The best way to address addiction is a holistic and nuanced approach that involves gentle intervention, says addiction specialist Dr Carl Erik Fisher.
In his new part-memoir, The Urge: Our History of Addiction, Fisher draws on his own recovery from alcoholism.
Photo: supplied
Fisher tells Kathryn Ryan that he was a young medical graduate when his "problems with alcohol and stimulants" took hold.
He ended up spending time in a New York psych ward - ironically, the same hospital he'd applied for a residency at just years earlier.
Once Fisher was mentally stable and felt he was not in danger of imminent relapse, he decided to write a history of addiction that incorporated his own insights.
“I thought that the history would be a useful [document] because medicine and science were my home, I had a lot of wisdom to offer there, but I had the sense that there was so much more to inform the story.”
As far back as the 1840s, and in Native American communities even earlier, some medical practitioners in the United States have shown great empathy and flexibility in addressing addiction and setting up self-help communities, he says.
“They had more acceptance then than we do now of the behavioural addictions – things like gambling addiction, for example ... And also, there were these mutual health movements that pre-date Alcoholics Anonymous, in some cases more than 100 years… We see this over and over, era after era, that there are many different responses to addiction. There are these medical responses, but then also these grassroots, very beautiful often, mutual-help movements.”
Over time, there have been many different definitions of addiction, Fisher says.
“I actually liked the definition from 500 years ago when the word first entered the English language. [Addiction was viewed as something more like] a strong ‘devotion’ ... it could be positive, it could be negative. But most importantly, it was something universal to the human condition.”
The idea that addiction has a physiological basis is very recent and has a strong cultural basis, he says.
“The notion that addiction is necessarily physical versus psychological is actually just the outgrowth of drugs policies, largely, but not exclusively, arising out of racist panics and xenophobia in the United States and elsewhere where certain drugs were associated with the wrong sort of people.
“When the world became partitioned into good drugs and bad drugs and the bad drugs were supposedly those that hijacked you or took you over like a possessing force.
“In actuality, I think the research backs this up as well. Addiction is not just the effects of a drug, we have to also consider the human factors, the personal factors and the broader social factors, as well.”
If we only consider the biological factors in addiction, Fisher says, we miss out on the identity considerations.
In the book, he considers a more nuanced understanding of how it relates to character and personality.
“Going back as far as I could trace it, the person’s idea of themselves, the perception of themselves, the stories that we tell about ourselves, are so important to the experiences of addiction.
“We must be careful to recognise the real human costs of addiction. I believe that addiction is something that exists in all of us, that there is nothing different in kind with my experiences and someone with severe addiction, compared to say some of my patients, who might struggle with more nuanced formulations of self-control. Whether it’s eating, social media or their relationship to work and external validation.
“There are elements of addiction and if you break the experience down into its constituent parts, willpower and self-control and all the rest – that stuff is connected. And at the same time, there is real life-threatening harm. Addiction is real in the sense that when you look at people’s lives in the present and when you look across multiple cultures into the past there’s always been this experience of people who really suffer out of the extremes.
“I think it’s really challenging to hold those two notions in mind at the same time, but if we keep harm as one of our watchwords, rather than controlling people’s use, or trying to slot people into our vision of how we think they should be relating to drugs, if we make our yardstick in other words, harm, wellbeing and control, then I think we’ve already gotten halfway there.”
He was in denial for years about his own addiction and his experience in medical school helped him to reinforce and rationalise that denial.
To recover, Fisher says he needed a level of confrontation, but gentle intervention, as opposed to harsh confrontation, is most effective.
Individual pathways to addiction recovery are also worthy of more respect.
“There’s a traditional model and that’s rooted in abstinence. I have a great love for that model. In a way, it saved my life in abstinence-based recovery. But we also know that a lot of people with substance-abuse problems, do not seek treatment, do not believe that they have a problem and a big factor that turns them away from treatment is sometimes we’re not able to meet the diversity of possible treatment goals.”
If an addict refuses complete abstinence, you need to be pragmatic and meet them where they’re at, he says.
“We have good data to show, rather than kicking someone out of treatment, you stick with it and give personal support to protect their lives and engage them. Then maybe that attempt gives them to data that they need to come back and eventually get into the mode of recovery that’s more supportive for them.”
Fisher worries that it's misleading to call addiction a 'disease'.
While this notion can be helpful for expanding compassion and funding, it can also be fatalistic and dehumanising, he says.
Pathologising a mental disorder such as addiction can increase a person's sense of pessimism and social isolation.
“The more important thing is to use [the word 'disease'] as a cue to look deeper, with more care and nuance as to what are we actually talking about when we use the word.”
Dr Carl Erik Fisher is an assistant professor of clinical psychiatry at Columbia University.
