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