Addiction Treatment Differs for the Poor
Hopefulness is the message, but only for the privileged.
Posted Sep 07, 2019
When people speak of inequality in America, they miss one of its powerful drivers: addiction treatment.
The concepts that dominate addiction treatment for most North Americans are all about deficits—ineradicable deficits—that affected people suffer. Along with the old disease-model bromides of genetic inheritance and other biological liabilities that predestine people for addiction, we now portray trauma and its double-whammy offshoot, intergenerational trauma—applied to communities that have been trapped by hostile social forces for generations—as immutable personality traits, rather than as external challenges to be overcome.
At one point, proponents of the disease model argued that alcoholism was an entirely inherited condition. That proposition is now widely rejected, even by those who count genetics as an important factor in addiction.
In place of that now-rejected claim, epigenetics—the idea that lived experience is encoded in DNA—is now most often cited as the source of addiction. In this view, trauma causes irreversible brain damage from which a person can never escape. This idea dominates contemporary addiction therapy.
Both the genetic and epigenetic models denote that addictive and other mental health problems people encounter are impossible to extirpate, and can at best merely be managed as a permanent part of sufferers’ lives and identities. Such notions are self-fulfilling, as shown by leading psychologist William Miller’s finding that a belief in the disease model of alcoholism predicts relapse.
But these disempowering ideas are far less apparent in the therapies and self-help programs now aimed at elite Americans. Rather, the upper economic echelon is more often encouraged to embrace the values of self-empowerment, responsibility and optimism for themselves and their children. And it just so happens that these approaches work best for the upper 20 percent to preserve their economic and occupational slots at the top of America’s social order. Martin Seligman, in Learned Optimism (2006), places this outlook at the center of fulfilling lives.
Privileged Americans embrace can-do psychological concepts like Seligman’s positive psychology, Angela Duckwirth’s Grit (2016), and yes, the aspirational self-efficacy preached by presidential candidate Marianne Williamson. Noted for her promotion of “A Course in Miracles,” a mind-over-matter philosophy about how you control your destiny, Williamson encountered problems when her past statements about depression and antidepressants were highlighted. She doesn’t believe that depression is a disease, or that suppressing the negative feelings your life and body send you is good therapy. She has accused American psychiatry of selling us antidepressants to ”mask” our unhappiness without addressing the sources of our feelings, an approach that may have disastrous results (as she said it did, for example, in a controversial tweet about Kate Spade).
“There is value sometimes in feeling the sadness" of difficult life events, Williamson told CNN. (For the record, I agree with her.)
Increasingly, 12-step and trauma-based approaches, although still the nuts and bolts of the private rehab industry, are being seeded in deprived inner cities and rural areas. Transgenerational trauma has become the go-to concept for explaining how “historical and cultural traumas affect survivors’ children for generations,” with little-to-no emphasis on individuals’ powerful capacity to leave it behind.
Meanwhile, those with more resources are encouraged to set their sights higher. Seligman premises his positive psychology approach on anticipating positive outcomes—in other words, optimism.
But the audience for this message is highly targeted. At which social groups do you think the wisdom of Marianne Willamson is primarily aimed? Or Tony Robbins’ Power of Positive Thinking courses (“adopt a mindset of abundance”)? Or Arianna Huffington’s Thrive Global (focusing on “life and love and the moment”)? Or Martin Seligman’s Positive Psychology Center’s work (“to promote research, training, education, and the dissemination of Positive Psychology, resilience and grit”)?
Seligman, writing in the New York Times (with John Tierney), doesn’t view trauma as permanently life-altering (including for future generations, as conveyed by the concept of epigenetics), or even as having a necessarily negative overall impact:
Our emotions are less reactions to the present than guides to future behavior. Therapists are exploring new ways to treat depression now that they see it as primarily not because of past traumas and present stresses but because of skewed visions of what lies ahead. . . .
While most people tend to be optimistic, those suffering from depression and anxiety have a bleak view of the future—and that in fact seems to be the chief cause of their problems, not their past traumas. ... While traumas do have a lasting impact, most people actually emerge stronger afterward. Others continue struggling because they over-predict failure and rejection.
While PTSD has become a focus of clinical practice, research does not support the notion that it is a permanent state of being. As author and journalist Sebastian Junger notes, as “terrible as such experiences are, roughly 80 percent of people exposed to them eventually recover.” Moreover, the occurrence, severity and persistence of PTSD is not a function of the degree of shock the person experiences, so much as it varies with how supportive the environment is for the returning veteran or other survivor.
But this sort of reassuring perspective is rarely offered to the generation of rust-belt and coal-mining non-college-educated whites whose life expectancy is declining due to “deaths of despair.” Nor to those communities of color that have been confronted by deprivation for far longer in inner cities like Baltimore and Detroit. These people are instead encouraged to “over-predict failure and rejection” as groups, making negative emotional outcomes for them all the more likely.
This analysis (like Junger’s) highlights the critical role that social factors play in people’s chances of developing, or recovering from, addiction. Social and economic inequalities fuel addiction—more so than anything else that human beings cope with. Eradicating social inequities is the surest way of reducing addiction, as I have often written.
Yet by peddling radically different addiction and mental health philosophies to different socio-economic classes, we actually exacerbate through “therapy” America’s pervasive inequality.
For the cultural elite, a switch from “self-flagellation” to appreciating, enhancing and taking care of oneself is a mental health phenomenon recently noted by the New York Times:
“Wellness” is a word that has come to encompass our latest dominant sociocultural obsession ... wellness has been positioned and marketed as self-care. This wellness is softer, gentler, more forgiving than its self-flagellating forebear.
So where does that leave the concepts we have long relied on in the addiction field—like powerlessness, biological inheritance, chronic brain disease, inescapable trauma, absence of control, and lifelong addict and alcoholic identities?
These keynote ideas underpinning the disease view of addiction are often short-circuited by the privileged, yet increasingly directed at those whose dismal fates privileged society considers unavoidable. In this way, we are simply reifying our failure to get a grip on the real social conditions that fuel addiction.