The Theater of the Brain

The play of consciousness.

Hoffman’s OD, Fallacies of Conventional Neuroscience

The idea is that Phillip Seymour Hoffman’s brain was "changed" and this was set in stone. The overt or covert implication is that Hoffman did not have a choice when he stuck the fateful needle in his arm. He was just like a rat who repeatedly presses the drug lever rather than the food lever. Read More

Amen to Dr. Berezin! You may

Amen to Dr. Berezin! You may not be able to turn the switch off in rats, but humans, despite their propensity to do the wrong thing, have free will and choice and can and do create new switches, new and better pathways by exercising and developing character. None of us our powerless if we have free will and the ability to make decisions. All change ultimately occurs because of decisions (THINKING) people make for themselves. People change with they are HURT ENOUGH and HAVE TO, or when the LEARN ENOUGH AND WANT TO.

Well said!

Well said!

Breaking the Broken Record

Dr. Berezin has done a great job of explaining the problem with a disease model for addiction. The addicted brain is different from the normal brain, but it is not the brain which is diseased rather it is the decision making process which is diseased.
The addicted brain functions differently. It plays a record which tells the addict what behaviors will bring the most relief quickly. This forms a grove (if you will) in the record. Eventually the groove will become so well played that the record will begin to skip in that grooved spot playing the same lyric or message over and over.
The disease model suggests that that a broken record is simply fated to be stuck at this same lyric forever. That is a fallacy which groups like AA depend on. As long as an addict believes they are fated with this broken record they will depend on AA to survive. Why would an addict choose to survive rather than live? The broken record prevents an addict from noticing all the other records available which are not broken.
By breaking the broken record of an addict we provide hope that they can recover. By providing alternative record options we give addicts the opportunity to heal. Teaching an addict to play a new record is what promotes recovery.
Philip Seymour Hoffman's death, while sad and disappointing, has given us a catalyst for this conversation. There have been reports that, like Amy Winehouse, Jerry Garcia and others, Hoffman had been substance free for many years prior to this tragic event. This demonstrates how ingrained broken records can become in the addicted brain.
Listening to the same lyric over and over for many years does change the brain, and these types of deaths suggest that it is forever. Each one of these deaths however came after a new record had started playing and each one of these people did have a choice of which record to play. It is therefore the decision making process which is afflicted. If we wish to know what exactly it is that goes wrong in the decision making process we should be talking to addicts who have managed to recover before they start playing broken records again.
All of these types of deaths are preventable because each individual has the ability to choose something different. It is important for those of us working in the area of mental health however, to recognize that this particular population does not make chooses in the same way that the healthy population does. It is here that we share the responsibility with addicts, it is here that we should be focusing our attention. By breaking the broken records of addicts and providing alternative records with new lyrics we could turn the inevitable overdose into a recovery story.

Very nice Dr. B

Very nice
Dr. B

Nice metaphor with the

Nice metaphor with the ingrained-broken record.
The tragedy of Hoffman was in my view,(based on Hoffman's words) that, "Job Excellence/Satisfaction," was his main purpose in life. I believe that in order to serve ourselves and others, that we best need a "Higher Purpose," in order to optimally enjoy and play all other records at our disposal.

But I also suspect that

But I also suspect that Hoffman had a dark side that we don't know anything about that interfered with his living well and thriving. To keep with the metaphor, there are many records...

AA is not just about god

AA teaches one how to find that Authentic Self. The 12 steps take a person on a journey of self assessment and self actualization. Yes there is this thing called God in there... But guess what... Talk to the highest priest/rabbi/monk etc, and they will all tell you God just a synonym for Authentic Self.

My suggestion is that you take a closer look at the ENTIRE AA program. There are so many pieces of AA which align with an array of psycotherapy modalities and techniques (Narrative, SFBT, Psychoanalysis... It's all there) it's astonishing.

Two Sides to Every Street

Dr. Berezin:
Thank you for taking the time to respond to my blog post in so much detail. I would respectfully suggest that the primary misunderstanding, rather than a function of my use of neuroscience in understanding addiction’s effects on the brain, lies in a misreading of some of my points and their implications. Of course, blog posts on Psychology Today have specific recommended parameters regarding length. As a result, bloggers have to make sometimes difficult decisions as to what content to include and prioritize in our posts. At times, material which could help clarify and complete certain points gets left on the “cutting room floor.”

The brain imaging demonstrating that active addiction causes changes to neuroanatomy and neurochemistry means the brain has changed. However, in no way did I say or mean to imply that such changes are “set in stone.” Quite the contrary, these kinds of changes are compelling evidence of neuroplasticity. As I wrote, with abstinence and recovery, “the addict’s brain has the opportunity to heal and rebuild the connections that were altered by active addiction.” In fact, brain imaging indicates that much of the damage incurred during active addiction is reversed after one year of abstinence, and after five years of abstinence the brains of most addicts resemble those of “normal” individuals. That notwithstanding, because some of these brain-based changes appear to be enduring people who have been actively addicted will always be at heightened risk of returning to active addiction.

In no way did I suggest that Mr. Hoffman had no choice in pursuing the path that killed him. Although active addiction absolutely impairs judgment, decision-making, and impulse-control, at the point at which someone has established stable and sustained abstinence, he or she regains full choice to resume using or not. Mr. Hoffman had been clean for well over two decades prior to his admitted relapse in 2013.

While the disease concept of addiction continues to be controversial in some circles, it is increasingly widely accepted, including by many mainstream expert authorities such as the National Institute on Drug Abuse (NIDA) of the US Department of Health and Human Services and the American Society of Addiction Medicine (ASAM).

I’ll also take this opportunity to clear up a couple of important misconceptions about twelve-step recovery programs: 1) Both NA and AA have a deep understanding that significant character challenges are inherent for addicts. This is the focus of Steps Six and Seven. 2) There is a vast difference between being powerless and surrendering (the twelve-step formulation is similar of that of Buddhism) and being helpless and absent of responsibility. Lastly, we are in agreement that recovery from addiction extends far beyond abstinence. Recovery is a process of learning, growth, and healing that involves mourning a whole host of losses. When embraced fully and multi-dimensionally, it is a process of self-actualization that leads people back to what Winnicott described as their True Self, or as you put it, their “Authentic Being.”

Dan, I appreciate your

I appreciate your thoughtful response to my response. I would like to elaborate as well. What is most central to my heart is that all human struggles are human problems and they are not brain diseases. There have always been two tracks in psychiatry – one is that suffering is a human problem, and the other is that it is a brain problem that lends itself to brain interventions. The history of brain interventions is not pretty – we’re talking lobotomy, ECT, Insulin Shock Therapy, and now $75.000,000,000 of psychoactive pharmaceuticals per year.
I find the explosion of neuroscience exciting. In fact, speaking of space constraints, it took me a whole book to present a new paradigm of consciousness. Can’t do it in a blog. In short consciousness is organized as play, with personas, feeling relationships between them, plots, scenarios, set designs and landscapes all created by the brain. The final form of the adult play results from the limbic-cortical neurotransmitter mapping of experience all the way through development, in concert with our temperaments. The varied array of psychiatric symptoms derives from problematic experience. Substance abuse is but one among many character problems.
Most neuroscience today looks at focal areas of problematic experience and comes to conclusions such as your own that they are the result of neuronal-neurotransmitter changes. And there is truth to this, up to a point. What is missing is how this fits into the actual organization of the mapping of personality in consciousness, and an understanding of the natural biological processes of the person (and the brain) to change. In short it is disuse, mourning, and new experience. This deactivates old-limbic cortical mappings and allows for new limbic-cortical-mappings to become the basis of our operations, grounded in authenticity and love.
I appreciate your well spoken and sophisticated take on alcoholism and addiction. I have valued AA as the most effective way that people have stopped drinking. For sure people are better off sober than killing themselves with drink and drugs. And of course the twelve steps contain a great deal of wisdom. Nonetheless, it has been my experience, as a kind of thirteenth step, that AA does not facilitate people to become whole and really recover from their problematic characters.
The disease concept, in my opinion is misleading and destructive, because the unintended consequence is that people take it to mean that they actually have a diseased brain. And it is not within their capacity to heal. This may not be the intent, (and I know it is not yours), but this is how it operates. It is operative in all the other areas of psychiatry - Anxiety is now actually believed to be a brain disease. Depression is considered a brain disease. So-called ADHD is considered a brain disease, etc. It is now seemingly radical to even question this. And these diseases are treated with pharmaceuticals like antibiotics for an infection. Paradoxically, in the pre-disease days of AA, I referred a patient to a three quarter way house. She had genuine manic-depression and needed to be on Lithium (The only two psychiatric conditions which have causative brain elements in their make-up are manic-depression and the schizophrenias.) I had to write a letter to justify the Lithium so they would take her in. In general, AA was otherwise correct back then about the use of psychoactive drugs.
Because national organizations consider addiction a disease, never mind all the rest of psychiatry are considered diseases, this does not make it so. I respect your grasp on these matters, and I appeal to you to rethink the neuroscience and the disease.
Dr. B

Robert A, Berezin, MD is the author of “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain”

Increasing Agreement

Dr. B:
It's a pleasure to engage in this dialogue with you. It makes clear that we really agree more than not. I very much appreciate the breadth of your experience and the depth of your wisdom. The one way in which contemporary neuroscience has been decidedly unhelpful - or at least utilized in unhelpful ways - is through the implication that all psychological/psychiatric conditions can be reduced to what occurs in the brain. And if the brain is the source of all such problems/challenges, then surely the solution must lie there as well - and, as you suggest, Big Pharma has the pill for us all. The pharmaceutical industry is the epitome of vulture capitalism, using its astonishing profits, along with neuroscience research to maximize its ability to influence prescribers & consumers in the quest to generate ever-more profits. The progressive pathologizing of an increasing slice of normative life experiences does us all a great disservice.

I agree that, with very few exceptions, the vast majority of mental/emotional/behavioral conditions (including addiction) stem from a combination of mental, emotional, physiological, & spiritual factors. Consequently, appropriate & effective treatment & ongoing recovery need to incorporate bio-psycho-social-spiritual elements.

It also took me a whole book (Some Assembly Required: A Balanced Approach to Recovery from Addiction and Chronic Pain) to lay out the approach I advocate vis-a-vis addiction treatment and recovery. I look forward to our paths crossing again.
With gratitude,

Dan, The feeling is

The feeling is completely mutual. A real dialogue is all too rare and a real pleasure. And yes, obviously we are kindred spirits in this enterprise. So lets make sure we further the connection.
The appreciation goes both ways,

Thank you and my apologies

Thank you both for carrying out your dialogue here. Although some of which is over my hear, it has furthered my desire understand addictions on the same level as you.

I must agree that many (the vast majority actually) in AA do not become whole and never really recover from their problematic characters. Unfortunately the majority of what many are exposed to regarding AA are the dogmatic practices which do seem to give some relief to some people. But with your further discussion and references to AA (pre-disease AA days), I think I was mistaken in your understanding of AA history and practices. My apologies.

Far to often what gets lost in the representation of AA is what the program is all about; The 12 steps. We tend to define AA by looking at the people who identify as being an AA member. When the reality is that many of these people don't practice the program of Alcoholics Anonymous, as a whole or at all. Those who take the 12 steps fully and completely, do recover and become whole. Unfortunately this seems to be the exception rather than the norm.

Again thank you, and I look forward to reading more from you in the future.

Mat Lempriere.

Genetic Predisoposition?

"Hoffman did not have an anchor of Authentic Being inside, a sufficiently strong core. And he went deeper into drug experience and of course all this was mapped. Even though it is true that these mappings exist for the rest of one’s life, as all of our character mappings do, this does not have lead to an inevitable destiny. Here is a more accurate neuroscience paradigm. Our experience is mapped in the brain for our regular cortical top down functioning. But they are plastic and not fixed. They reflect experience. They are not genetically programmed. Change takes place in the brain its standard way." - - Are you saying that there is NOT a genetic predisposition to addition?

Yes I am. In fact everybody

Yes I am. In fact everybody is capable of addiction. There is a wide range of addictive behavior and it is built into our limbic cortex for all of us to be prone. I do not subscribe to the explanation that there is some special genetic predisposition, that makes somebody not responsible, because they are so powerfully programmed. This is used to explain why one person becomes addicted and somebody else doesn't. I believe this is neuro myth for which there is no real evidence. It is consonant with the faulty part of AA that teaches that addiction is a disease over which one is powerless. I cannot detail my understanding for what constitutes a fertile ground for addiction in a blog. It is spelled out in my book.

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Robert Berezin, M.D., is the author of Psychotherapy of Character. He taught psychiatry at Cambridge Hospital, Harvard Medical School for thirty years.


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