The Victim Meme In Addiction and Recovery

The popular press has created a victim meme in discussing addiction and the recovery process.  An example would be the popular quote from the NYTimes: "Only in death do drug users become victims. Until then, they are criminals".  I have problems with these quotes that have become memes in social media because the idea that people with substance use disorders are victims does not seem to originate in either the medical field and the physicians who treat them or the recovery literature written by the affected people themselves.  The other operative word in this quote is "users".  To me that means that nobody here is forced to initiate drug use or assaulted and forcibly given addictive drugs.

My first year as a psychiatry resident, I can recall a fellow resident presenting a patient to the senior attending.  He used the term unfortunate to describe the patient, a homeless middle aged man with a chronic psychosis and alcoholism.  The attending cut him off and said "What do you mean by unfortunate?"  In the next ten minutes or so, we learned that the patient was no more unfortunate than any of the other 20 men with severe psychiatric disorders on that unit. By extension the term was essentially meaningless, because it did not discriminate that person from any one else and it was irrelevant to the diagnosis and treatment planning. Years later, I learned it could also be an impediment to the treatment relationship.  A ban on smoking rapidly went into effect and the staff were split on what that meant. Many believed that it would result in more violence and aggression. Part of the ensuing rhetoric was "That is all that these unfortunate people have.  If we take smoking away from them - what's left?"  A very dim view of a person's life is required to see it as existence for the sake of smoking.  I would go so far to say it is blatantly dehumanizing.

The idea of patient as victims occurred again in psychiatry during the satanic ritualistic abuse phase and more recently during the patients are all victims of childhood abuse phase.  In the former case it lead to a proliferation of multiple personality disorder diagnoses and encouraging the proliferation of this myth with the associated unnecessary treatment.  In the case of treating everyone like a victim,  that program was correlated with an increase in aggression and staff assaults in state hospital settings and an eventual abandonment of the program.  Somewhere along the way, the application of a broad implementation of treatment based on whether or not a person is a victim is problematic from a programmatic standpoint, as well as the individual treatment relationship.

In terms of the individual evaluation, being victimized is a part of the clinical history.  Like grief, practically everyone has a history of some type of physical, emotional, verbal, or sexual abuse in the past.  The psychiatrists job is determining if it is relevant to the current problem and how it has impacted the patient's long term conscious state on an ongoing basis.  At a practical level it has resulted in an  ICD-11 diagnostic criteria set that identifies fewer patients as having PTSD compared with DSM-5.  From the linked reference it appears that there will be concern over identification of PTSD as well as under identification.  It is a more difficult task than just matching clinical criteria.  In many cases, PTSD symptoms recur in the context of depressive episodes and significant episodes of anxiety and resolve again when those episodes are treated.  In acute situations like intimate partner violence, advocates can provide a valuable function until a patient's living situation has been stabilized.  If victimization is a relevant clinical theme, it is addressed by addressing the associated syndromes and psychotherapy that is focused on maintaining safety, alleviating symptoms, and facilitating relevant lifestyle changes.           

Apart from victims the concept of the criminalization of the drug user is also a popular meme.  Simplified it is that drug users and alcoholics should be treated and not incarcerated.  It is based on the assumption that most of these folks are incarcerated on trivial drug or alcohol charges or probation violations from those trivial charges.  That can certainly happen.  Unfortunately real crimes involving loss of life, serious injury, and property crimes also happen.  I recently heard a District Attorney talk about the scope of the problem at the Minnesota Society of Addiction Medicine May 30 meeting.  He was keenly aware of the problem because law enforcement resources are currently flooded with opioid and methamphetamine users as well as people with severe mental illnesses.  He presented the problem to his prosecuting attorney and asked them to come up with a solution for people being prosecuted for drug crimes.   They ended up with a three step plan for sentencing offenders to maximize the likelihood of treatment and the ability to change felony crimes to misdemeanors after adjudication. The main message was that there is no interest on the part of prosecutors to incarcerate drug offenders, but there is clearly a limit with the associated crimes.

In the recovery literature, victim is rarely seen.  The Narcotics Anonymous book uses it in one place in the Eighth Step:  "Many of us have difficulty admitting that we caused harm for others, because we thought that we were victims of our addiction.  Avoiding this rationalization is crucial to the Eighth Step"  (p 38).  The AA 12 and 12 (2) contains the words victim in Steps 1, 3, 4, 10 and 12.  The term is used to make the general argument for powerlessness (Step 1), to discuss the effects of remorse and guilt (Step 3), to discuss the effects of erratic emotions (Step 4),  to illustrate the problem with resentments (Step 10), and how the program can free members from irrational fears (Step 12).  The bedrock of 12-step recovery is powerlessness and that is not the same thing as being a victim even though that word is used in Step 1. 

I don't think that I am going too far out on a limb in suggesting that the victim meme is not relevant in addiction, addiction psychiatry, or recovery. The importance of powerlessness as opposed to being a victim is captured from reference 2:

"Our admissions of personal powerlessness finally turn out to be the firm bedrock upon which happy and purposeful lives can be built."  (p. 21).


George Dawson, MD, DFAPA


Supplementary:

For other variations on the victim meme see these previous posts:


The Whitening of the Opioid Epidemic:

https://real-psychiatry.blogspot.com/2018/05/the-whitening-of-opioid-epidemic.html

Addiction Narratives Versus Reality:
https://real-psychiatry.blogspot.com/2018/05/addiction-narratives-versus-reality.html



References:

1.  Narcotics Anonymous (6th Edition).  World Service Office.  California, USA 2008, p 38.

2.  12 Steps and 12 Traditions.  AA World Services, Inc.  New York City 2007.

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.


Attributions:

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.

Personally Intervening in the Case of Public Intoxication

I am at the Fairmont Copley Plaza Hotel in Boston.  I made the trip for the Harvard Neuropsychiatry Course.  My wife and I decided to go out and look at some architecture and walked out the side entrance onto Dartmouth Street.  There on the sidewalk was a young woman who appeared to be doing a down dog.  The only problem is that she did not seem to be able to get out of it.  As she pushed herself up, it was apparent she was severely intoxicated.  She had drawn a small group of observers, people were staring at her and not doing much of anything.  Being strangers in town we decided to keep moving and let the locals handle it and headed down Dartmouth toward Boylston Street.  After about 100 yards the young woman got up and started walking down the sidewalk and at times staggering into the street.  Vehicles travelling at about 30-40 mph had to stop or take evasive action in order to avoid her.  She was not aware of the near misses and kept wandering farther out into traffic.  This was unfolding in full view of hundreds of people in Copley Square and three television camera trucks interviewing people about the election results.

At that point, I could not stand by to wait for her to get hit by a car.  I was in Philadelphia once back in 1975 on a packed sidewalk.  At the red light a guy next to me inexplicably stepped off the curb against the light and was hit by a speeding van.  I can still see his body arcing through the air and landing face down on the asphalt about 50 yards away. I don't want to see that again.  I walked up to the woman and physically guided her back onto the sidewalk and asked if I could call someone.  She was obviously intoxicated and her speech was 80% unintelligible.  She was able to tell me that she wanted to get on a subway train to a suburb.  There were two subway stations available and a passerby helped us out by telling us where we needed to take her.  I helped her across Dartmouth and at that point she became agitated and started to walk out into the street again.  I tried to guide her to a seat at a bus stop and she slumped against the edge of the bus shelter and it looked like she was going to fall asleep.  At that point, I asked my wife to call 911, because it was obvious that she could not safely travel on her own.

She became agitated and angry.  She demanded to know where I was taking her and bolted across the street to the the wrong subway station.  We had the 911 operator on the line and when we reported what happened, the operator said: "well she's on the subway - it's out of our hands now" and hung up!  We crossed the street and went underground looking for her.  I was concerned that she would fall off the subway platform.  She had negotiated the turnstiles and it was not obvious how that happened, but there were some embarrassed looks on the faces of the transit personnel.

I watched her get on the train.  One precarious short step forward, followed by a long lean backwards.  During the lean, all of the exiting passengers halted in their tracks as if they were waiting for her to fall over.  After a few seconds - she regained her balance and plummeted past them onto the train.  The train pulled out and she was gone....

We helped her as much as we could.  Two people assisted us, hundreds did not.  We avoided a catastrophe - at least in our immediate vicinity.  From the public official we called, that was apparently all that the citizenry of Boston expected.  I did not notice until later at night that there were a significant number of people with chronic mental illness around Copley Square.  Many of them were incoherent or shouting illogical statements in a loud and vaguely threatening manner.  Still - they were not wandering in traffic and appearing to be at high risk for a fatal encounter.  It is possible I guess that the threshold for intervention is altered in that context, but the young women in question was neatly dressed and obviously ataxic, dysarthric, and sedated at times. In that case, the many people who saw her decided to do nothing but watch.

I thought I would document this all here with a suggestion.  If you see a fellow citizen intoxicated and in danger, I recommend intervening in that situation.  I don't think that you want to be second guessing yourself if you elect to do nothing and witness a catastrophic event.  This is a clear example about why public intoxication is not a humorous event like it is typically portrayed in the movies. It is also an example of the limits of what can be done.  Of course you always have to use your judgment in these situations.  You  can't put yourself in danger.  Private citizens cannot take physical custody of another person.  I could only help this person as much as she would allow even though her judgment was clearly impaired.

Acute intoxication can easily be a life threatening experience.  The danger can be either the direct result of the intoxicant or the result of inadequate self care.  I have seen too many people killed outright or in a trauma or burn unit because of that lack of ability to take care of oneself.  Even an unsupervised fall at home can be fatal.

So - do what you can.......


George Dawson, MD, DFAPA      


Supplementary:

For some reason, I have had the opportunity to intervene in many of these incidents in the past varying from a retiree backpedaling out of a rural convenience store and slamming into me at 7AM in northern Wisconsin - to picking up someone off a hospital floor and getting him to the Emergency Department.  My wife was with me for the first incident and she was quite upset thinking that the old guy had a heart attack or a stroke.  I told her not to worry - he was drunk even though it was 7 AM and he had driven himself to the store across a busy highway.


Attribution:

Photo at the top is from Wikimedia Commons with the following references from that site: By User:Eos12 (Own work) [Public domain], via Wikimedia Commons https://commons.wikimedia.org/wiki/File%3ACopleySquare.jpg per the listed release into the public domain by the originator.