Words&Dirt

“Grandmother was rigorous and unswerving. It was her belief in the value of effort itself that prevented her from buying a television set.

She was a passionate reader, and she thought that reading was one of the noblest efforts of all; in contrast, she found writing to be a great waste of time––a childish self-indulgence, even messier than finger painting––but she admired reading, which she believed was an unselfish activity that provided information and inspiration. She must have thought it a pity that some poor fools had to waste their lives writing in order for us to have sufficient reading material. Reading also gave one confidence in and familiarity with language, which was a necessary tool for forming those nearly constant comments on what one had observed. Grandmother had her doubts about the radio, although she conceded that the modern world moved at such a pace that keeping up with it defied the written word; listening, after all, required some effort, and the language one heard on the radio was not much worse than the language one increasingly stumbled over in newspapers and magazines.

But she drew the line at television. It took no effort to watch––it was infinitely more beneficial to the soul, and to the intelligence, to read or listen.”

––A Prayer for Owen Meany, by John Irving, pg. 256-7

“The authors of the chronic-brain-disease narrative were inspired by discoveries about the effects of drugs on the brain. The promise of finding powerful antiaddiction medications seemed great. The maturing science of addiction biology would mean that once and for all, the condition would be taken seriously as an illness––a condition that began with the explicit, voluntary decision to try drugs but transitioned into an involuntary and uncontrollable state. This knowledge, they hoped, would sensitize policy makers and the public to the needs of addicts, including access to public treatment and better private insurance coverage. A softening of puritanical attitudes and an easing of punitive law enforcement were also on the agenda.

The mission was worthy, but the outcome has been less salutary. The neurocentric perspective encourages unwarranted optimism regarding pharmaceutical cures and oversells the need for professional help. It labels as ‘chronic’ a condition that typically remits in early adulthood. The brain-disease story gives short shrift to the reality that substances serve a purpose in addicts’ lives and that neurobiological changes induced by alcohol and drugs can be overridden.

Like many misleading metaphors, the brain-disease model contains some truth. There is indeed a genetic influence on alcoholism and other addictions, and prolonged substance use often alters brain structures and functions that mediate self-governance. Yet the problem with the brain-disease model is its misplaced emphasis on biology as the star feature of addiction and its relegation of psychological and behavioral elements to at best supporting roles. ‘If the brain is the core of the problem, attending to the brain needs to be a core part of the solution,’ as Leshner put it. The clinical reality is just the opposite: The most effective interventions aim not at the brain but at the person. It’s the minds of addicts that contain the stories of how addiction happens, why people continue to use drugs, and, if they decide to stop, how they manage to do so. This deeply personal history can’t be understood exclusively by inspecting neural circuitry.

In the end, the most useful definition of addiction is a descriptive one, such as this: Addiction is a behavior marked by repeated use despite destructive consequences and by difficulty quitting notwithstanding the user’s resolution to do so. This ‘definition’ isn’t theoretical; it explains nothing about why one ‘gets’ addiction––and how could it offer a satisfying causal account when there are multiple levels at which the process can be understood? Our proposed definition merely states an observable fact about the behavior generally recognized as addiction. That’s a good thing because a blank explanatory slate (unbiased by biological orientation or any other theoretical model) inspires broad-minded thinking about research, treatment, and policy. Is there room for neuroscience in this tableau? Of course. Brain research is yielding valuable information about the neural mechanisms associated with desire, compulsion, and self-control––discoveries that may one day be better harnessed for clinical use. But the daily work of recovery, whether or not it is abetted by medication, is a human process that is most effectively pursued in the idiom of purposeful action, meaning, choice and consequence.”

––Brainwashed: The Seductive Appeal of Mindless Neuroscience, by Sally Satel and Scott O. Lilienfeld, pg. 69-70