scientific evidence, whereas other treatments with strong evidence of efficacy are rarely delivered in practice." (Miller et al, 2006). Another review of evidence-based treatment found that the best treatments were cognitive–behavioral, community reinforcement approach, motivational interviewing, relapse prevention, and social skills training (Miller et al, 2005) This shows that there are treatments that have success, but it does not say what the recovery rates are. The evidence surveyed by Gene Heyman in his recent book Addiction: A Disorder of Choice show that recovery rates for treatment programs are low, and that the recovery rates for people who have not gone into treatment are higher. A recent study of heroin addiction says that little is known about the recovery process, and that the only predictors of recovery in a ten-year follow up of heroin addicts were ethnicity, self-efficacy, and psychological distress -- the treatment programs used by the addicts did not predict recovery. (Hser, 2007).
Any approach that is not open about the scientific evidence regarding the different effectiveness of treatments and the poor prognosis of many condition of addiction risks problems with its credulity. Any approach that ramps up the rhetoric risks further suspicion. However, a more fundamental worry is that the constant emphasis by defenders of the medical model on the idea of addiction as a brain disease is that it may backfire, and convince addicts that they cannot change. Corrigan and Watson (2004) have argued that framing mental illness as a brain disease can be disempowering to people with the disorders, and reinforces beliefs that recovery will not be possible. Furthermore, in the case of addiction, if we tell people that they don't have control over their behavior, they will start to believe us and stop trying to change.
In short then, Chasing the High is a good example of a humanistic application of the medical model, and as such it is problematic. Some of its advice is especially questionable. For example, in the Frequently Asked Questions section at the end, asks: "I drink on the weekends with my friends, and sometimes we smoke pot. But nothing bad has ever happened. Why should I stop?" Keegan and Moss then supply the answer, starting "Because eventually something bad will almost inevitably happen; whether it's something as immediate and serious as a bad car wreck, as seemingly minor as a fight with your boyfriend or girlfriend, or as remote as eventual damage to your body." This sort of puritanical scaremongering is not backed by any evidence. It is true that there is some danger associated with alcohol and marijuana, but that's a far cry from the "almost inevitable" bad consequences the authors specify, and again, it undermines the credibility of the whole book. The Annenburg Foundation Trust at Sunnylands' website says that its aim is "to advance public understanding of and appreciation for democracy and to address serious issues facing the country and the world" and the aim of the Adolescent Mental Health Initiative is to "synthesize and disseminate scientific research on the prevention and treatment of mental disorders in adolescents." Unfortunately, in sponsoring the publication of Chasing the High, they as much engaged in promoting ideology as conveying the results of psychiatric science.
Corrigan, P. and A Watson. "At Issue: Stop the Stigma: Call Mental Illness a Brain Disease" Schizophrenia Bulletin, 30(3):477-479, 2004.
Hser, Yih-Ing "Predicting Long-Term Stable Recovery from Heroin Addiction: Findings from a 33-Year Follow-Up Study, Journal of Addictive Diseases; 2007, Vol. 26 Issue 1, p51-60
Miller, William R., Joan Zweben, Wendy R. Johnson "Evidence-based treatment: Why, what, where, when, and how?," Journal of Substance Abuse Treatment, Volume 29, Issue 4, December 2005, Pages 267-276.
William R. Miller, James L. Sorensen, Jeffrey A. Selzer, Gregory S. Brigham. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions, Journal of Substance Abuse Treatment, Volume 31, Issue 1, July 2006, Pages 25-39.
Link: The Annenberg Foundation Trust at Sunnylands' Adolescent Mental Health Initiative
© 2009 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.