I’m afraid I have to take issue with my Blog colleague Dan Mager in his article “Who Is an Addict?” I have already addressed the disease fallacy in my own blog on Phillip Seymour Hoffman. And I won’t repeat it here. In my view this article is a good example of conventional neuroscience misunderstanding about the brain. And its implications are misleading. He informs us that brain imaging shows physical changes in various areas of the brain along with various activated neurotransmitters. This means the brain is changed and this is set in stone. The inevitable implication is that Phillip Seymour 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. People who do not understand neuroscience hear this as conclusive evidence. His pleasure reward systems were simply too ineradicably strong. Even if this is not specifically what Mr. Mager means, it fosters the idea that Hoffman had no free will and responsibility. And he was just a victim of the “physical changes” in his brain with no ability for judgment, decision-making, learning, memory, and behavior control. This is not true.
So, here is what happened. After he crossed a certain threshold, Hoffman’s drug experience was mapped in his brain, along with the limbic mappings, pleasure mappings, and neurotransmitter stimulations, pretty much as Mr. Mager described. There is nothing particularly special about this. All of our adolescent experience is mapped in precisely the same way. Substance abuse is but one among the many temptations of adolescence that to one degree or another we are all subject to—sex, drugs, drink, gambling, eating (from gluttony to anorexia), reckless action, and sensation-seeking, stealing and cheating, egotism, and sadomasochistic attachment and anger. When the brain maps any of these experiences it does so through the similar limbic, pleasure, and neurotransmitter systems. All of this is physically established in the brain. It is also true that the experience of kids with certain temperaments who are subject to abuse and deprivation in childhood, map anxiety, and depression in exactly the same way. These mappings too are physically present and activated in the brain. None of them are diseases. None of them are fixed.
The point of all of this is that this becomes our adult character. Why do some kids experiment with and then stop self-destructive behavior, while other kids go deeper into the dark side of life? The teenager who has had good-enough loving in childhood retains the presence of his Authentic-Being as the core of his self. The Authentic-Being is the rudder by which one navigates through the smorgasbord of experience and life’s temptations. When this adolescent strays too far in a self-destructive avenue, as all kids do, there is a quiet voice inside him that says, “What am I doing? I’ve got to stop this.”
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.
There are two agencies for change in the brain. After the essential abstention, the key is mourning where one can truly deactivate established pathways. Once this is accomplished, they are still there as a potential, but they do not have compelling power. This is true of all character problems (of which substance abuse is but one). Then the experience of real trust with responsiveness and caring, establishes a fulfillment of the Authentic Being. This creates an entirely new limbic and neurotransmitter mapping of experience. Once established, the individual is free to listen to his own self possession.
AA and recovery programs certainly do a lot to help people abstain. And of course this has been very valuable. But they do not allow the person to mourn and become whole. Since AA tells us, as does Mr. Mager that recovery is life long, the addict must establish a life long dependence on the AA organization or he will go back and use. He does not truly graduate to a genuine self-possession. The disease model is a paradoxical trick where the addict is told that it is not his fault, (and not a character problem), that he is truly powerless over his addiction. But a higher power (i.e. God) can keep you from your demons. Recognize the contradiction. Although AA says that people do not have the power to stop, in fact, people stop drinking and drugging in very high numbers all the time.
I am suggesting that the neuroscience paradigm here is faulty. It’s a fancy explanation that means the same as AA. You are powerless due to your brain. All the smorgasbord of life’s temptations are basic human character problems. I know how hard it is for an addict to give up drugs. I have treated many, many substance abusers of all stripes. And they can all be addressed in human ways in psychotherapy. All character problems are deeply held and difficult to address. Drugs are no more or less difficult than the others. And you are not powerless and your brain does not make it so.
Robert A. Berezin, MD is the author of “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain”