Tuesday, January 24, 2017

Can A Philosophy For Living Prevent Addiction?

A couple of years ago, I responded to a New York Times editorial by a philosopher.  It was focused on the release of the DSM-5 and like most pieces in the press, it was highly critical of psychiatry.  The philosopher's argument was basically that the DSM-5 had an implicit agenda.  That agenda was that it was a blueprint for living.  As an acute care psychiatrist for most of my life, that analysis was more than off the mark - it struck me as absurd.  The only advice about living that I gave people was lowest common denominator advice:

1.  Get a stable place to live where you feel safe and you can unwind each day.

2.  Get adequate sleep.

3.  Eat nutritious food.

4.  Get some exercise.

5.  Stop drinking.

6.  Stop using street drugs.

7.  Try to stop smoking.

This is advice where the patient has been unable to secure any of these elements, is also often physically ill, and we could offer active help.  None of that advice is contained in the DSM-5, but when you are treating people with severe psychiatric disorders it is useful and potentially life saving advice.  You can read about the "blueprint for living" argument and several additional arguments in the comments at this link.  One of my main points is that psychiatry and medicine in general are focused on extremes and not normative human conditions.  Medicine generally tries to draw a line (however imprecise) between the pathological and non-pathological.  The only real life lessons there are is how to avoid some pathological states.

The other part of my career in the outpatient setting is trying to convince people to stop using drugs and alcohol at various stages of addiction.  The pathway to addiction and the pathway to recovery back out again are complex.  Not everybody makes it.  The argument for recovery has always been quite basic.  Stop using or end up "crazy, in jail, or dead."  Far too many people are exposed.  As a reductionist, I teach that there is a certain portion of the population that is at high risk for addiction due to neurobiological factors.   There is also a portion of the population at low risk because of dissimilar factors.  With the current push toward universal cannabis legalization, widespread availability of opioids, and the idealization of hallucinogens and psychedelics larger and larger numbers of people at put at risk, just based on their biology.  The backdrop here of cycling between permissiveness and prohibition at the cultural level was noted by Musto a few decades ago.  The problem is that American society deals with that conflict by political arguments.  Those arguments are focused on liberalized drug use or prohibition without any common sense in between.  In the United States that no man's land points directly to a lack of a philosophy for living.

What do I mean by a philosophy for living?  To me it means a way of living that is based on reasoned principles rather than popular culture.  A way of living based on contemplation rather than impulse.  A way of living based on conscious decisions long before the time when the decisions are no longer conscious or reasoned.

The best example I can think of is from the field of addiction.  There is always a lot of confusion over the issue of decision making in psychiatry and addiction.  Patients without addictions are often told that they have choices.  That is a gross oversimplification when it comes to how people with mental illness make decisions.  The same thing is true of addiction.  The main difference is that a moralistic approach to addiction is still acceptable at many levels of society.  That is - if you correct your moral problem -  the addiction will be solved.  That is presently a lot harder to do with severe mental illness in most settings short of a not-guilty-by-reason-of-insanity defense.  Even in the case of severe mental illness that clearly caused the crime, the the NGRI defense is usually not exculpatory.

Given those scenarios a philosophy for living can be considered a preventive measure rather than a primary cure.  As such it is outside the scope of psychiatry.  There have been a few psychiatrists who were philosophers, but the vast majority were not.  Over the years, I have found a first rate philosopher who I have followed on his blogs and in several of his books.  Massimo Pigliucci has written and edited several excellent books including Denying Evolution and Philosophy of Pseudoscience.  He also stopped writing what I consider to have been and outstanding blog about philosophy called Rationally Speaking that is still available to read.

For the purpose of this post he also writes the blog How To Be A Stoic. Most people have a truncated view of Stoicism.  It is really not like the stereotypical Norwegian bachelor farmers of the upper Midwest.  It is not the image that many of us got studying ancient governments and cultures.  It turns out that Stoicism is a philosophical approach to life.  That makes it unique in the field of philosophy, since most philosophies are not about how to live your life.  He recently offered to field some questions and answer them according to his interpretation of Stoicism.

It is against that backdrop that I sent Massimo the following question:

"I am currently an addiction psychiatrist and that means 100% of the people I see have one or more serious addictions.  While I operate from the neurobiological perspective with regard to addiction - phenotypic plasticity is operative.  I would estimate that 40% of the population is at risk for addiction if exposed to a matching intoxicant.  Availability of drugs as seen in the current opioid epidemic is always a significant factor.  

It is hard to ignore the cultural biases that lead to this exposure.  It seems to be part of the American culture that people expose themselves to drugs and alcohol at an early age.  In Middle School and High School as well as college there is peer pressure.  People who abstain from intoxicants are viewed as being square or possibly closet prohibitionists.  The former President of Mexico Vincente Fox suggested the entire reason for the War on Drugs was "America's insatiable appetite for drugs.."  I think that he was right.

I think that an important public health strategy would be to intervene at the "philosophy for living stage" that currently seems based on hedonism before the significant neurobiological effects from the intoxicants takes over. 

Is there any advice that Stoics may have to offer in this situation?  I guess I see the problem as a lack of a reasonable plan for living at the bare minimum when it comes to excessive drug and alcohol consumption.  

There is not much of a window between that and a full blown addiction."

And this is what he said.  Please read his well thought out post that contains some additional references.  His  discussion of the ancient version of the Serenity Prayer was very interesting.

Can Stoicism as a philosophy for living prevent addiction and a lot of other decisions that Americans make that are not in their best interest?  I agree with Massimo and think there are paths in addition to Stoicism.  The point of this post today is here is one example of what might be possible.  Here is an alternative to moral development that does not quite go the way it is taught in psychiatric texts.  Here is an alternative that offers more than a relatively bankrupt culture that emphasizes money, violence and hedonism.  Here is an alternative to prohibition.  After all if you are contemplative and are assessing your life on a daily basis relative to specific virtues - you will not need external controls.

Having a philosophy of life seems much better than not having one.

George Dawson, MD, DFAPA

Supplementary:  I wrote all of this post except for the book titles and the conclusory paragraph before reading Massimo's reply.  I did not want to be biased by his reply and try to seem more knowledgeable about Stoicism than I am.  A philosophy for living is definitely outside the expertise of most psychiatrists.


Photo at the top is  Agora of Smyrna, built during the Hellenistic era at the base of Pagos Hill and totally rebuilt under Marcus Aurelius after the destructive 178 AD earthquake, Izmir, Turkey from Wikimedia Commons By Carole Raddato from FRANKFURT, Germany [CC BY-SA 2.0 (htta significant hsitroical basis of Stop://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons.

Marcus Aurelius was a Roman emperor and also a practitioner of Stoicism.  His surviving writings provides a modern day resource of Stoicism.  From the number of quotations I think it is safe to say that modern day Stoics consider him to be a Stoic philosopher as well as practitioner.


  1. A lot of this relates to expectations management and inability to delay gratification (see marshmallow experiment). Eastern Buddhism in addition to Western Stoicism is a nice alternative to the horrid popular culture (thanks MTV and Instagram). The real Buddhism, not the California good vibes kind that works its way into Burning Man.

    1. Agree - I have been impressed with the number of people who found Buddhism to be a superior alternative to endless psychotherapy.

      I think that Buddhism was mindfulness before there was mindfulness therapy.

      As far as I can tell Stoicism and Buddhism share a lot of common concepts and Massimo points out it is an alternate belief system to American consumerism. Just learning how Buddha invented the system is awareness expanding.

  2. It also beats many contemporary approaches to pain management:


  3. Freedom from expectations is a great tenet and I agree it is helpful. Happiness=Reality-Expectations

    The freedom from desire is a bit more problematic, especially after studying drive theory and Freud. That sounds a lot like denial and failed repression. Plus even if one somehow manages to be celibate, I don't know how you don't desire good food.

  4. Massimo Pigliucci speculated that it may be time to resume inculcating a philosophy of life in children as a substitute for the despised blandishments of popular culture. While some adolescents do indeed glom onto some form of idealism and enthusiastically profess its merits, perhaps for a decade or two prior to disillusionment; and while it has become fashionable to describe or tout "life-changing" events, in general moralistic and quasi-moralistic precepts, neither life lessons nor what pass for profound experiences penetrate deeply into nor pervade the important behavioral patterns or choices of their target population. The stereotyped teachings imposed on children in former, even not so former, times now generally seem quaint, laughable or downright distasteful echos of a hypocritical and confining society, the kind of stuff 19th century novels exploited with great relish. To be sure, there is comfort, rescue from dread of chaos and despair, hope, and a sense of belonging and self-worth to be gained from words of wisdom, adages and, yes, from philosophical musings and positions and, of course, from novels; and there is good reason to believe that exposing young people to a broad range and rich array of such would benefit them and, to some extent, provide a bit of protection against falling into an addiction. But the baleful influence of elements of popular entertainment (AKA "culture") that are misunderstood and/or disliked and/or feared by older people is likely less of a contributor to the incidence of becoming addicted than are poverty, unemployment, "bad" neighborhoods, persecution by police and other authorities, poor healthcare services and other dysfunctional aspects of our society. Looking to philosophical platitudes for solutions diverts attention from what may actually work.

    1. "But the baleful influence of elements of popular entertainment (AKA "culture") that are misunderstood and/or disliked and/or feared by older people is likely less of a contributor to the incidence of becoming addicted than are poverty, unemployment, "bad" neighborhoods, persecution by police and other authorities, poor healthcare services and other dysfunctional aspects of our society. Looking to philosophical platitudes for solutions diverts attention from what may actually work."

      The current heroin epidemic in upper middle class to affluent youths with the associate mortality speaks against poverty as being a social etiology. Prior to that there was the issue of disproportionate punishment for crack cocaine users (poverty stricken neighborhoods) versus powdered cocaine users in more affluent neighborhoods. On the issue of healthcare services addiction services were the first victims of managed care rationing - the level of service is generally pathetic and transferred to the non-medical public sector as much as possible so I doubt they are saving anybody.

      On the cultural issue - I would not minimize it to the baleful media elements. There are clear differences. The teaching example I use is the difference between growing up in Northern Minnesota in the 1970s and in the early 21st century if you are a middle class teenager whose father and grandfather were alcoholics. You are clearly at risk but does the risk increase greatly going from needing to avoid alcohol and cannabis (primarily) in the 1970s to the same two substances plus heroin plus methamphetamine plus synthetics, etc. I would argue that it does increase risk, just as the risk is high for any inner city youth who has to walk past 5 or 6 drug dealers a day to get to middle school.

      I am sure there are some economists out there who might see it as enterprising drug dealers and supply and demand. But none of this happens unless it is part of your culture and you are not inoculated unless you can set yourself apart from it.

      I certainly agree that widespread attempts to educate youths on the advantages of a philosophy for living would be a very low yield enterprise for the same reasons that religion and algebra don't gain wide traction. The yield seemed fairly low in my freshman philosophy course, but the focus was on more typical philosophy.

      I do think getting it out there does offer some hope for prevention for the people who are open to it both at a primary and secondary level.