I got some insightful notes from a reader who said it'd be ok to post these thoughts anonymously. I love this focus on virtue ethics, the self, and transformational change:
"A few quick thoughts: I think Bill White is right that our definitions of recovery should incorporate a changed relationship with the destructive behaviour (transforming your substance use, gambling, etc.), but also a cessation of unwanted negative consequences connected with the behaviour. In clinical terms, remission is not recovery, but (full) recovery should include remission. This is my response to the motto of "every positive change." As healers, we should support every positive change, but overtime these changes should lead to a cessation of unwanted suffering. That might take a lifetime. And it might not be fully possible for some people. But it is the horizon within which we should judge our efforts.
Another problem is the lack of a theory of self in most post-analytic psychology. Self is not just identity, or consciousness, or cognitive mechanisms, but something we build over the course of our lives through embodied practice. Self is at the core of virtue ethics, but is related to concepts like habitus (Bourdieu), and explored extensively in the late Foucualt's work. Once repetitive, destructive practices become incorporated within our selves (at the levels of identity, our social relationships, and embodied being-in-the-world), transforming the behaviour requires a transformation of self. It's blurry, but I think there is a genuine dividing line between behavior change that does and does not require this type of global transformation. And outside the language of recovery or religious language, I am not sure we have a language to describe this type of transformation.
I think part of what makes AA, but also a lot of New Age self-help, attractive is that they provide working models of self to guide a process of behaviour change--a model of an object to act on that also has meaning or is connected to the search for meaning. Not that these models are good--they are often harmful--but they give people a way to think about what they are changing that connects the effort to something larger. Much contemporary psychology is a cluster of processes, mechanisms, schemas--adding up to nothing, and divorced from the problem of how to live. That is why your starting with Jung resonates for me."
Great post. I grew up in a family with 2 jungian analysts who felt that Jung’s theories and by extension Jungian analysis provided the framework and the method to uncover life’s meaning. Given that so much of Jung’s thinking revolved around symbolism as the language of the unconscious, I’ve never understood the belief that there is any one answer, definition or meaning in life. Symbols and metaphors, much like koans, point to the ineffability of life. Pinning things down renders them lifeless. I find this with so many psychological methods - CBT, DBT, positive psychology etc. The narrowing of the human psyche into formulaic “treatments” feels like an affront to the unconscious. My son tells me that life without definitions and answers is unbearable and I tell him to focus on the grey. Maybe what we need changes with age. In early recovery I needed the structure rehab provided. Learning to accept the absolute ordinariness and at the same time the unknowable mystery of life is how I practice recovery now. Needless to say it’s an ongoing process. Isn’t life in many ways a series of recoveries - each requiring different strengths? Birth, death, grief, breakups, breakdowns, addiction, trauma, burnout ………
Jungian analysis may be great for New York intellectuals with plenty of cash to spend on it. For those of us who don't fit that tiny niche, maybe real, rigorous, modern science and modalities like CBT, DBT, ACT, and others are more appropriate.
I would be interested in reading your thoughts concerning the disease theory of addiction so emphasized in the 12 step movement. For my part, I regard it as a useful fiction - useful because it helps some people drop the guilty feelings that only fuel the problem.
And I don't like turning my addiction into an identity. My blood pressure tends to run a bit high, but I have never introduced myself by saying "Hi. My name is Eric and I'm a hypertensive."
Great question Eric, and I reply only tentatively here because I devoted essentially a chapter to this notion in my book, then continued to develop it as a theme across other chapters. I did try to boil my thoughts down to a NYTimes Op-Ed, which in retrospect is a bit simpler and shorter than I would have liked, though I can still stand behind what I wrote.
One thing I'd argue as a starting point is there is no "theory" or a "model" of addiction as a disease. The arguments associated with that claim are actually not that cohesive. A common position associated with addiction as a disease is that it is an essential category, which is an idea we can get our arms around a bit better and which I discuss above. There are probably beneficial elements of the label of disease... some people do draw strength, clarity, or compassion from that language. But there are other ideas commonly associated with the disease label, which include permanence, inevitable progression, irreversibility, a necessarily and primary biological cause, etc.
The bottom line is I consider calling addiction a disease a double-edged sword, and many but not all uses of the word can be misleading.
Excellent post, Carl! Some preliminary thoughts. Concepts have histories, often messy histories, and their significance comes from the manner in which a community of people relate to them and put them to use. This is particularly true of concepts that don’t refer to or demarcate “natural kinds.” If we take them out of their history, if we take them out of the context that gives them significance, their utility seems to deflate. As descriptions disconnected from a meaningful context, they seem to apply to everything and nothing. Recovery seems to me to be such a concept. It’s a notion that unites people who are working towards better versions of themselves and better versions of their lives in the context of experiencing the loss of control and despair that characterizes addiction. It is no surprise that we should find overlaps between flourishing (wellbeing/eudaemonia) and recovery. What distinguishes the two is the context. Recovery is (in part) flourishing for a community of people united by their experiences of addiction. To the extent that this community differs from the general population (in terms of the severity, persistence, disability of the problems experienced), the strategies needed to flourish will also be different. And to the extent that certain phenomena are near universal (eg, various forms of loss of control over our behavior), many outside the community would also stand to benefit from those strategies.
Fantastic reflections Awais, thank you. Very useful to hear the perspective of someone who is not necessarily immersed in the addiction world. One interesting possibility your comment raises is the "community of people" united by the experience of addiction is undergoing some interesting changes as we, for example, continue wrestling with a historic overdose epidemic, grapple with the reality of many pathways to recovery, and reflect on all of this at a time of (one can hope) peak therapy culture. The default for many years was recovery = orthodox 12-step. Even among folks deeply committed to 12-step practices, this is no longer true. This has made and will continue to make for some interesting complications in sense-making.
I read this. I promise to read it again. What I found most interesting was your own "crash and burn" situation. I grew up watching stress and trauma symptoms firsthand before PTSD was a "thing" even. I know I modeled my response to both based on my childhood observations. Countless numbers of us grew up in such environs. I look forward to more of your personal reflections, and the environment that you emerged from.
Sounds like a pragmatists approach to addiction - one I'm in agreement with.
Addiction, like much of psychiatry, has sadly fallen prey to reification of the abstract. Paul Bloom writes a lot about this, but we humans appear to have a strong bias towards essentializing things.
It is an unfortunate circumstance that Plato was wrong - nature does not appear to be carvable at the joints. Schemas are useful and help us make sense of truth but are not real themselves. Factor analyses have shown that virtually all of our subjects of interest are found on dimensional planes. Where to decide whether something is "pathological," an "illness," or as the DSM fell upon "disordered" becomes a judgement, with the inexactitude that judgement entails. "Addiction" is one such judgement. Saying what is an addiction is an appropriate question, but in the non-essentialist way. What that question should mean is how do we want to define addiction in a useful way, knowing that it is an abstraction.
I'm early in my psychiatric training, but even with awareness of this I have to actively remind myself not to fall in to these ideas that addiction or depression are these "real" things (beyond being projected, useful abstractions).
The difficulty really comes from practical experience. As you may touch on elsewhere there is a strange paradox in biology though where despite things being dimensional and thus arbitrary at the margins, when certain examples are juxtaposed, things feel quite categorically different e.g. grossly psychotic from the non-psychotic, the ascetic next to the individual struggling with fentanyl use. Can there be a unifying framework that provides practicality to these circumstances, and to the person who eats too much after dinner, or is on their phone too much? Can it be done in a way that reduces feelings of morbid shame and guilt but also encourages people to make the right decisions (of which shame is a powerful motivator), and empower them with a central locus of control? I'm not 100% skeptical, but I think ultimately a framework has some amount of judgement, and that with any judgement we make, there are trade-offs.
For now, I will try to practice with the ones that I think are most humane and useful to the person in front of me.
Thanks Quinn, I'm biased of course but I'm glad to hear you are thinking and practicing that way. I assume you also have to actively remind yourself not to think this rigid and essential way during your training because there are lots of folks, and market forces too, that promote that view!
I really like what you say here, Carl. I'm going to beat my favorite dead horse again, that four legged, aged, decrepit, smelly beast called The 12 Step Movement's Influence. Bill W wrote in the Big Book that alcoholics are "bodily and mentally" different from normal people. While this may be true in a very literal sense, since the brain is part of the body and the alcohol addict's brain is wired somewhat differently, I now believe Bill's statement is outdated, false, and harmful. The contrast I heard reinforced in 12 Step groups between addicts and earth people affected how I saw myself and the world. It made me feel both inferior and isolated. Not good.
Truth matters. Delusions can be helpful (at least temporarily), but they are still delusions. The prime example is the God delusion. We have no reliable evidence of the existence of supernatural powers or beings, but the 12 Step movement, much of the treatment industry, and society writ large casually accept the God delusion, whether the brand of that delusion is Christian, 12 Step, Buddhist, Hindu, Universalist, New Age or something else. How much harm has been done and is being done on the basis of these delusions?
P.S. The dead horse isn't really dead, is it? If the 12 Step delusion wasn't still so influential, especially here in these hinterlands hundreds of miles from NYC and Columbia U, I'd gladly put my whip away.
Thanks for this Dean. I too dislike it when people really hammer on the notion of some sort of essential separation between people with addiction and the rest of the population. Some people in 12-step recovery do really seem to hold on to that notion very tightly, whereas others are more in the "came for my drinking, stayed for my thinking" camp. Maybe some in the former camp are actually helped by the clarity and certainty? Hard to say. Likely to be a double-edged sword. I touch on this issue at a few points in my book. I think that like a lot of other beliefs and practices in mutual help recovery, this kind of essentialism is one of those elements that varies across groups, geographies, populations, etc. An important broader point is, I think there are a lot of ways that within mutual help recovery groups, including AA, stigma is perpetuated. When I talked to Ryan Hampton about this on my podcast, he called it a kind of internal stigma; i.e., internal to the groups. There are advantages to those groups for some, but we shouldn't be too blase about the potential harms.
Now as for "spirituality," that's a big topic that I plan to discuss in some future posts in this series on frameworks for recovery. I do think we need to make more space for people in recovery who roundly reject religion or spirituality. I touch on this a little with my next guest on the podcast, who has some experience with secular recovery, although he is more of an agnostic than an atheist. I hope to find some more committed atheists in the future.
I like Bill White though I consider him something of an AA apologist, which isn't surprising considering White's history. I'm not anti AA, or at least I don't think I am. However, AA's theory of self starts from a theological position. Any concept of self based on theology is going to alienate a lot of people, not to mention that it will be pretty useless scientifically. But unfortunately AA theology has had an outsized influence on the treatment industry and probably on White. I also wouldn't seriously consider starting with Jung or any other classic analytic theorist. I realize that modality is still popular in some places (notably the NYC area), but Freud, Jung, et al were basically armchair theorists. Their theories may contain a lot of truth, but many of their ideas are untestable. In other words, from a scientific standpoint much of what they said is interesting but seems irrelevant at this point in time.
Instead, why not start with someone like Dan McAdams? While McAdams draws heavily on another armchair theorist, Erik Erikson, from my layman's perspective it appears McAdams does good science. I also think his lifespan perspective of self makes a lot of sense.
Another person who comes to mind is Sam Harris. In his book The Moral Landscape he argues that we don't need theology or religious traditions to define human nature or the moral good; science and philosophy can provide what we need. They are also much more likely to appeal on a universal level.
I got some insightful notes from a reader who said it'd be ok to post these thoughts anonymously. I love this focus on virtue ethics, the self, and transformational change:
"A few quick thoughts: I think Bill White is right that our definitions of recovery should incorporate a changed relationship with the destructive behaviour (transforming your substance use, gambling, etc.), but also a cessation of unwanted negative consequences connected with the behaviour. In clinical terms, remission is not recovery, but (full) recovery should include remission. This is my response to the motto of "every positive change." As healers, we should support every positive change, but overtime these changes should lead to a cessation of unwanted suffering. That might take a lifetime. And it might not be fully possible for some people. But it is the horizon within which we should judge our efforts.
Another problem is the lack of a theory of self in most post-analytic psychology. Self is not just identity, or consciousness, or cognitive mechanisms, but something we build over the course of our lives through embodied practice. Self is at the core of virtue ethics, but is related to concepts like habitus (Bourdieu), and explored extensively in the late Foucualt's work. Once repetitive, destructive practices become incorporated within our selves (at the levels of identity, our social relationships, and embodied being-in-the-world), transforming the behaviour requires a transformation of self. It's blurry, but I think there is a genuine dividing line between behavior change that does and does not require this type of global transformation. And outside the language of recovery or religious language, I am not sure we have a language to describe this type of transformation.
I think part of what makes AA, but also a lot of New Age self-help, attractive is that they provide working models of self to guide a process of behaviour change--a model of an object to act on that also has meaning or is connected to the search for meaning. Not that these models are good--they are often harmful--but they give people a way to think about what they are changing that connects the effort to something larger. Much contemporary psychology is a cluster of processes, mechanisms, schemas--adding up to nothing, and divorced from the problem of how to live. That is why your starting with Jung resonates for me."
Great post. I grew up in a family with 2 jungian analysts who felt that Jung’s theories and by extension Jungian analysis provided the framework and the method to uncover life’s meaning. Given that so much of Jung’s thinking revolved around symbolism as the language of the unconscious, I’ve never understood the belief that there is any one answer, definition or meaning in life. Symbols and metaphors, much like koans, point to the ineffability of life. Pinning things down renders them lifeless. I find this with so many psychological methods - CBT, DBT, positive psychology etc. The narrowing of the human psyche into formulaic “treatments” feels like an affront to the unconscious. My son tells me that life without definitions and answers is unbearable and I tell him to focus on the grey. Maybe what we need changes with age. In early recovery I needed the structure rehab provided. Learning to accept the absolute ordinariness and at the same time the unknowable mystery of life is how I practice recovery now. Needless to say it’s an ongoing process. Isn’t life in many ways a series of recoveries - each requiring different strengths? Birth, death, grief, breakups, breakdowns, addiction, trauma, burnout ………
Jungian analysis may be great for New York intellectuals with plenty of cash to spend on it. For those of us who don't fit that tiny niche, maybe real, rigorous, modern science and modalities like CBT, DBT, ACT, and others are more appropriate.
I would be interested in reading your thoughts concerning the disease theory of addiction so emphasized in the 12 step movement. For my part, I regard it as a useful fiction - useful because it helps some people drop the guilty feelings that only fuel the problem.
And I don't like turning my addiction into an identity. My blood pressure tends to run a bit high, but I have never introduced myself by saying "Hi. My name is Eric and I'm a hypertensive."
Great question Eric, and I reply only tentatively here because I devoted essentially a chapter to this notion in my book, then continued to develop it as a theme across other chapters. I did try to boil my thoughts down to a NYTimes Op-Ed, which in retrospect is a bit simpler and shorter than I would have liked, though I can still stand behind what I wrote.
One thing I'd argue as a starting point is there is no "theory" or a "model" of addiction as a disease. The arguments associated with that claim are actually not that cohesive. A common position associated with addiction as a disease is that it is an essential category, which is an idea we can get our arms around a bit better and which I discuss above. There are probably beneficial elements of the label of disease... some people do draw strength, clarity, or compassion from that language. But there are other ideas commonly associated with the disease label, which include permanence, inevitable progression, irreversibility, a necessarily and primary biological cause, etc.
The bottom line is I consider calling addiction a disease a double-edged sword, and many but not all uses of the word can be misleading.
I agree Eric. My father's survivors' guilt was responsible for at least a third of his addiction.
Excellent post, Carl! Some preliminary thoughts. Concepts have histories, often messy histories, and their significance comes from the manner in which a community of people relate to them and put them to use. This is particularly true of concepts that don’t refer to or demarcate “natural kinds.” If we take them out of their history, if we take them out of the context that gives them significance, their utility seems to deflate. As descriptions disconnected from a meaningful context, they seem to apply to everything and nothing. Recovery seems to me to be such a concept. It’s a notion that unites people who are working towards better versions of themselves and better versions of their lives in the context of experiencing the loss of control and despair that characterizes addiction. It is no surprise that we should find overlaps between flourishing (wellbeing/eudaemonia) and recovery. What distinguishes the two is the context. Recovery is (in part) flourishing for a community of people united by their experiences of addiction. To the extent that this community differs from the general population (in terms of the severity, persistence, disability of the problems experienced), the strategies needed to flourish will also be different. And to the extent that certain phenomena are near universal (eg, various forms of loss of control over our behavior), many outside the community would also stand to benefit from those strategies.
Fantastic reflections Awais, thank you. Very useful to hear the perspective of someone who is not necessarily immersed in the addiction world. One interesting possibility your comment raises is the "community of people" united by the experience of addiction is undergoing some interesting changes as we, for example, continue wrestling with a historic overdose epidemic, grapple with the reality of many pathways to recovery, and reflect on all of this at a time of (one can hope) peak therapy culture. The default for many years was recovery = orthodox 12-step. Even among folks deeply committed to 12-step practices, this is no longer true. This has made and will continue to make for some interesting complications in sense-making.
Doc,
I read this. I promise to read it again. What I found most interesting was your own "crash and burn" situation. I grew up watching stress and trauma symptoms firsthand before PTSD was a "thing" even. I know I modeled my response to both based on my childhood observations. Countless numbers of us grew up in such environs. I look forward to more of your personal reflections, and the environment that you emerged from.
Thanks Andrew, will do for sure.
Sounds like a pragmatists approach to addiction - one I'm in agreement with.
Addiction, like much of psychiatry, has sadly fallen prey to reification of the abstract. Paul Bloom writes a lot about this, but we humans appear to have a strong bias towards essentializing things.
It is an unfortunate circumstance that Plato was wrong - nature does not appear to be carvable at the joints. Schemas are useful and help us make sense of truth but are not real themselves. Factor analyses have shown that virtually all of our subjects of interest are found on dimensional planes. Where to decide whether something is "pathological," an "illness," or as the DSM fell upon "disordered" becomes a judgement, with the inexactitude that judgement entails. "Addiction" is one such judgement. Saying what is an addiction is an appropriate question, but in the non-essentialist way. What that question should mean is how do we want to define addiction in a useful way, knowing that it is an abstraction.
I'm early in my psychiatric training, but even with awareness of this I have to actively remind myself not to fall in to these ideas that addiction or depression are these "real" things (beyond being projected, useful abstractions).
The difficulty really comes from practical experience. As you may touch on elsewhere there is a strange paradox in biology though where despite things being dimensional and thus arbitrary at the margins, when certain examples are juxtaposed, things feel quite categorically different e.g. grossly psychotic from the non-psychotic, the ascetic next to the individual struggling with fentanyl use. Can there be a unifying framework that provides practicality to these circumstances, and to the person who eats too much after dinner, or is on their phone too much? Can it be done in a way that reduces feelings of morbid shame and guilt but also encourages people to make the right decisions (of which shame is a powerful motivator), and empower them with a central locus of control? I'm not 100% skeptical, but I think ultimately a framework has some amount of judgement, and that with any judgement we make, there are trade-offs.
For now, I will try to practice with the ones that I think are most humane and useful to the person in front of me.
Thanks Quinn, I'm biased of course but I'm glad to hear you are thinking and practicing that way. I assume you also have to actively remind yourself not to think this rigid and essential way during your training because there are lots of folks, and market forces too, that promote that view!
Re Addiction is in All of Us
I really like what you say here, Carl. I'm going to beat my favorite dead horse again, that four legged, aged, decrepit, smelly beast called The 12 Step Movement's Influence. Bill W wrote in the Big Book that alcoholics are "bodily and mentally" different from normal people. While this may be true in a very literal sense, since the brain is part of the body and the alcohol addict's brain is wired somewhat differently, I now believe Bill's statement is outdated, false, and harmful. The contrast I heard reinforced in 12 Step groups between addicts and earth people affected how I saw myself and the world. It made me feel both inferior and isolated. Not good.
Truth matters. Delusions can be helpful (at least temporarily), but they are still delusions. The prime example is the God delusion. We have no reliable evidence of the existence of supernatural powers or beings, but the 12 Step movement, much of the treatment industry, and society writ large casually accept the God delusion, whether the brand of that delusion is Christian, 12 Step, Buddhist, Hindu, Universalist, New Age or something else. How much harm has been done and is being done on the basis of these delusions?
P.S. The dead horse isn't really dead, is it? If the 12 Step delusion wasn't still so influential, especially here in these hinterlands hundreds of miles from NYC and Columbia U, I'd gladly put my whip away.
Thanks for this Dean. I too dislike it when people really hammer on the notion of some sort of essential separation between people with addiction and the rest of the population. Some people in 12-step recovery do really seem to hold on to that notion very tightly, whereas others are more in the "came for my drinking, stayed for my thinking" camp. Maybe some in the former camp are actually helped by the clarity and certainty? Hard to say. Likely to be a double-edged sword. I touch on this issue at a few points in my book. I think that like a lot of other beliefs and practices in mutual help recovery, this kind of essentialism is one of those elements that varies across groups, geographies, populations, etc. An important broader point is, I think there are a lot of ways that within mutual help recovery groups, including AA, stigma is perpetuated. When I talked to Ryan Hampton about this on my podcast, he called it a kind of internal stigma; i.e., internal to the groups. There are advantages to those groups for some, but we shouldn't be too blase about the potential harms.
Now as for "spirituality," that's a big topic that I plan to discuss in some future posts in this series on frameworks for recovery. I do think we need to make more space for people in recovery who roundly reject religion or spirituality. I touch on this a little with my next guest on the podcast, who has some experience with secular recovery, although he is more of an agnostic than an atheist. I hope to find some more committed atheists in the future.
Thanks for writing and glad you're here
I like Bill White though I consider him something of an AA apologist, which isn't surprising considering White's history. I'm not anti AA, or at least I don't think I am. However, AA's theory of self starts from a theological position. Any concept of self based on theology is going to alienate a lot of people, not to mention that it will be pretty useless scientifically. But unfortunately AA theology has had an outsized influence on the treatment industry and probably on White. I also wouldn't seriously consider starting with Jung or any other classic analytic theorist. I realize that modality is still popular in some places (notably the NYC area), but Freud, Jung, et al were basically armchair theorists. Their theories may contain a lot of truth, but many of their ideas are untestable. In other words, from a scientific standpoint much of what they said is interesting but seems irrelevant at this point in time.
Instead, why not start with someone like Dan McAdams? While McAdams draws heavily on another armchair theorist, Erik Erikson, from my layman's perspective it appears McAdams does good science. I also think his lifespan perspective of self makes a lot of sense.
Another person who comes to mind is Sam Harris. In his book The Moral Landscape he argues that we don't need theology or religious traditions to define human nature or the moral good; science and philosophy can provide what we need. They are also much more likely to appeal on a universal level.