Treatment & Recovery
Healing Addiction Through Community: A Much Longer Road Than it Seems?
Healing Addiction Through Community: A Much Longer Road Than it Seems?
Bruce K. Alexander
Revised Version of Keynote Address at the “Creating Caring Communities” Conference
Selkirk College, May 14, 2015
The winds of change are blowing in the field of addiction. I sense the change in the discourse of the most stimulating scholars and the discussions of the audiences after I give public presentations. Both the moralistic view of addiction as wilful evil and the disease/medical model of addiction have lost much of the impregnable power they once had (Pickard, 2012; Ahmed, Lenoir, & Guillem, 2013; Levy, 2013; Satel & Lilienfeld, 2013; Hall, Carter, & Forlini, 2014). A new understanding is gradually emerging in their place: Addiction is a way that needy people respond to what is missing or traumatic in their own lives and communities (Maté, 2008; Hart, 2013; Peele & Thompson, 2014, esp. pp. 197-200; Lewis, 2015). Along with this understanding comes a much greater emphasis on attempting to establish addicted people in a welcoming community, thereby reducing their need for addictive compensations. This expanding trend is associated with googleable phrases like “building community”, “restoring community”, “recovery houses”, and “support groups”.
After a long career of opposing the moralistic and disease views of addiction, beginning with the “Rat Park” experiments of the 1970s (Alexander, Peele, Hadaway, Brodsky, and Beyerstein, 1985; Alexander, 1990, 2008/2010), I consider this trend a cause for celebration. However, I have a nagging fear that “restoring community” as currently discussed and practiced by many influential thinkers and organizations, may not be much more successful in the end than the interventions that grew from the War on Drugs and the disease model.
My fear is that the current thinking that underlies the community-oriented understanding is still too narrowly focussed on the travails of individual addicted people, rather than also taking into account the broad, historical causes of a society that carries a huge burden of severe addictions to habits of all sorts. Tonight, I will summarize a global, historical account of the causes and consequences of addiction (Alexander, 2008/2010, chap. 3; Alexander, 2014). My account, like the accounts that I have referred to above, concludes that addicted people can best be helped by restoring their place in a functioning community. However, it also shows why restoring people’s place in community is much more difficult than it seems and why bringing addiction under control requires much more than therapy.
This talk ends with a radical long-term view of what it will take for community life to bring addiction under control. This view would have been almost unthinkable when I began my career in the psychology of addiction a half-century ago, but can be better appreciated in the today’s state of global chaos.
A Global, Historical View of Addiction
In Figure 1, I have drawn a global, historical view of addiction as a feedback loop or “vicious cycle”. In the center of the cycle is an old portrait of Christopher Columbus looking worried. I hope that it will be clear very soon why he appears as the central image, and why he was right to be worried.
Please keep two caveats in mind: First, the global, historical view of addiction does not focus on single individuals. Rather, it focuses on the societal causes of the rising tide of addiction in a 500-year period that historians know as “the modern era.” Of course each addicted person’s story in unique, but the global view is needed both to explain the rising tide of addictions that threatens to engulf us, and to enrich our understanding of the individual life stories of addicted and recovering people.
Second, the historical view of addiction is not an attempt to explain drug use, or “substance abuse”. People use psychoactive drugs for all kinds of reasons, many of which have nothing to do with addiction. The historical perspective is about addiction in the sense of a powerful dedication or devotion to a particular habit or pursuit that may interfere with the life that a person wants to live and that their society expects them to live (see Oxford English Dictionary, definition 1a). Addictions to drugs and alcohol are important of course, and they dominate the mass media, but they by no means comprise all or even most of the addiction problem. Rather than concentrating on drug and alcohol addictions, The historical perspective focuses on the full range of potentially destructive addictions, including sex, wealth, power, gambling, love, eating, shopping, hoarding, dieting, internet games, social media, narcissistic self promotion, alcohol, drugs, pets, and so on and on and on.
The historical view of addiction starts with the fact that societies everywhere have become severely fragmented in the last five centuries (See Fig. 1, top quadrant). From the time of Christopher Columbus onward, large scale colonization by western powers has crushed defenseless societies around the globe by conquest, disease, enslavement, economic exploitation, religious domination, and devastation of local ecosystems (Wright, 2004; Mann, 2011). Canadians know the history of colonization very well because it is our own history, both as the colonizers and the colonized. But is also the history of the entire western hemisphere, as well as Africa, Asia, the Middle East, and much of Europe.
At about the same time that the colonizing European powers conquered the outer world, they also crushed defenseless subcultures within their own countries, although with somewhat more restraint. The agricultural and industrial revolutions overran and crushed stable peasant villages and commons throughout Europe (Polanyi, 1944; Bollier, 2014). More recently, dazzling new technologies, corporate strategies, predatory lending practices, and neo-liberal government policies are re-invading and re-fragmenting local urban and rural societies, social safety nets, universities, and Internet-based groups that were emerging from the ruins of traditional cultures (Rowbotham, 1998; Reding, 2009; Klein, 2014a; Bollier, 2014, chaps. 1-5).
Thousands of different aspects of the global fragmentation story have come to light. Beneath the repeated passes of the steamroller of modernity, nuclear families have been crushed, extended families have been scattered, religions have been twisted into shallow caricatures, and cultures and ethnic traditions have been pulverized.
The social fragmentation of society that began in the early modern era continues to escalate in the modern world of the 21st century, amidst the globalization of free-market capitalism, neoliberalism, corporate culture, high-tech surveillance, ecological devastation, “development”, “restructuring”, and “austerity” imposed on poor countries, mercilessly increasing efficiency in manufacturing and agribusiness, and unending financial crises (Chossudovsky, 2003; Dufour, 2003; Harvey, 2011, pp. 66, 176; Snowden, 2014; McWilliams, 2015.) Some excellent recent authors associate these kinds of fragmentation with “postmodernity” more than “modernity” (e.g., Berardi, 2009), but the analysis remains essentially the same.
In today’s Canada, we struggle to protect society from further social and environmental fragmentation that will be produced by oil and gas pipelines, fracking, destruction of the terrains near the tar sands, hard-rock mining, overfishing, real estate bubbles, uncontrolled banks and financial markets, pollution of the fresh water supply, privatization of our excellent medical and educational systems, increasing “linespeed” in meat processing plants, and the Internetification of private life (Nikiforuk, 2015; Levitin, 2015). These are not separate problems, but diverse manifestations of the steamroller of fragmentation.
Fragmentation seems inescapable because it is a side effect of an economic, political, and technological evolution that has bestowed enormous increases in industrial productivity and technical advancement on the human species, and has made it possible for the earth to support a world civilization of seven billion people. However, this bourgeoning world civilization is in deep, and possibly terminal trouble, in large part because of the consequences of this fragmentation, including dislocation and addiction.
Following Karl Polanyi (1944), I use the word “dislocation” to describe the individual, psychological devastation that is rooted in unrelenting societal fragmentation. “Alienation” and “disconnection” are equally good terms for “dislocation.”
Dislocation refers to the experience of a void that can be described on many levels. On a social level it is the absence of enduring and sustaining connections between individuals and their families and/or local societies, nations, traditions, and natural environments. In existential terms, it is the absence of vital feelings of belonging, identity, meaning, and purpose. In spiritual terms it can be called poverty of the spirit, lack of spiritual strength, homelessness of the soul, or feeling forgotten by God.
Mass dislocation has real benefits for economic growth and geopolitical power. The free market system that underlies the modern global economy needs dislocation. For the modern economy to function well, individuals must perform competitively and efficiently, unimpeded by sentimental ties to families, friends, traditional values, needs for a sense of meaning, love of the earth, or religious commandments. In classical economics, it is this severe economic rationality that is said to make the law of supply and demand function, and thus to “clear the markets” each day. Nations that have adopted the free market system in recent years, such as China and Russia, have become geopolitical superpowers.
Dislocation has genuine hedonistic advantages for modern individuals as well for economies. It provides opportunities for personal initiative, individual creativity, and self-actualization. Everyone probably enjoys indulging in unrestricted individualism from time to time (Ryan, 2013).
However, prolonged, severe dislocation has a high price, because it eventually undermines the normal societal bases of belonging, identity, meaning, and purpose, leaving people with an empty and dismal experience of the world [Polanyi, 1944; Frankl, 1963; Berry, 2009, pp. 35-48; Tolman, 2013; Klein, 2014a, pp. 158-160; Verhaeghe, 2014].
Decrying fragmentation and dislocation is not just the nostalgic lament of existential philosopher, social workers, historians, theologians, romantic poets, and gurus. The concrete damage caused by dislocation and the specific linkages between societal fragmentation and individual dislocation have been described – and sometimes quantitatively measured – at every stage of the human life cycle, beginning before birth.
For example, intrauterine consequences of stress endured by pregnant women in a fragmented society can make render their children socially fearful year later and, hence, dislocated. Some of the brain mechanisms underlying this causal relationship have been worked out (Maté, 2008, 2015).
Lack of stable attachment in infancy or traumatic abuse, due to fragmentation of families (or any other reason) can make a child insecure and unlikely to achieve satisfactory integration in society later in life (Bowlby, 1969).
Lack of stable housing in volatile real estate markets dominated by speculators can make settled family and neighbourhood life difficult or impossible for adults, even those experienced little stress early in life. I witness this first hand amongst young relatives and friends in the insanely-inflated real estate market in Vancouver (Surowiecki, 2104).
Work in a dehumanizing factory system like Foxconn, where my cell phone – and perhaps yours – was made, can leave people so empty of meaning that suicide becomes a widespread alternative (Tharoor, 2014).
Existence in a hypocritical, corrupt political system run by politicians who shamelessly serve financial and industrial megacorporation and military bureaucracies leads to profound apathy in adults (Brand, 2013; Risen, 2014).
Lack of family and neighbourhood support can leave elderly people in a state of incapacitating despair (McLaren, 2014).
Severe, prolonged dislocation is unbearable; most of us cannot just “tough it out.” It precipitates anguish, suicide, depression, disorientation, and domestic violence (Durkheim, 1897/1951; Polanyi, 1944; Chandler, Lalonde, Sokol, & Hallet, 2003; Deraniyagala, (2013), Berardi, 2009; White, 2014; Alexander, in preparation).
Because it is unbearable, dislocation has been imposed as an extreme punishment (in the form of solitary confinement, exile, ostracism, banishment, and excommunication) from ancient times to the present. Because it is unbearable, radical social isolation remains an essential component of today’s terrifyingly scientific technology of torture (Klein, 2007, chap. 1; Democracy Now, 2014).
It is hard to describe dislocation precisely because it needs to be discussed on several levels at once. It is even harder to describe what it is like not to be dislocated. It would be wrong to say that the opposite of dislocation is “normal” because in a fragmented society like our own, dislocation is closer to the norm. I prefer to use the term “psychosocial integration” for the opposite of dislocation. This term originally comes from Erik Erikson. My best attempt it summarize psychosocial integration quickly is to say that it is the mentality of people whose place in a well functioning society enables them to that they belong, yet still feel free.
Avoiding Oversimplification. “Dislocation” and “psychosocial integration” are multilayered concepts that lose their meaning if they are over-simplified or rigidly operationalized. For example, extreme income inequality is an obscene fact of today’s world and can exacerbate many aspects of dislocation. However, dislocation is much more than either poverty or income inequality. Many wealthy people feel the full anguish of dislocation. (Slater, 1980; Alexander, 2008/2010, chaps. 9,10). No matter how rich you are, you cannot buy your way out of dislocation although you may be able to create the appearance that you have (Alexander, 2008/2010, pp. 131-136; Sheff, 2008; Sheff, 2009; Klein, 2014a, pp. 161-170).
Dislocation is also more than just loneliness. It is possible to have a busy, or even frantic, social life in a fragmented society and still feel the full force of dislocation if a person is bereft of truly functional social connections, a meaningful sense of place in the natural world, or a home I the world of the spirit (e.g., Lewis, 2015, chap. 5). Unlike rats, the cages that make people vulnerable to addiction are often invisible.
Concern about dislocation is more than just romantic nostalgia for the real or imagined “good old days.” The modern era is no more evil than previous eras but, like earlier eras, it brings its particular problems to be solved. Widespread dislocation is one of them. Of course, individuals can also be severely dislocated by events that have nothing to do with modernity, including earthquakes and tsunamis and individual genetic and epigenetic misfortunes. These occurred in pre-modern as well as modern times. Nonetheless, modernity itself is the dominant source of dislocation in our era, and many modern thinkers believe that dislocation is now inescapable and almost universal (Dufour, 2003; Berardi, 2009; Albrecht, 2012; Welch, 2015).
Dislocation is experienced as the absence of belonging, identity, meaning, and purpose. But how much of each is required to achieve psychosocial integration? For example, can a lot of identity make up for an absence of meaning? It is impossible to say. Dislocation is a human state that is widely recognized but only loosely defined. There is no precise formula for defining or measuring it. This makes its existence easy to deny in an age dominated by rigid scientific epistemology. Unfortunately rigid scientific epistemology cannot make dislocation disappear, although it can make it invisible to people who push scientific logic beyond the limits of its utility.
Addiction: A Common Way of Adapting to Dislocation
Just as high levels of dislocation follow high levels of social fragmentation, a flood of addiction inevitably tracks high levels of dislocation (see Fig. 1, bottom quadrant). A wealth of historical and anthropological evidence shows the predictability of this sequence. Clinical and biographical evidence shows why addiction tracks dislocation so closely: Addiction can provide dislocated people with some much needed relief and compensation for their bleak existence, when nothing else seems to be working. (Alexander, 2008/2010, chaps. 6-8; Watson, 2015).
Addiction can become an intense and even overwhelming involvement that can provide a partial substitute for people who are severely dislocated. Addiction can fill the excruciating void of dislocation, to a degree and for a time. Because addictions provide only a partial solution, severely addicted people must work them for all they are worth – insatiably – even if they feel terribly guilty about the people they are hurting in the process, or the other parts of their life that they are letting fall to ruin.
To say that addiction serves a vital adaptive function is not to say that it is harmless, or to make light of it. Rather, it is to point out that it serves a vital function for people who cannot find a better way to respond to desperate and dangerous levels of dislocation under the circumstances of their lives. That is why it is so common in a fragmented global society.
Of course addiction is not the kind of adaptation that people generally want for themselves, or that their societies want for them, but it at least provides them with some meagre sense of belonging, identity, meaning, and purpose (even when it is accompanied by guilt and remorse). Without their addictions, many people would have terrifyingly little reason to live and might fall into incapacitating depression or suicide.
For example, when "junkies" wake up, they at least know who they are and what they must accomplish that day. Rather than being overwhelmed by the emptiness of their existence, they keep very, very busy chasing drugs, sometimes in collaboration with their fellow users, sometimes in competition with them. At the same time, they can hold onto a tragic but exotic junkie identity, and identify themselves with William S. Burroughs, Curt Cobain, Phillip Seymour Hoffman, Russell Brand, or Robin Williams. A kind of junkie mystique dilutes the misery of their existence with the glamorous imagery of the “tragically hip” or “the coolest” (Burroughs, 1967; Pryor, 2003).
For another example, people who are addicted to horserace gambling have not found anything more important in their lives than incessantly exchanging information and hunches within a colourful subculture of characters at the track, with a mythology of famous gamblers and legendary horses of the past and an imagined future of fabulous success (Ryan, 2014a, b).
Much larger numbers of people use drugs only moderately or go to the track recreationally. They have found more effective ways of fulfilling their needs most of the time. The tragic reality, however, is that there are countless millions of people who cannot use drugs or gamble recreationally. Their needs for belonging, identity, meaning, and purpose are too great and they seize onto these recreations as saviours, and try to build a life around them. Because addiction is essential to dislocated people’s ability to function in the world, people cling to their addictions with the iron grip that they would apply to a piece of floating junk in a stormy sea.
The adaptive function of addiction is often hidden. Many addicted people deny that they live in a state of dislocation, because they feel ashamed of their inability to find a secure social life, a sense of who they are, some values they can believe in, a place they can call their own, or a reason to get up in the morning, even though they live in a fragmented society that makes filling these needs problematic for everybody. They may deny their dislocation because it feels like an unbearable personal failure and they may be only dimly aware of the adaptive function of their addiction. In moments of insight however, even these people can explain the function of their addiction with surprising candour (Alexander, 2008/2010, pp. 158-160).
Long ago, when I worked as a family therapist, I saw parents of addicted people cling with an iron grip to the Official View that their children’s addictions were caused by addictive drugs, or by irresistible peer pressure, or by genetic predispositions, or by incurable brain dysfunctions. Acknowledging the adaptive functions that addictions served for their son or daughter would require acknowledging how much was missing in the family and neighbourhood environment they had been able to provide. I think that all of us who are parents can recognize how excruciating painful that acknowledgement could be. It would seem to be an admission of abject failure as a parent, although it is perfectly clear that many of these parents did everything within their power for their children.
Finally, the Official View of Addiction lavishly funded and sponsored by our governments, especially through NIDA (Alexander, 2014) and other governmental and professional agencies authoritatively proclaims addiction a chronic disease caused by drug use -- rather than an adaptation -- with all the force of scientific authority and media dramatization. Is it possible that this dogma spares the officials who promulgate it from another kind of anguish about the kind of society that they perpetuate in loco parentis?
Consequences of Addiction: The Cycle Continues
Beyond the fact that addictions are only partially successful in reducing individual dislocation, there is another, more social reason why addiction is so hard to overcome in modern society. Many of the harmful consequences of addiction exacerbate the fragmentation of modern society and, thus increase the dislocation that flows from it. Ultimately, these increase the prevalence of addiction. The vicious cycle keeps turning.
Think of the fragmentation produced by wealth and power addicts in the executive suites of multinational corporations. Then think of the environmental harm caused by the compulsive consumption of their products by millions of their customers. Think of the fragmentation produced by all the talented children who cannot be educated and socialized as productive adults because their school years have been lost to the world of video games and social media. Think of all the adults who are lost from reflective work and citizenship because they are lost in active addictions to money, power, drugs, sex, wealth, celebrity worship, spectator sports, fashion, pets, social networking, Internet gaming and so forth. Think of all the addicted people lost in an endless cycle of tenuous recovery, relapse, and re-recovery. Think of all the elders who will not pass their accumulated wisdom to their descendants because they are lost in their addictive involvements in television, crossword puzzles, or prescription drugs.
Moreover, when people’s addictions last too long or become too overwhelming, their adaptive functions go awry. Health consequences of severe addictions further burden and fragment the addicted persons’ families, communities, and societies. In all these ways, addiction perpetuates social fragmentation, and the cycle roles on through the generations.
Addiction is not only a downstream response to societal fragmentation but also ultimately an upstream cause of it. With each new turn of the cycle the flood of addiction rises to new heights and the costs to society increase.
Treatment of Dislocation and Addiction
The global, historical view gives us a fresh basis for looking at the innumerable current forms of treatment and prevention of addiction. It enables us to understand why our current methods aren’t more effective and what we can do better. It allows us to imagine a world where we would no longer have to live with high levels of addiction to all kinds of habits, and where so many parents would not endure so many sleepless nights worrying about their children’s possible addictions.
Here one way of classifying the approaches that have been prevalent in the western world since the 19th century. They are organized according to the degree to which they can address the problem of societal fragmentation and individual dislocation by restoring community, starting with the least relevant.
1. Punish drug users, producers, and traffickers; anti drug propaganda: The “War on Drugs”
2. Treat the addicted individuals in a medical or psychotherapeutic context: The Medical Approach
3. Eliminate both punishment and treatment, allowing addicted people to respond to the natural consequences of their lifestyles: The libertarian approach
4. Introduce various esoteric practices to enable people to bear dislocation in a fragmented world: e.g., Meditation, Yoga, Mindfulness,
5. Reduce harm by caring for addicted people whether or not they attempt to give up their addictions: Harm Reduction and Harm Reduction Treatment
6. Provide community-oriented support, acceptance, spirituality, and treatment to overcome addictions: The Recovery Movement (Small Scale Social Change)
7. Restructure modern society to reduce fragmentation, dislocation, and addiction: Large Scale Social Change
In the course of a long professional lifetime I learned to appreciate advocates of each of these approaches. Each can justly claim some successes: Even advocates of the War on Drugs can point to some addicted people who have found better lives under threat of punishment.
Few workers can be completely pigeonholed in a single one of these boxes. Most allow for the importance of more than one or them, although most do put their primary faith in a single approach. Nonetheless, still today, many practitioners of each of the seven approaches express strong disapproval for the practitioners of the other six, ranging from amusement to dark contempt. This persistent antagonism may stem from the profound ideological and metaphysical schisms between the proponents of different points of view, for example between atheists and theists. It is probably exacerbated by the fact that the addiction treatment industry in the US alone has been estimated to have a $35 billion market, and to be “poised for accelerated growth” (Munro, 2015)
The mutual disparagement is counterproductive: All seven approaches deserve acknowledgement for their compassionate intentions and for the people that they have helped over the years. However, it must be said that until now, all of them together have not accomplished much. All indications are that the flood of addictions to habits of all sorts is rising, not receding.
I believe that, once addiction is understood historically, it becomes clear that the best hope at this moment in history lies in much greater emphasis on the seventh approach, Large Scale Social Change.
I will discuss each approach briefly in my remaining minutes:
1. The War on Drugs
The War on Drugs was by far the most visible approach in the late 19th century and the first two-thirds of the twentieth century, although all seven approaches were understood and practiced throughout this period (White, 1998; Alexander, 2009). The drug war is originally based on the assumption that drug addiction and drug distribution are wilful acts of evil.
The outcome of a century of drug war has been ghastly. The horrors of the drug war are best documented in the US (Hari, 2015), but horrors also occurred in Canada (Alexander, 1990, pp. 24-51) and other countries. Faith in drug wars has still not entirely disappeared. It is startlingly evident, for example, in the rhetoric and actions of the current Harper government of Canada (Macpherson, 2014; Webster, 2014; Woo, 2015).
MY VIEW: The war on drugs is an idea whose time has come – and gone. It has now lost its credibility among well-informed people virtually everywhere (e.g., Neuman & Romero, 2015. We will be better off when we are completely rid of it.
However, just as the War on Drugs proved not to be a panacea for ending the problem of addiction, it is important to remember than ending it will not solve the addiction problem either. Even the most enlightened policies of regulation and taxation of drugs will not remove the fragmentation and dislocation that makes even legal drugs addictive to many people. And ending the drug war cannot contribute much to the solution of all the other addiction problems that are engulfing modern society. Today’s societal fragmentation has a much wider basis.
2. The Medical Approach
Medical and quasi-medical treatments include detoxification, cognitive behavioural therapy, motivational enhancement therapy, monitoring and reinforcement, some forms of personal and pastoral counselling, and prescription of naltrexone, nalmefene, disulifram, acamprosate, vaccines against various drugs, megavitamins, ghrelin hormone, deep brain stimulation, and many more. Recently treatment with methadone and suboxone are being classified as medical treatment as well.
(Other kinds of therapy are much more focussed on the underlying problems of dislocation and social fragmentation. These forms of treatment will be considered later, as part of the Recovery Movement and Harm Reduction Approaches.)
MY VIEW: Medical and psychological treatments that focus on addictive thinking, behaviour, and brain states of individuals with little or no concern for the underlying problems of fragmentation and dislocation have failed to do much good. Relapse followed by further treatment is the most likely outcome.
This kind of narrowly conceived treatment has a long history. Many of the treatments that have been used are perfectly sensible – within the limitations of their individualized scope – but some of them seem to me more like miracle cures. Various miracle cures of addiction have become popular for considerable periods over the last century (White, 1998), and new ones are proposed or actually put in to practice all the time (e.g., Friedman, 2015; Scripps Research Institute News Release, 2015). However, upon closer examination, these have all turned out to have little sustained effect for most addicted people (White, 1998) and to be based on gross oversimplifications of scientific research (Horgan, 2015). Nonetheless, hopes for miracle cures continue to materialize in the era of high-tech neuroscience, when so many other, genuine medical miracles have been produced.
Of course medical treatment has helped some people, particularly those who use it to augment their own natural recovery that is already in progress. It offers the gift of social legitimacy and compassion whether it has any substantial efficacy or not.
Addiction treatment is an expression of the natural, compassionate human impulse to attempt to heal those who suffer. But, because there is no reason to think that any kind of narrowly conceived, medical treatment can quell the ever-rising flood of addiction, I predict that it will never be more than a minor part of the solution to the problem of addiction.
3. The Libertarian Approach
In the libertarian tradition, addiction can be seen as nothing more than a moralistic social construction. Indeed, it is often true that people who society labels “addicted” are basically living the way that they want to live without harming others or themselves. If these people find that their “addiction” does not work for them, they will drop it. Focussing attention on these inappropriately-labelled people evokes the possibility of complete legalization of drugs use and conscientiously leaving people to work out their own addiction problems. It finds expression in the libertarian philosophy of Thomas Szasz, John Davies, Jeffrey Schaler, Peter Cohen and others, some of whom argue it with great eloquence.
MY VIEW: The importance of this view is that it provides a reasonable argument for ignoring many instances of addiction and simple dependence (Alexander, 2008/2010, pp. 45-46) that do minimal harm. It also provides a basis for accepting the usually benign marijuana culture of many young adults in Canada and other countries and much of the blatant public drug consumption that goes on at rock concerts.
However, I think it deeply unwise to ignore severe, prolonged addiction, which often entails terrible suffering and social harm. My experience is that when someone believes that they need help because are harming themselves and their family with their addiction, they are usually right. Although many severely addicted people do recover naturally, there are literally millions who do not. And even if our feeble interventions do not work for most people, they do work for some and should be available.
4. Esoteric Practices: e.g., Meditation, Yoga, Mindfulness
The dominant theme of these approaches is working to helping people keep their attention on the immediate experiential reality of the current moment, and away from ugly memories from their past, narratives that obscure present experience, and fears of the future. Often it entails focussing specifically on the present experience of craving and relapse. The dominant methods are derived from Eastern Spiritual Practices and New Age Religions (Chödrön, 2000, esp. chap. 7; Eckhardt Tolle, 2005; Williams, Teasdale, Segal, and Kabat-Zinn, 2007; Peltz, 2013, esp. pp. 18-23 and chap. 3).
MY VIEW: Ameliorating the pain of dislocation can be very helpful. I believe that focussing on the present moment can protect some dislocated people from obsession, depression, addiction, or suicide and facilitate better choices. I know that my own occasional forays into these esoteric practices have been good for my marriage (my wife agrees!) and that practicing mindfulness when I drive my car helps me to be less of a menace on the road in my old age.
But these esoteric practices are far from an adequate solution to the problem of addiction. The global, historical view suggests that it will be impossible for society to bring addiction under control without addressing the dislocation and social fragmentation that underlie it. Our onerous perceptions and feelings are not entirely self-generated, but are mostly normal reactions to the world we inhabit. Even if we can handle our reactions to the severely fragmented world we occupy in the most enlightened possible way, we may still experience severe anguish from our profound dislocation.
A solution to the addiction problem, both on an individual and a social level, takes more than peripheralizing the experience of dislocation and analysing the experience of relapse with a clear mind. It also requires reducing the fragmentation that makes it so difficult to put together a life that contains enough belonging, identity, meaning, and purpose to keep dislocation under control without having to meditate two hours a day. (As society’s fragmentation increases, I fear that it could soon require 4 or 8 or 16 hours of meditation each day to keep dislocation at bay)
I also have misgivings about living-in-the-present-moment doctrines, because I think living a full life depends on directing full attention to past history and the challenges of the future as informed by memories of the past, rather than focussing too intently on oneself in the present moment. One of the chief problems of addicted people who I know is that they never stop focussing on themselves. Of course there are moments when we need to take care of our addictive issues in solitude by concentrating on our own experience of the present moment (e.g., Peltz, 2013, pp. 26-30), but this seems to me far from an adequate philosophy for therapy or for life.
I am uncertain about this issue, because many friends disagree with me and because I have benefitted from these esoteric practices myself. But in the end, I fear that intervention based on esoteric practices will comprise, at most, one component in successful treatment experiences and that treatment itself, in all its forms, will comprise only a small part in bringing the problem of addiction under control in the modern world.
5. Harm Reduction.
Needle exchanges, Methadone maintenance, safe injection sites, buprenorphine, Suboxone, heroin maintenance, and stimulant maintenance are offered to drug users in many places, along with information about how to use their drugs in the safest possible ways.
Addicted people who are receiving harm reduction services are often offered access to treatment as well, but are not asked to give up their addictive habits as a condition of treatment – although they may chose abstinence if it makes sense to them. This approach is now being called “harm reduction treatment” (Little, 2015; Rothschild, 2015). The emphasis in harm reduction treatment is often on encouraging people to pursue their own plans for recovery, either alone or in cooperation with others.
MY VIEW: Harm reduction services have proved valuable for many people who desperately need drugs to function in the world but are not addicted to more self-destructive, criminal aspects of the injecting drug user life style. Lives are saved that would otherwise be lost to needle-born diseases, overdoses, and violence. And harm reduction services keep harmless people out of jail and reduce the harm that desperate street drug users do to society as well. Increasingly, harm reduction treatment is not necessarily restricted to people who are using harm reduction services. I am proud of the fact that Vancouver has become a model city for harm reduction in North America.
The term, “harm reduction,” has so far been mostly limited to drug and alcohol addictions, but I think there is room for expansion of harm reduction into other kinds of addiction as well.
Still, harm reduction leaves the underlying societal roots of addiction in place and only minimally incorporates addicted people into the lives of their community. It scarcely reduces the harmful consequences of addiction on society, because it is still largely limited to drug addiction. Moreover, it offers little by way of preventing people from falling into addiction in the first place. Although I have been an enthusiastic part of the harm reduction movement throughout much of my career, I predict that, like biomedical and psychological treatment, it will eventually have only a small role in overcoming global society’s addiction problem.
6. Recovery Movement (Small Scale Social Change).
Many organizations are now devoted to organizing with others to transform society on a local level so that people can live a less dislocated life. When this is done specifically for or by people who are struggling with addictions, it is sometimes called the “Recovery Movement.” I have seen many more of the groups that comprise the Recovery Movement in Vancouver and elsewhere than I can mention here: e.g., Heart of the City Festival; many endeavours of the Portland Hotel Society (e.g., The Life Skills project), the Longhouse Ministry of the United Church in East Vancouver; the many branches of Addaction in the UK, “Housing First” in the US, Gaadejuristen in Denmark, and Ozanam House in Kelowna, BC.
The churches of mainstream religions, and the twelve-step groups that have derived from Alcoholics Anonymous have a place of honour as pioneers of the recovery movement and still provide much of its energy. However many of the more recent groups have modified some fundamental religious beliefs and some of the original twelve-step principles and practices.
Much personal counselling and social work can be considered part of the recovery movement as well, when it focuses on helping people to find a place in their community and to maintain it. Professionals often steer people towards twelve-step and other recovery groups as well as encouraging them to join other groups and treating them individually.
Some aspects of the Recovery Movement work with children in a preventative way, before the children are at serious risk of any form of adult addiction: The St. James Music Academy in Vancouver is a wonderful example of this.
MY VIEW: Historical and clinical studies of addiction reveal that when people’s dislocation is overcome, most of them do not become addicted and people who have become addicted can leave their addictions behind. However, it is extremely difficult to help people overcome their dislocation even in the enlightened context of today’s recovery movement, for two reasons.
The first reason is that the dislocation arising from a deeply fragmented outer world still breaks though into a less fragmented local society. The second is that there is no universal formula for overcoming dislocation. Each person has a unique set of requirements for what constitutes a fulfilling. A local culture that effectively minimizes dislocation cannot be established by fiat. It has to be constructed painstakingly over a considerable period of time, probably generations, and it is impossible to know in advance what combination of possibilities will provide a basis for psychosocial integration in a particular group of people. As Marc Lewis (2015) has pointed out, “recovery” may not be quite the right term, because much of the work that is necessary to overcome addiction is not returning to a kind of psychosocial integration that they had previously, but fabricating a quite new kind of individual outlook and local culture from the wreckage of the past.
We know how to put elements that support individual and social well-being in place, but we don’t know exactly how to breathe life into them. In a sense psychosocial integration is like the biology of life itself: We know all the chemical ingredients of life, but we still do not know how to create it in the laboratory. As some point we just have to do all that we can and sit back and wait, and hope, for the results of recovery groups to appear – and they often do.
7. Large Scale Social Change.
Ultimately, changing the vicious cycle that underlies addiction – and many other interrelated social problems – will require large-scale social change. In fact, it will require nothing less than reshaping world society to defang the vicious cycle that is depicted by the historical view. Ultimately, this kind of change must come much more at the national and international level than at the individual or local level.
Of course, emphasizing large-scale social change does not deny the utility of the kinds of intervention that have already been discussed. They do help many people, but they cannot by themselves overcome the flood of addict that is engulfing modern civilization.
The clearest call for large scale social change that I know is contained in a legend first told to me by a native grandmother who was also a drug counsellor for the people on her reserve. The legend is that drug counsellors of her tribe in northern Canada sit by the side of a raging northern mountain river and watch. When they see somebody being swept away in the raging white foam of addiction they jump in to rescue them. They know how to swim through the rapids to the drowning swimmer because their elders have told them where the rocks are hidden. Using all their strength, they eventually reach the addicted person and drag him or her through the torrent to the shore and with their last ounce of strength heave them up on the bank.
Sometimes it is too late and the effort is wasted. The addicted person slips off the riverbank and is lost again in the foam. But sometimes he or she stands up and walks from the river into the forest, re-joining the people, returning to the land.
When someone is saved, the storyteller told me, counsellors swell with pride. They feel that they are warriors! They would feel that they are making a great contribution to their people except…
… Except, she said, that some son-of-a-bitch upstream is throwing more and more people into the water all the time! The counsellors eventually realize that they are not winning but losing, for all their heroic efforts, but they persist anyway.
I believe that we who care about addiction and the environment must continue the heroic rescue work, but I also believe that the even more essential task is getting rid of “the-son of-a-bitch upstream,” i.e., the vicious cycle that is described by the global, historical view of addiction.
When we get around to facing the son of a bitch upstream, we will also need to face the fact that we don’t know exactly what to do about him yet, despite the genuine sophistication that we have achieved in understanding and treating addiction on an individual level. People sometimes say that if our society can put a man on the moon, surely we can solve our addiction problem and all the related psychological, social, and environmental issues. But is this right? I am fond of a quote from Ed Ayers who pointed out that: “Building a liveable world isn’t rocket science; it’s far more complex than that.” (quoted by Klein, 2014a, p. 280).
I am even more fond of a quote from the great religious and scientific thinker, Thomas Berry, who argues that we need a deep cultural therapy that cannot be described entirely in the language of science because it has a spiritual aspect that is as important as its rational aspect. As Berry put it:
What is most needed in addition to the new technologies integrating our human needs with solar energy and the organic functioning of planetary life systems is a deep cultural therapy that will identify the sources of our pathology and provide a way of returning to the jubilant life expression that should characterize any human mode of being (Berry, 2009, p. 138, italics added).
If Berry is right, we cannot envision or plan our future. However, we can work towards it nonetheless. This is possible because of the countless spiritual, social activist, environmentalist, and social recovery groups that are each seeking to overcome the vicious cycle in its own way (Hawken, 2007). These groups are found around the world, in every country. The eventual fusion of this enormous pool of human energy into a new, more coherent civilization that can provide a sustainable habitat for psychosocially integrated human beings who will be unlikely to become addicted in the first place, as well as providing an environment in which people who have become addicted are likely to recover. Unlike most of the other six approaches to addiction this one does not focus primarily on drug addiction, because all kinds of addiction can be alleviated in the more coherent civilization that it envisions.
Within this approach the distinction between the problem of addiction and the other, interrelated problems of modernity such as environmental destruction and unbearable social inequalities fades away. The task of major social change is to be undertaken with hope and faith, even in the absence of a definite blueprint for the outcome, but with assurance that success is possible. Do we have a more credible source of hope than this?
Is it conceivable that the entire global society should be reshaped to bring addiction under control? The idea seems outlandish when it is stated that narrowly. But when the broader social context is considered historically, the picture changes.
The emerging global society of the twenty-first century is going to be reshaped, if it is going to survive. At the very least it will have go be reshaped socially and politically to avoid catastrophic climate change (Klein, 2014a; Pope Francis, 2015). It will have to be reshaped economically to overcome the obscene inequalities of wealth between individuals and nations that are quickly reaching the point of breaking down the existing system (Rowbotham, 1998; Stiglitz, 2015). It will have to be reshaped on the geopolitical level to reduce the ever-hovering threat of thermonuclear war, which remains a terminal accident waiting to happen.
If the nightmare scenarios are to be avoided, the coming changes are going to be designed by the rational and compassionate thinkers, who will see that psychological problems, including addiction, are inextricably intertwined with the environmental, economic, and political problems that threaten us so severely. (For a detailed analysis of the connections between addiction and the ecological crisis, see Alexander, 2015). The forthcoming changes in twenty-first century civilization will deal with the psychological aspects of global problems, if they are to achieve their vital ends.
Controlling addiction, and the other interrelated problems, in this context will be the work of generations. It will be carried out partly by people working together to help other people recover from addiction by finding a place in their community. More immediately, bringing addiction under control depends on the success of a great variety of social and environmental movements that seek to reduce societal fragmentation in diverse ways. None of these movements can offer a short-term solution. However, they can offer both the possibility of success and the opportunity for enhancing our own belonging, identity, meaning, and purpose. It is hard for me to imagine a better project for the remaining years of my own life.
This line of thought was unthinkable to all but a very few people when I began my career in the study of addiction almost a half century ago. Still today, it remains unthinkable in the vast institutions of wealth and power that rule the world at this point, as well as the mainstream media and the national governments that faithfully serve them. This is a change that must flow upwards from the bottom of the hierarchy of power and wealth.
This process is underway, although its success is by no means guaranteed. Will you join in? You will not have to look very far in your own locality to find local organizations with potentially broad impact of the sort I am describing. They provide the best hope of the world solving its addiction problem – and many other crucial, interrelated problems – and they need your help.
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