Speaker 1: Choose whatever variety of psychological suffering you want to, whether
Speaker 1: it's extreme depression or extreme anxiety, or obsessional thinking or
Speaker 1: whatever that's not neatly demarcated from the rest of humankind.
Speaker 1: For me, as a psychiatrist, when I can meet my
Speaker 1: patients or other sufferers who are struggling with those types
Speaker 1: of conditions, I can always see myself in them. Welcome
Speaker 1: to the one you feed. Throughout time, great thinkers have
Speaker 1: recognized the importance of the thoughts we have. Quotes like
Speaker 1: garbage in, garbage out, or you are what you think
Speaker 1: ring true. And yet for many of us, our thoughts
Speaker 1: don't strengthen or empower us. We tend toward negativity, self pity, jealousy,
Speaker 1: or fear. We see what we don't have instead of
Speaker 1: what we do. We think things that hold us back
Speaker 1: and dampen our spirit. But it's not just about thinking.
Speaker 1: Our actions matter. It takes conscious, consistent and creative effort
Speaker 1: to a life worth living. This podcast is about how
Speaker 1: other people keep themselves moving in the right direction, how
Speaker 1: they feed their good wolf. Thanks for joining us. Our
Speaker 1: guest on this episode is Carl Eric Fisher and addiction
Speaker 1: psychiatrist bioethics scholar and author. He's the Assistant Professor of
Speaker 1: Clinical Psychiatry at Columbia University. Carl also has a podcast
Speaker 1: called Flourishing after Addiction and is the author of the
Speaker 1: book discussed here, The urge Our History of Addiction. Hi, Carl,
Speaker 1: Welcome to the show. Thanks so much, Eric, Thanks for
Speaker 1: having me. Yeah, we're gonna be discussing your book, The
Speaker 1: urge Our History of Addiction. And as I said to
Speaker 1: you before we started, I have read a lot of
Speaker 1: books on addiction and recovery over the years, and I
Speaker 1: still learned a ton from years. It's so good. Before
Speaker 1: we get to that, will start like we always do
Speaker 1: with the parable. There's a grandparent who's talking with their
Speaker 1: grandchild and they say, in life, there are two wolves
Speaker 1: inside of us that are always at battle. Once a
Speaker 1: good wolf, which represents things like kindness and bravery and love,
Speaker 1: and the other is a bad wolf, which represents things
Speaker 1: like greed and hatred and fear. And the grandchild stops
Speaker 1: and thinks about it for seconds, says, well, which one wins?
Speaker 1: And the grandparents says, the one you feed. So I'd
Speaker 1: like to start off by asking you what that parable
Speaker 1: means to you in your life and in the work
Speaker 1: that you do. It has amazing personal resonance with me,
Speaker 1: in part just because we were hammered with it in
Speaker 1: art therapy class, in impatient rehab when I first got
Speaker 1: into recovery, and like many of these things, at first
Speaker 1: we hated it. Me and some of the other physicians
Speaker 1: are in the program saying not these wolves again. But
Speaker 1: I eventually came to love it. So it has it
Speaker 1: has a personal resonance for me. But I also love
Speaker 1: the content of it, in the message of it. I
Speaker 1: love the notion of being to change your mind and
Speaker 1: train your mind through conscious, intentional action. I know that's
Speaker 1: a big theme of your show and relevant to my work.
Speaker 1: There's even a prior insight that comes from that parable,
Speaker 1: which is the realization in the first place, that we
Speaker 1: have a divided mind at all, that there are different
Speaker 1: parts in our minds, and that that's beautiful, that's insightful
Speaker 1: and really actionable for addiction. That's been a crucial way
Speaker 1: that thinkers have tried to understand self control since the
Speaker 1: time of Aristotle, St. Augustine, the Buddha. You know, I
Speaker 1: get into that pretty early on in the book that
Speaker 1: sometimes today there's this water down stereotype of addiction as
Speaker 1: being total loss of control versus supposedly healthy, totally free
Speaker 1: choice on the other and in a way, the ancients
Speaker 1: did better at this by recognizing the divided mind and
Speaker 1: all of those varied ways that we could sometimes be
Speaker 1: divided against ourselves. Yeah, and we're going to talk in
Speaker 1: a minute about a action in the different ways people
Speaker 1: have thought about it, the ways that we think about
Speaker 1: it today. There's lots of different paradigms, but one paradigm
Speaker 1: for it is this idea of it being disordered choice.
Speaker 1: You know, our ability to make choices goes awry, which,
Speaker 1: to me, the parable is primarily about choice, right. It says, hey,
Speaker 1: we have choices to make and they lead to certain outcomes.
Speaker 1: I too heard that parable and recovery very early on,
Speaker 1: and at the time just really had a strong, strong
Speaker 1: resonance to me talk a little bit more about this
Speaker 1: disordered choice. Choice has become sort of a dirty word
Speaker 1: in addiction and recovery, and not without good reason. Going
Speaker 1: back hundreds of years, people have enacted stigma and stereotypes
Speaker 1: against people with addiction by saying, oh, it's just a choice,
Speaker 1: it's just a vice. People are addicts by their own choice,
Speaker 1: or they're choosing to be this way, and that's really
Speaker 1: limiting and dangerous because it paints people with addiction as
Speaker 1: if they're justly hurting people or hurting themselves. At the
Speaker 1: same time, I think in the contemporary discourse, we've lost
Speaker 1: some of the richness of choice in the way the
Speaker 1: choice actually is operative in addiction. Most people who have
Speaker 1: an experience of addiction know that there's very complicated and
Speaker 1: really active choice involved, sometimes even in the worst stages
Speaker 1: of addiction. That people can have a sense of being
Speaker 1: an agent, being someone who chooses planning to support their
Speaker 1: addiction or other activities related to it. And we lose
Speaker 1: a lot if we revert to that old stereotype of
Speaker 1: people as if they're hijacked or depersonalized or just being
Speaker 1: led around by an addiction that is somehow stronger than them.
Speaker 1: I think the first step is just recognizing that disordered
Speaker 1: choice is a useful paradigm, and I think it's squares
Speaker 1: with at least my experience of addiction and many of
Speaker 1: my patients experience of addiction, that there's something about choice
Speaker 1: that matters. I agree, I thought about this question a lot,
Speaker 1: and the question really is to what degree do addicts
Speaker 1: have have choice at different stages in their recovery or addiction.
Speaker 1: Because I had a choice not to use heroin, I
Speaker 1: had it, then, I have it now, it is a
Speaker 1: very simple choice right now, right, it's almost not even
Speaker 1: a choice, right, it's just not even there. Years ago,
Speaker 1: it felt like the the amount of choice I had
Speaker 1: was so slender. And that's to me one of the
Speaker 1: frustrating things about addiction, even having been around it for
Speaker 1: so many years and having friends that are in it,
Speaker 1: that there's this part of you that wants to go
Speaker 1: but just don't do it, even though I know how
Speaker 1: hard that is. And at the end of the day,
Speaker 1: it does come down to you do have to choose
Speaker 1: not to. So what are some ways that you can
Speaker 1: think of to give people more choice, the ability to
Speaker 1: make better choices, you know, if they are caught in addiction.
Speaker 1: What are some of the things we know about that.
Speaker 1: I love the way you phrase that question, because it's
Speaker 1: not just the individual choice can sometimes imply that it's
Speaker 1: all up to me, it's an individualistic project of self control,
Speaker 1: and that's not true in my own case. In my
Speaker 1: own story. I got the opportunity to pursue recovery because
Speaker 1: I was situated in the middle of a physician health program,
Speaker 1: which is a special kind of program that gives doctors
Speaker 1: tough choices. If you want to practice medicine, which is
Speaker 1: a privilege, not a right, then we would like you
Speaker 1: to go ahead and get treatment for this really dangerous condition.
Speaker 1: I don't know if I would have recovered without that
Speaker 1: initial push, without that structure, And there are analogies for
Speaker 1: other situations. Some of the best evidence we have right
Speaker 1: now for methamphetamine addiction, which unlike opiois, doesn't have good
Speaker 1: medicines to treat it, is something called contingency management, where people,
Speaker 1: as part of a psychotherapy process are given rewards if
Speaker 1: they pass certain milestones, if they have a urine test
Speaker 1: that doesn't have substance of abuse in it. And a
Speaker 1: lot of people balk at that, they say, what, you're
Speaker 1: paying people to have an abstinent urine. That doesn't make
Speaker 1: any sense to me. But it's the exact same situation
Speaker 1: as say husband and a wife might get into. When
Speaker 1: someone's getting a tough choice. That's a form of informal coercion.
Speaker 1: Of course, This can be done unhealthily, but it can
Speaker 1: be healthy too. I need you to get help and
Speaker 1: to make a change, otherwise I can't stick around. And
Speaker 1: people are responsive to choices. Sometimes that works, sometimes it doesn't,
Speaker 1: As we know a lot of times tragically that's sort
Speaker 1: of informal pressure doesn't always work. But again, thinking of
Speaker 1: choice is something that's operative in a social network, in
Speaker 1: a relational network, in a community, in a societal network
Speaker 1: is really important. And to think about how can we
Speaker 1: set people up to make those tough choices more possible,
Speaker 1: more supported, more likely to lead them what I think
Speaker 1: every human being is naturally inclined toward, which is flourishing.
Speaker 1: There's some form of happiness or satisfaction or freedom from pain.
Speaker 1: Right you talk about addiction, you say some people insisted
Speaker 1: that addiction was primarily a brain disease. Others claim that
Speaker 1: this brain centric view blinded us to the psychological, cultural,
Speaker 1: and social dimensions, including trauma and systems of oppression. One
Speaker 1: summary of theories of addiction listed no fewer than thirty
Speaker 1: different models. We're not going to obviously solve what addiction
Speaker 1: is in this conversation, but do you have a short,
Speaker 1: working definition for you of what it is. Yeah, my
Speaker 1: definition is more literary than it is scientific or theoretical,
Speaker 1: because today in two I don't think that we have
Speaker 1: something scientifically speaking that encapsulates the whole experience of addiction,
Speaker 1: that explains it across all the necessary levels in the
Speaker 1: kind of reductive, straightforward simplicity that we might want. So
Speaker 1: I really like the sixteenth century definition of addiction when
Speaker 1: it first entered the English language. It's actually a philosophical
Speaker 1: and a theological term that early Protestant reform ms got
Speaker 1: attracted to. They love this term because they thought it
Speaker 1: pointed towards something mysterious about the human condition. Protestants in
Speaker 1: particular very interested in the notion of sin, free will,
Speaker 1: choice control, and as they were writing up theological text
Speaker 1: during this time of religious formant and energy, addiction was
Speaker 1: something that was suggestive of a gray area between free
Speaker 1: will and powerlessness. It meant something like voluntarily giving up choice,
Speaker 1: a choice to give up choice, or a devotion is
Speaker 1: a word that's often associated with addiction. I think that
Speaker 1: addiction is something universal to the human condition. In fact,
Speaker 1: just in greater, lesser portions. I always shy away from
Speaker 1: definitions to try to establish a dividing line between so
Speaker 1: called healthy and not so I just think of it
Speaker 1: as a powerful devotion that takes away power. Interesting. Yeah,
Speaker 1: it seems to me that it's a little bit like
Speaker 1: depression or other mental illness categories. We talk about them
Speaker 1: as if they are discreete thing, and they are much
Speaker 1: more like I don't know if this is the technically
Speaker 1: correct world, but you know, to me, it's always much
Speaker 1: more of a syndrome. And and you say it somewhere
Speaker 1: in the book basically that the number of variables that
Speaker 1: go into causing an addiction are I mean, who knows
Speaker 1: how many there are. There are so many. There's our genetics,
Speaker 1: there's our upbringing. There's our society that we're in. There's
Speaker 1: the people we hang out with. There's the drugs that
Speaker 1: we actually take the substances themselves. There's the culture we're in.
Speaker 1: There are so many factors that are each so complicated
Speaker 1: that to try and understand why is so difficult. People
Speaker 1: often ask me that question, well, why do you think
Speaker 1: you started doing that? Oh my god. I mean, I
Speaker 1: can tell you some theories about how maybe I didn't
Speaker 1: get certain needs met when I was a child, but
Speaker 1: the honest truth is, I don't know. We can't figure
Speaker 1: this out exactly. Thankfully, we don't have to tweez it
Speaker 1: all apart and understand all the causes and conditions to
Speaker 1: find our way towards recovery, or we'd be in really
Speaker 1: deep trouble, exactly right. I've always liked the pragmatic traditions
Speaker 1: around personal development and change in community support. A lot
Speaker 1: of today's traditional recovery supports, including twelve step groups, are
Speaker 1: like that. There's a focus on pragmatism and not so
Speaker 1: much naval gazing or trying to come up with some
Speaker 1: story or explanation. We also find that in William James's philosophy,
Speaker 1: which was very influential on certain other strands of understanding
Speaker 1: addiction in the States. We also find that in other
Speaker 1: spiritual traditions, in any sort of mystical tradition, I think
Speaker 1: there's a tendency to turn away from the metaphysical. You know,
Speaker 1: for me, my my main spiritual path is Buddhism. So
Speaker 1: I'm not a teacher, but as I understand it, the
Speaker 1: Buddhoo is very rigorous about saying, listen, don't spend your
Speaker 1: time wondering about the arrow don't ask me if it's
Speaker 1: made with a goose feather, dove's feather. What, I don't
Speaker 1: know how people make arrows. Let's focus on the wound.
Speaker 1: How do you get better? What is actually going to
Speaker 1: help in this moment? Just like what we were talking
Speaker 1: about with a broader view of addiction, I think that's
Speaker 1: about human suffering and psychological flexibility. It's not specific to
Speaker 1: addiction or not. It's all on the same spectrum, as
Speaker 1: part of the same set of syndromes, as you put it. Yeah,
Speaker 1: you often talk in the book about how addiction seems
Speaker 1: to be a matter of degree rather than kind, in
Speaker 1: that we all could have it, we could all be
Speaker 1: somewhere on a spectrum of having it. And I love this.
Speaker 1: You say, addiction is just the place where our universal
Speaker 1: human vulnerabilities are most clearly on display. It's a beautiful sentence. Well,
Speaker 1: thank you. I got it in part from the writing
Speaker 1: of Richard Rore, who I think returns to it over
Speaker 1: and over again, this notion in a variety of his
Speaker 1: writings and other psychological thinkers to like Stephen Hayes, the
Speaker 1: founder of Act Acceptance and Commitment therapy, a similar angle
Speaker 1: on the same notion that choose whatever variety of psychological
Speaker 1: suffering you want to, whether it's extreme depression or extreme anxiety,
Speaker 1: or obsessional thinking or whatever that's not neatly demarketed from
Speaker 1: the rest of human kind. For me as a psychiatrist,
Speaker 1: when I can meet my patients or other sufferers who
Speaker 1: are struggling with those types of conditions, I can always
Speaker 1: see myself in them. Even though I've never had some
Speaker 1: sort of debilitating depression on its own, apart from substance
Speaker 1: use problems, I've never had panic disorder. But the same
Speaker 1: process is the same sort of psychological inflexibility, and the
Speaker 1: attempts to modulate or escape from our pain are there,
Speaker 1: just in a different flavor. Yeah. I love that term
Speaker 1: around psychological flexibility. We've had Steven on the show a
Speaker 1: couple of times, and he's so good. That term of
Speaker 1: what we're after is psychological flexibility, I think is such
Speaker 1: a useful term. So there are four broad approaches that
Speaker 1: you talk about that people have used to think about
Speaker 1: addiction and substance use disorder, both societally and individually throughout
Speaker 1: the years. I thought maybe we could run through those
Speaker 1: four real quick. Sure. Yeah, I got interested in the
Speaker 1: way that society has responded to big picture addiction epidemics,
Speaker 1: because in those responses we could see the governing model
Speaker 1: of addiction. They were sort of a nice reflection of
Speaker 1: how a society made sense of problems of addiction, whether
Speaker 1: it was the first opiate epidemic in the United States
Speaker 1: in the eighteen sixties or whether it was the jin
Speaker 1: craze in the UK in the seventeen twenties. That was
Speaker 1: one of the big surprises of the book, that human
Speaker 1: societies have had these drug epidemics over and over and
Speaker 1: over again. So I was interested in what societies do,
Speaker 1: how do they try to help, and how do they
Speaker 1: fall short, what works, what doesn't. So just really quick,
Speaker 1: the four categories that I came up with, which overlap
Speaker 1: and blend into each other at times, are therapeutic, mutual help, reductionist,
Speaker 1: and prohibitionist. And therapeutic tends to mean that there's a
Speaker 1: medical model, a sort of psychotherapy or other sort of
Speaker 1: professionalized response. Reductionist is related but different in that a
Speaker 1: scientific cure or some sort of basic biological discovery is
Speaker 1: supposed to eradicate addiction. Mutual help is interesting because not
Speaker 1: just in the case of twelve step groups, but at
Speaker 1: various other times in different societies, there's been predominantly a
Speaker 1: bottom up, grassroots, community level response to addiction. We can
Speaker 1: talk about that more if you want, But analogous groups
Speaker 1: in the eighteen forties or even in Native American communities
Speaker 1: around the time of the American Revolutionary War, with striking
Speaker 1: similarities to today's mutual help groups but totally separate, no
Speaker 1: lineage that I could find connecting them. And then the
Speaker 1: last is prohibitionists and prohibitionist means any supply side law
Speaker 1: and order criminal justice method of trying to stamp out addiction.
Speaker 1: And the thing about all these responses is that no
Speaker 1: single one of them works. We need a little dash
Speaker 1: of each of them for the best responses to addiction problems.
Speaker 1: But unfortunately societies tend to have short memories and limited
Speaker 1: attention spans, and so unfortunately it's been more common that
Speaker 1: we've swung from extreme to extreme to extreme, that there's
Speaker 1: been too much faith in a therapeutic approach alone, and
Speaker 1: then when people get disappointed, it swings back around to
Speaker 1: a prohibitionist crackdown, and so forth and so on. Yeah,
Speaker 1: you make the point throughout the book that there are
Speaker 1: opportunities where these different approaches are, these different views of
Speaker 1: addiction could work together, but they usually don't. You know,
Speaker 1: one that comes to mind is recovery that insists on
Speaker 1: abstinence versus recovery that is more a harm reduction approach,
Speaker 1: and that they could blend and they could work together
Speaker 1: and they could coexist. But people get divided into their camp.
Speaker 1: You know, this is the right way, This is the
Speaker 1: right way. And I think something as often as personal
Speaker 1: as addiction can be, whether it's yourself or people you loved,
Speaker 1: brings about really wrong feelings and really strong feelings don't
Speaker 1: lend themselves to us thinking about things in a nuanced way,
Speaker 1: which is what we need. I think. Yeah, the ideological
Speaker 1: divisions are so strong across different dimensions of human behavior,
Speaker 1: whether it's the mutual help oriented sort of divisions. There
Speaker 1: are even huge divisions within a as it developed. That
Speaker 1: was another fun surprise, and a bunch of that didn't
Speaker 1: even get into the final book, But people had really
Speaker 1: strong opinions about, for example, how do we revise some
Speaker 1: of our core literature or not. And likewise, at the
Speaker 1: society level, right now, there's such battles over what I
Speaker 1: think are ultimately false divisions. And it sounds like you
Speaker 1: do too, that there isn't some sort of natural essential
Speaker 1: conflict between what we usually mean when we say harm
Speaker 1: reduction and absinence spased recovery. Those two things can work together.
Speaker 1: The problem is when somebody says essence only that's the
Speaker 1: only way to recover, for example, because we know a
Speaker 1: lot of people don't want to help, or they receive
Speaker 1: help and then they have trouble maintaining abstinence. And for
Speaker 1: so much of modern medicine history, we've had a lot
Speaker 1: of trouble meeting the needs of people. Some researchers are
Speaker 1: called this the the underserved majority, the meeting the needs
Speaker 1: of people who are not ready to stop, or maybe
Speaker 1: even their uses kind of mild to moderate, and they're
Speaker 1: not sure that they have a full blown addiction. And
Speaker 1: so we need flexibility, and that's not incompatible with abstinence,
Speaker 1: because you meet people where they're at, and then eventually
Speaker 1: a lot of people do make it to abstinence. You
Speaker 1: save their lives. You're give them the opportunity to engage
Speaker 1: with care, and some people will and some people won't.
Speaker 1: A lot of times, the ideological divisions I think are
Speaker 1: just a fiction, there's just a construction. I was, as
Speaker 1: I like to say, raised in the twelve step tradition, right,
Speaker 1: So I came out of that with certain beliefs about
Speaker 1: the way recovery works, and I'm pleased to say I've
Speaker 1: had my mind changed about most of that over the years.
Speaker 1: Not my mind changed as far as that the twelve
Speaker 1: step approach isn't useful, because it's saved my life and
Speaker 1: lots people that I know. But to think that that's
Speaker 1: the only way that works for people, or it's the
Speaker 1: best way, or that everybody needs to go that way
Speaker 1: is arrogant. And even early A writing says that's not true.
Speaker 1: We're not the only way to do this. Yeah. One
Speaker 1: of the things I found in the historical research is
Speaker 1: that arrogance that twelves up group should be the only
Speaker 1: way is a historical accident. It's not because there's some
Speaker 1: secret cabal as far as I know of the A leaders,
Speaker 1: which doesn't even have leaders, by the way, It's not
Speaker 1: that sen some secret cabal back pulling the strings to
Speaker 1: try to convince everyone to sign on to some sort
Speaker 1: of program. It's that the medical profession, for a variety
Speaker 1: of complicated reasons, basically abandoned the treatment of people with addiction.
Speaker 1: Back in the earlier part of the twentieth century, say
Speaker 1: around nine nine twenties, a group in the American Medical
Speaker 1: Association said, opioid addiction is a vice, it's not a
Speaker 1: he is, it's not for doctors to treat and forget
Speaker 1: about them. And then that vacuum continued, and we had
Speaker 1: to deal with that vacuum into the nineteen sixties, even
Speaker 1: into the nineteen seventies, and we're still playing catch up today,
Speaker 1: where thankfully there are a lot of great addiction medicine
Speaker 1: counselors and doctors and psychologists who are trying to play
Speaker 1: catch up, but still we have this funny system where
Speaker 1: addiction cares for some reason segregated from the rest of
Speaker 1: medicine or even mental health treatment. And in that vacuum,
Speaker 1: certain extreme beliefs got exacerbated and people needed something to
Speaker 1: hold onto in the absence of the kind of appropriate
Speaker 1: support that maybe medicine or science could have provided, and
Speaker 1: so it got very polarized. I think from where I
Speaker 1: sit and sort of like the front lines and seeing
Speaker 1: some of the policy nowadays, there's a lot more integration
Speaker 1: and there's a lot less of that ideological division now
Speaker 1: and that gives me a lot of hope. But of
Speaker 1: course we still have the legacies of some of those
Speaker 1: ideological divisions. So there's obviously lots of different approaches to
Speaker 1: treating addict and we talked about sort of four broad approaches.
Speaker 1: One of them is the reductionist approach. And I can't
Speaker 1: resist getting this story in here because you know, when
Speaker 1: you have a reductionist approach, you think it's just this thing,
Speaker 1: and you know you could take a pill and fix
Speaker 1: it right, And you say that unending processions of would
Speaker 1: be heroes have proposed endless bizarre treatments founded on over
Speaker 1: confident reductionist theories. And though it's a crowded field, Leslie
Speaker 1: Keiley and nineteenth century addiction entrepreneur probably takes first prize.
Speaker 1: Tell me about Leslie Keeley. Thank you for asking Eric.
Speaker 1: I don't think anybody else has asked me that, and
Speaker 1: all of my present interviews, but I think he's such
Speaker 1: a fascinating, fascinating guy. So Leslie Keely has a sort
Speaker 1: of shadowy past. I don't know that he's a doctor
Speaker 1: or not. We don't know a lot about his upbringing.
Speaker 1: But he came to prominence during a time in American medicine,
Speaker 1: the latter part of the nineteenth century, let's say, like
Speaker 1: eighteen seventies, eighteen eighties, so forth and so on, when
Speaker 1: there was a lot of marketing, a lot of self promotion,
Speaker 1: and a lot of miracle cures. We didn't have an
Speaker 1: FDA back then, there wasn't any regulation. Most things that
Speaker 1: we would consider pharmaceutical compounds people could just buy via
Speaker 1: mail order, just by walking into their local store. And
Speaker 1: Leslie Keeley came up with this thing called the Gold Cure,
Speaker 1: which apparently didn't have gold in it, but he did
Speaker 1: a sort of male marketing, male like M A I
Speaker 1: L marketing go. I'm sure a lot of his clients
Speaker 1: were mail too, and it got really popular and he
Speaker 1: made a lot of money. And then the innovation that
Speaker 1: he did was to build on the success of that
Speaker 1: miracle cure and build out this whole network of what
Speaker 1: we would call in patient rehabs today, and a special
Speaker 1: cure that you had to come to his treatment facilities
Speaker 1: to get which involved a red, white and blue syringe
Speaker 1: that people would just be all up and get injected.
Speaker 1: It's all nonsense. It's all nonsense. But the part that's
Speaker 1: non nonsense actually is that whether it's because of a
Speaker 1: real sense that it would be how ful or if
Speaker 1: it was just some sort of beneficial side effect. He
Speaker 1: also helped people to band together in mutual health groups,
Speaker 1: and so probably the only thing that he did that
Speaker 1: was useful, aside from raising the profile of just the
Speaker 1: problem of addiction, is that he organized these things called
Speaker 1: Keeley Leagues. He did it because it was marketing. He
Speaker 1: told everybody once he left his institutes to say, I've
Speaker 1: been to Dwight, because Dwight was the town where his
Speaker 1: his main institute was, and wear a little badge on
Speaker 1: your lapel and tell people about all the great treatment
Speaker 1: you got for me. But what that also did is
Speaker 1: it encouraged people to band together and share their experiences
Speaker 1: and support each other once they left his treatment facilities
Speaker 1: at a time when there wasn't a very robust mutual
Speaker 1: health tradition. There's one in the eighteen forties, but then
Speaker 1: it kind of fell away and we were decades before
Speaker 1: the rise of twelve step groups. And that was actually
Speaker 1: a really useful thing for a lot of people who
Speaker 1: who went through his treatments. So the syringe. Notwithstanding, I
Speaker 1: assume that some of these things what we would consider
Speaker 1: a wacky cure, that there's some degree of placebo effect
Speaker 1: that goes on there. I would have to imagine that
Speaker 1: some of the times that's with with the disease of addiction.
Speaker 1: I'm going to take that word back. I'm going to
Speaker 1: strike that condition like addiction, that's so psychological that that
Speaker 1: the placebo effect probably actually there's something to it. What
Speaker 1: did you find around that any thoughts? Well, I know
Speaker 1: for a fact that the polacebo effect is very powerful.
Speaker 1: There are great researchers and clinicians who are studying this today,
Speaker 1: some folks up at Columbia doing neuroimaging on this subject.
Speaker 1: And forget about mental distress. There's placebo effects on physical
Speaker 1: ailments because there's no real division. If you believe that,
Speaker 1: for example, that the mind is what the brain does
Speaker 1: at least as a starting point, then mental things will
Speaker 1: have an impact on your body, including stress and the
Speaker 1: balance of fight or flight versus rest and relax I mean,
Speaker 1: we could have a whole episode on those sorts of topics,
Speaker 1: But there are plenty of ways that cures or other
Speaker 1: treatments that we would say from today's perspective, no way
Speaker 1: that that's helpful. Still had some sort of effect, and
Speaker 1: I think it's partly placebo, but it's also because people practiced,
Speaker 1: you know, getting back to the title of your show,
Speaker 1: that they they directed their minds in an intentional way
Speaker 1: towards the good. They brought their focus to the addiction.
Speaker 1: They asked themselves this question that we tell people to
Speaker 1: ask themselves in psychotherapy about addiction, which is what am
Speaker 1: I actually getting out of this? What is this doing
Speaker 1: for me? You know, whether that's the key Y cure
Speaker 1: or any of these other like horse pills or another
Speaker 1: one is an immunological treatment where they made they basically
Speaker 1: got is drunk and then withdrew their serum and then
Speaker 1: injected that into humans because they thought maybe addiction had
Speaker 1: something to do with immunology. All of that stuff is bunk,
Speaker 1: but at least in the cases where it's not actively
Speaker 1: hurting the person, it's still a ritual. Yes, it's a
Speaker 1: ritual that directs people's attention to the problem and helps
Speaker 1: them to wake up to how they're relating to their mind.
Speaker 1: My favorite key lea cure that Chris and I have
Speaker 1: been laughing about all week is the White Star Secret
Speaker 1: Liquor cure cents for a box of thirty cocaine capsules. Yeah,
Speaker 1: so that we could put that in the column of
Speaker 1: ones that are not helpful probably counterproduct. Yeah. Yeah. Somewhere
Speaker 1: else in the book you talk about someone else who
Speaker 1: thought cocaine was a cure for morphine addiction, and Chris
Speaker 1: is a recovering cocaine addict, among other things. He's like,
Speaker 1: I think I'm gonna go get a morphine addiction so
Speaker 1: I can start doing cocaine again. Yeah, they're both at
Speaker 1: the same time, as it often works out. That's right. Yes,
Speaker 1: that was something I greatly enjoyed. Anyway, Let's talk about
Speaker 1: good drugs versus bad drugs. What does that mean? Yeah.
Speaker 1: Throughout history, people have sought to divide up drug users
Speaker 1: by supposed good drugs and bad drugs. Usually that's about
Speaker 1: the groups or the types of people who are getting
Speaker 1: the attention. You know, certain types of drugs are associated
Speaker 1: with the supposedly wrong sorts of users. Others are associated
Speaker 1: with the right sorts of users. Some of the classic
Speaker 1: cases are at the end of the nineteenth century. Let's
Speaker 1: stick with the end of the nineteenth century, smoked opium
Speaker 1: was considered a Chinese drug because there were a lot
Speaker 1: of Chinese immigrants, especially on the West coast of the US,
Speaker 1: but morphine pills were considered a sort of upper class
Speaker 1: white drug, and people treated the smoke dopium as if
Speaker 1: it was more dangerous, even though injected morphine can certainly
Speaker 1: pack a much bigger punch. So in that example, in
Speaker 1: many other examples, we see how dangerous that division is.
Speaker 1: To divide up drugs into good drugs and bad drugs
Speaker 1: allows ideas about drugs and addiction to be used as
Speaker 1: a weapon on one hand, but it also misses out
Speaker 1: on the true dangers of addiction on the other end.
Speaker 1: Then the misguided ideas about addiction come back to hurt
Speaker 1: all of us. And that that happened over and over
Speaker 1: again when we overestimate the harms of certain drugs but
Speaker 1: then almost invariably underestimate the dangers of others in a
Speaker 1: way that was a major major factor in the development
Speaker 1: of today's opiate overdose crisis. That opioids were a good drug,
Speaker 1: and they were a good drug in part because at
Speaker 1: that time crack cocaine was a bad drug. I have
Speaker 1: a quote in the book about one dopamine researcher who
Speaker 1: said in the nineteen eighties, if I had a choice
Speaker 1: about whether my daughter could use either cocaine or heroin,
Speaker 1: I would choose the heroine, which is mind boggling today.
Speaker 1: Nobody would say that today. And this is a good
Speaker 1: researcher who later moderated some of his statements to his credit.
Speaker 1: And so I say that not to knock him, but
Speaker 1: just to illustrate how powerfully our scientific ideas and our
Speaker 1: medical ideas about addiction and drugs can be influenced by
Speaker 1: the social and cultural context. We would like to think
Speaker 1: that it's some sort of objective, quantitative science, but we
Speaker 1: can't escape from the cultural and social baggage. Right. You
Speaker 1: say that this is a double edged sword causing great
Speaker 1: harms on both sides, destructive, ineffective drug wars on one
Speaker 1: side and lax pharmaceutical regulations on the other. I think
Speaker 1: that's one thing that was really helpful to me early
Speaker 1: on in my recovery was they just said all the time,
Speaker 1: a drug as a drug, as a drug as a drug.
Speaker 1: You know. I was like, well, cough, medicine is just
Speaker 1: as dangerous to me, maybe not just as dangerous, but
Speaker 1: cough medicine is not a good thing. Here's the story.
Speaker 1: I don't know if we ever told this on the
Speaker 1: show before. I've told a lot of stories too many times.
Speaker 1: My brother and I I don't know where we got
Speaker 1: this idea, but we've heard somewhere that if you drank
Speaker 1: like an entire bottle of robotussan and then took some
Speaker 1: other cold medicine with it, it was called the lizard
Speaker 1: and uh yeah, and it kind of made you feel
Speaker 1: like a lizard. It was actually a fairly apt description
Speaker 1: of of of how you felt after you did it.
Speaker 1: But a drug is a drug. Is a drug is
Speaker 1: I think kind of what you are saying here. And
Speaker 1: you're also talking about the ways in which we have
Speaker 1: used drug policy to stigmatize certain segments of society. Yeah,
Speaker 1: that's such a common threat. It's a little bit disheartening.
Speaker 1: But I think recognizing the way that history rhymes with
Speaker 1: the use of drug policies as a weapon helps us
Speaker 1: to take some of the stigma in the ideology out
Speaker 1: of the whole picture. One example is in the ninet
Speaker 1: thirties when cannabis was villainized and the Harry Anslinger, who
Speaker 1: is this famous figure in drug prohibition, basically the founder
Speaker 1: of the organization that eventually became the d e A.
Speaker 1: He didn't care about cannabis is very well documented. He
Speaker 1: didn't care, but he saw, for a variety of reasons,
Speaker 1: including the South and Mexican immigration, that cannabis was politically ripe,
Speaker 1: and that's the way that he could build his power
Speaker 1: and build the rest of his career. It even happened
Speaker 1: back in the first tobacco epidemic in say the fifteen
Speaker 1: hundreds through the exteenth century, that the wrong sorts of
Speaker 1: users were considered the sort of lower class tobacco users,
Speaker 1: and they were threatened with excommunication and death. And in
Speaker 1: Russia they have their nostril slit. And none of that
Speaker 1: stopped people from using tobacco, because as we know from
Speaker 1: cigarettes today, it's a hard one to kick. But the
Speaker 1: association with the supposedly wrong sorts of users extended all
Speaker 1: the way to the English king saying, oh, it's just
Speaker 1: like the barbarous, beastly and slavish Indians, that you're basically
Speaker 1: like beasts. You're not even full men, according to the
Speaker 1: sort of racist logic of that time. And that's a
Speaker 1: great example because they didn't have a concept of addiction
Speaker 1: back then. So we don't even need an idea of
Speaker 1: addiction to associate these sorts of caricatures of the dangers
Speaker 1: of drugs. People have been doing it for hundreds and
Speaker 1: hundreds and hundreds of years. So given all the research
Speaker 1: you've done, and you just mentioned to me that you're
Speaker 1: in Portugal for a couple of reasons, but one of
Speaker 1: them is to understand that you know some of the
Speaker 1: drug policy there. What is reasonable drug policy right? Because
Speaker 1: on one hand, you know, we've seen prohibition doesn't really work.
Speaker 1: A war against drugs doesn't really work. Is the other extreme,
Speaker 1: there's no regulation. Do you have an opinion at this
Speaker 1: point of what sensible drug policy might look like. I
Speaker 1: don't have a formula because I don't think that that
Speaker 1: is useful. I think a quick fix or some sort
Speaker 1: of you know, bullet point list of what to do
Speaker 1: is misleading. You're starting from first principles. I think the
Speaker 1: first principle has to be that we won't see the
Speaker 1: end of addiction. We won't see the end of drug use,
Speaker 1: and that usually attempts to eradicate it through some kind
Speaker 1: of technocratic drug policy have caused more harm than good.
Speaker 1: That was true back when people were slitting nostrils for
Speaker 1: tobacco use, and that's true through the and until today.
Speaker 1: It's not to say that there aren't things that we
Speaker 1: can do today, because there are. There's so many simple
Speaker 1: things that we could do to save lives. I desperately
Speaker 1: need to expand addiction treatment while also improving the quality
Speaker 1: of addiction treaty meant so there's not so much chicanery
Speaker 1: and just outright nonsense. We need to expand sensible, evidence
Speaker 1: based harm reduction programs which are proven to save lives
Speaker 1: without increasing drug use. And if everybody got all their
Speaker 1: wish lists of those simple strategies to save lives, there
Speaker 1: would still be addiction. And so any drug policy that's
Speaker 1: founded on the notion that we can somehow stop addiction
Speaker 1: eradicate addiction has lost before it started, already misleading. But
Speaker 1: you ask about Portugal, I mean, one of the really
Speaker 1: right questions right now, especially because Oregon is also experimenting
Speaker 1: with this, is the notion of decriminalization, which means different
Speaker 1: things to different people. It's worth doing, I mean, not
Speaker 1: necessarily me right now today, but it's it's worth doing
Speaker 1: a deep investigation into what decriminalization actually means, because it
Speaker 1: means different things in different places, and sometimes the Portugal
Speaker 1: experience is presented as if in two thousand and one
Speaker 1: Portugal waved magic wand they decriminalized drugs for personal use
Speaker 1: and then everything got better. And the truth of the
Speaker 1: matters I'm finding more and more and more each day,
Speaker 1: is that the decriminalization was one of the least important
Speaker 1: parts of the Portuguese policy. There may be very good
Speaker 1: reasons to carefully decriminalize drug use for personal possession that
Speaker 1: by itself is not what lowered Portuguese overdose rates, and
Speaker 1: it's not what by itself lowered Portuguese rates of harmful
Speaker 1: drug use. They also made massive investments, not just in
Speaker 1: quality treatment, but in just general social care, making sure
Speaker 1: people had a housing, making sure people had access to
Speaker 1: meaningful work, and to make sure that people weren't stigmatized
Speaker 1: and criticized and certainly not like saddled with some awful
Speaker 1: criminal sentence just because of using a drug related to
Speaker 1: their addiction. I don't want to speak against decriminalization, but
Speaker 1: I also don't want to say we should enact it
Speaker 1: as a blanket policy. Because the devil's really in the details. Here.
Speaker 1: You say, we will not end addiction, but we must
Speaker 1: find ways of working with it, ways that are sometimes
Speaker 1: gentle and times vigorous, but never warlike, because it's fuel
Speaker 1: to wage a war on our own nature. It's a
Speaker 1: very elegant sentence there to sort of sum up some
Speaker 1: of what you're saying, which is, hey, addiction is part
Speaker 1: of the human condition. It's not going away. And some
Speaker 1: of our policies might be more gentle, some of them
Speaker 1: might be more firm. But but to think we're going
Speaker 1: to get rid of this is to miss the point,
Speaker 1: is to profoundly misunderstand what we're dealing with. There's another
Speaker 1: line you have that I think is so good here,
Speaker 1: and you say addiction is profoundly ordinary, a way of
Speaker 1: working with the pleasures and pains of life. It's this
Speaker 1: part coming up that is so good and just one
Speaker 1: manifestation of the central human task of working with suffering.
Speaker 1: And so none of us are foolish enough to think
Speaker 1: we're going to get rid of human suffering. It's just
Speaker 1: not going to happen, right. I think a clear eyed
Speaker 1: view is the same with addiction. It's not going away
Speaker 1: as long as there are substances, there are people who
Speaker 1: use them in ways that are destructive. I just think
Speaker 1: that's it's kind of baked into us. Will use ache
Speaker 1: in ways that are destructive, will use gambling and sex
Speaker 1: and you name it, video games. Right, we have the
Speaker 1: capacity to use things in ways that are not good
Speaker 1: for us. It's endemic. Yeah, really, well, put, that's exactly right.
Speaker 1: That's exactly in line with what what my views are
Speaker 1: at the social level, that there will always be some
Speaker 1: people who use drugs in a in a way that's
Speaker 1: harmful to themselves and others. And also at the individual level,
Speaker 1: that even after someone achieves some measure of abstinence from
Speaker 1: say a certain problem substance, or they enter recovery in
Speaker 1: some way, that doesn't mean addictions gone. I see it
Speaker 1: in myself in my own recovery. You mentioned cake. I'm
Speaker 1: not a cake guy. I'm an ice cream guy. But
Speaker 1: the goal for me today in my recovery is not
Speaker 1: some sort of perfect mastery of all of my urges
Speaker 1: and cravings. I could say a lot of goals, but
Speaker 1: this is not my therapy session. I'm saying. You know,
Speaker 1: my vision for recovery is more friendly acceptance, and facility
Speaker 1: in dealing with the difficult feelings. And I don't think
Speaker 1: that ends. I don't think that stops. You know, I've
Speaker 1: talked to monks who have meditated for forty years in
Speaker 1: silent retreats and serious practice and whatever tradition, and you know,
Speaker 1: they're not floating around in the cloud. Even the ones
Speaker 1: who seem very content and happy and joyous, they you know,
Speaker 1: maybe have gotten a lot out of that. But it
Speaker 1: doesn't mean that you're just some robot that exists without suffering. Yeah,
Speaker 1: that wouldn't be a life worth living if you could
Speaker 1: somehow eradicate that kind of feeling. Let's turn our attention
Speaker 1: for a few minutes to your recovery, because I think
Speaker 1: there's some things in there that I love to talk about.
Speaker 1: One is you alluded to it earlier. How to use
Speaker 1: the word we used today. You had a lot of privilege,
Speaker 1: which meant that, as a white male doctor, you were
Speaker 1: given treatment options that were really good. I am similar.
Speaker 1: I was a homeless heroin attic, so I was not
Speaker 1: a doctor. I could never achieve that level. But I
Speaker 1: was a white male who had been raised in an
Speaker 1: upper middle class place, and I was given options that
Speaker 1: so many people I was around as I went through
Speaker 1: my treatments and stayed in halfway houses options that so
Speaker 1: many people were simply not given. This speaks to an
Speaker 1: idea that's become prominent, which is the idea of recovery capital.
Speaker 1: Can you share a little bit about what recovery capital is. Yeah,
Speaker 1: I love this notion of recovery capital because it's so
Speaker 1: flexible in all encompassing, and I suppose the broadest definition
Speaker 1: of it is anything in a person's life, psychological resources,
Speaker 1: concrete resources, family for relationships, jobs, so forth that supports
Speaker 1: the recovery. And we don't all start from zero, and
Speaker 1: we don't all and to recovery at zero. Some people
Speaker 1: have a lot of recovery capital, and some people have
Speaker 1: next to none or almost none. And like you were saying,
Speaker 1: sometimes that's a function of what the person individually has,
Speaker 1: like having enough money in the bank account, literal capital
Speaker 1: to a four expensive treatment, and sometimes that that capital
Speaker 1: might be more at the level of ideas and perceptions
Speaker 1: and stigma, certain people are not afforded the same sorts
Speaker 1: of privileges or access or second chances or third chances
Speaker 1: or four chances. People who use certain types of drugs.
Speaker 1: I was primarily having a problem with alcohol and primarily
Speaker 1: a problem with prescribed stimulants, And even into my earlier recovery,
Speaker 1: was really important to me that I told you that
Speaker 1: I was using doctor prescribed stimulants. I wasn't a bad boy.
Speaker 1: I wasn't off running and buying my stimulants on the street,
Speaker 1: as if that made a difference. Identity and the sort
Speaker 1: of ways we present ourselves to the world be misleading
Speaker 1: and a source of denial and confusing thing, but also
Speaker 1: sometimes it really has concrete effects that if I can
Speaker 1: present myself as the right sort of person with addiction,
Speaker 1: maybe I get more opportunities. And who knows, who knows
Speaker 1: what would have happened if you know, choose any dimension
Speaker 1: of that recovery capital if I didn't have it, what
Speaker 1: would have happened. Even in my early days of treatment,
Speaker 1: I was sort of rebelling against it and saying, well,
Speaker 1: I'm not sure I'm really an alcoholic, and I think
Speaker 1: what you're saying is pretty dumb. I'm a psychiatrist, and
Speaker 1: I know better than you counselors and so forth and
Speaker 1: so on, and yeah, on a different circumstances, that might
Speaker 1: have just gotten kicked out of the program and then
Speaker 1: I'd lose my medical license, or at least it takes
Speaker 1: me years and years and years to get it back.
Speaker 1: You know, for me, the phrase that I always think
Speaker 1: of in reference to this as an accident of birth. Yeah,
Speaker 1: I'm in recovery now because of an accident of birth.
Speaker 1: I also had a problem with addiction because of an
Speaker 1: accident of birth. But that forces me to be humble
Speaker 1: and grateful for what I do have and what I
Speaker 1: had the opportunity to pursue. You talked about how you
Speaker 1: were in recovery and you felt like you weren't doing
Speaker 1: enough recovery. You felt like you weren't doing it right.
Speaker 1: Talk to me a little bit about that and how
Speaker 1: you sort of came out of that. When I was
Speaker 1: sent to treatment, it was a fairly old school twelve
Speaker 1: step oriented program, meaning for some but not all people there,
Speaker 1: twelve steps were presented as the only way, and for
Speaker 1: some but not all of the counselors there, medications were
Speaker 1: a bad thing. There's something that's not quite clean about
Speaker 1: needing to be or even choosing to be on a
Speaker 1: medication that helps with the diction. Treatment like buprenour fine
Speaker 1: or methodone. Along with that, there was some I think,
Speaker 1: ideological notions about how you recover. And when I way
Speaker 1: back and I did the research, I saw these notions
Speaker 1: echoed in quotes, and even the head of a major
Speaker 1: rehab in the nineties said, I can guarantee you if
Speaker 1: you don't go to a after you leave here, you
Speaker 1: won't make it. It's false. We we have very good
Speaker 1: data that shows that, you know, maybe it's dangerous, maybe
Speaker 1: it's not right for everyone, but a lot of people
Speaker 1: with even severe substance problems can return to moderation. And
Speaker 1: again I don't want to be cavalier about that. I
Speaker 1: don't advise people to go out and play games, especially
Speaker 1: after they've had a severe substance use problem. But we
Speaker 1: also know that there are many different pathways to recovery,
Speaker 1: as I'm sure you know, is a big buzzword right
Speaker 1: now in addiction treatment, respecting the many different pathways to recovery.
Speaker 1: But I had never heard that concept or never learned
Speaker 1: about it in medical school. I had never learned about
Speaker 1: it in my psychiatry training. I never learned about it
Speaker 1: when I was a rehab and I think that does
Speaker 1: people a disservice because kind of like what we're talking
Speaker 1: about earlier with an accidence only ideology, we have to
Speaker 1: come to terms with real world. What happens in real
Speaker 1: life is that people will go on a variety of
Speaker 1: different pathways, and even if we don't know that they're
Speaker 1: on the right path, we meet them where they are
Speaker 1: if we want to give them the best chance, if
Speaker 1: we want to give ourselves the best chance of supporting
Speaker 1: them in those pathways. So you're asking about shame what
Speaker 1: I might call the internalized stigma of recovering in the
Speaker 1: wrong way. I got a lot of messages like if
Speaker 1: you don't do a ninety and ninety, and if you
Speaker 1: don't get a sponsor right away, and if you don't
Speaker 1: start doing service, and if you don't do this and
Speaker 1: you don't do that, then you're gonna relapse and I'm
Speaker 1: going to see you back here again. And I didn't
Speaker 1: do everything by the book at first, and guess what,
Speaker 1: I didn't relapse and I got through it. And it
Speaker 1: was actually learning about and getting the opportunity to recover
Speaker 1: along those more flexible lines that gave me the space,
Speaker 1: the psychological space to come back and appreciate more of
Speaker 1: a twelve step pathway and appreciate more the kinds of
Speaker 1: things that I think the best kind of twelve step
Speaker 1: activity are trying to promote, like developing a spiritual practice
Speaker 1: and finding a community and all the rest. I think
Speaker 1: that when we're too rigid and too ideological, and by
Speaker 1: way I mean like addiction treaters and otherwise, when we're
Speaker 1: too rigid and ideological, then we push people away from
Speaker 1: exploring things with one's own agency and finding one's way
Speaker 1: back to what actually works. Yeah, I think even within
Speaker 1: a twelve step fellowship, let's just take a A. Even
Speaker 1: within a A the way that it's presented can be
Speaker 1: radically different. You could come here to Columbus and you
Speaker 1: and I could go out on a Wednesday night and
Speaker 1: hit three different meetings and get three potentially very different
Speaker 1: views on how you recover an A. A one meeting
Speaker 1: would say exactly like you said, every word in the
Speaker 1: Big Book is the literal word of God, and you've
Speaker 1: got to treat it exactly right. And if you don't
Speaker 1: go to ninety meetings, if you don't go to a
Speaker 1: meeting every day, you're gonna die. And then you could
Speaker 1: go somewhere else, it's a whole lot more like you know,
Speaker 1: the twelve steps or suggestions, and we're here for you
Speaker 1: and you know, and everybody's got to find their own.
Speaker 1: I find it unfortunate that a lot of people who
Speaker 1: are looking for help can go to a certain type
Speaker 1: of meeting and get turned off to the whole thing.
Speaker 1: By that. I always say to people, if you're gonna
Speaker 1: try a a like, at least just give it like
Speaker 1: five different meetings before you rule it out. Go look
Speaker 1: around a little bit. You know. One way that I
Speaker 1: think about this, and I'm curious what you think you
Speaker 1: mentioned in the book, and I don't remember what you
Speaker 1: call it. It's something like a stepped approach to recovery.
Speaker 1: You start out by doing a little bit of something
Speaker 1: step care model, step care model. I often think that
Speaker 1: that is a really wise way, whether you're being treated
Speaker 1: by a physician or you're looking at recovery on your own,
Speaker 1: is you know, sort of a step care model, Like,
Speaker 1: all right, here's what I'm willing to do for recovery today.
Speaker 1: Did that work. If it did, then maybe I found
Speaker 1: what works for me. If it didn't, then I probably
Speaker 1: need to look at getting some more support now. That
Speaker 1: could look lots of different ways, but it tells me
Speaker 1: that I don't have enough recovery support in my life,
Speaker 1: so I need to step it up. That seemed like
Speaker 1: a reasonable way of thinking about it in your mind. Yeah,
Speaker 1: absolutely absolutely, And some of those diverse views within a
Speaker 1: A I think are at least in part a legacy
Speaker 1: of historical developments through the mid twentieth century. And I
Speaker 1: needed that for myself to understand what's going on with
Speaker 1: our treatment system. Why does it seem so screwed up? Yeah?
Speaker 1: Why is it so hard to access quality care? And
Speaker 1: why is it so ideologically driven? A lot of those
Speaker 1: I think, more hardcore ideas about twelve SEP recovery are
Speaker 1: more a function of the treatment system. And one former
Speaker 1: senator and even the a A member himself, Harold Hughes,
Speaker 1: called the treatment industrial complex. He helped to establish the
Speaker 1: whole thing, and then later in life he said, this
Speaker 1: is this is getting dangerous. You guys are too ideological,
Speaker 1: probably mostly the guys at that point, And it was
Speaker 1: really important to me to untangle the threads of that
Speaker 1: sort of one sized fits all treatment system versus mutual
Speaker 1: help recovery, because I think they're different things, and there
Speaker 1: can be lots of overlaps and lots of interconnectedness because
Speaker 1: a lot of people who are counselors, are working in
Speaker 1: rehabs are also in mutual health failure. But these are
Speaker 1: distinct things. The treatment system is different than mutual health recovery.
Speaker 1: Because of that, and because of the way the treatment
Speaker 1: system evolved, we wound up with a one size fits
Speaker 1: all model, and that's still primarily how care is delivered.
Speaker 1: The sort of folk psychological idea of what you do
Speaker 1: if you have an addiction problem is going to rehab.
Speaker 1: But that doesn't make sense. You know, we had cases
Speaker 1: in the nineteen eighties when people would just get a
Speaker 1: couple of d u s and they would be forced
Speaker 1: to go to an impatient rehab. It's preposterous. We don't
Speaker 1: treat other mental health problems that way too. It's not like, oh,
Speaker 1: you're a little bit sad you had a crying spell yesterday,
Speaker 1: go way to impatient psychiatric hospitalization. It doesn't make any sense.
Speaker 1: Every listener of this show would have been just put
Speaker 1: in an asylum by that criteria. Yeah, yeah, and you
Speaker 1: wouldn't tell anybody because you'd be scared, which is a
Speaker 1: big part of all of it too. So you know
Speaker 1: that one size fits all model is almost like a
Speaker 1: remnant of that American medical advocation of its duty to
Speaker 1: help people with addiction. And so we're still making up
Speaker 1: for lost time and still trying to come up with
Speaker 1: something like the step care model, where you meet people
Speaker 1: where they're at and if somebody is, say, not too dangerous,
Speaker 1: and they're not that interested in treatment, then you you
Speaker 1: engage at a lower level. It doesn't preclude you from
Speaker 1: offering higher levels of care. Somebody comes in and they say,
Speaker 1: I've got accesses up and down my arm, and I've
Speaker 1: overdosed three times and I'm worried I'm gonna die. Please
Speaker 1: help me. Then okay, mind, Maybe impatient care is right
Speaker 1: for that person, but it's not necessarily right for everyone,
Speaker 1: right Yeah. In the same way, if I went to
Speaker 1: my doctor and, like you said, said I was feeling
Speaker 1: a little bit sad, we would not immediately move to
Speaker 1: electro convulsive therapy, right, Like, that's gonna come way down
Speaker 1: the road. Not that it's not a valuable treatment, because
Speaker 1: it is for some people, but it's certainly not a
Speaker 1: starting point. And I think this is so interesting because
Speaker 1: it gets back to the moderation piece a little bit,
Speaker 1: which is this idea that not everybody needs abstinence, which
Speaker 1: I think is unquestionably true. That's not necessarily the starting point.
Speaker 1: Now that becomes tricky because it's also the thing that
Speaker 1: every one of us, as an addict wants to believe
Speaker 1: is true. Right, It's the thing that every one of
Speaker 1: us that needs abstinence wants to believe. I thank my
Speaker 1: lucky stars. I got sober at twenty four from heroin
Speaker 1: it states ober about eight years, went out and drank again,
Speaker 1: start drinking, never went back to heroin, started drinking, smoking
Speaker 1: pot for about three years. And I've been back sober
Speaker 1: fifteen years. But before I did that, I did not
Speaker 1: want to come back to twelve step recovery. I did
Speaker 1: not want to come back to abstinence. Desperately did not
Speaker 1: want to. So I went to moderation management, which is
Speaker 1: a program. And I've told this story before, and I
Speaker 1: would have been the valedictorian of moderation management if it
Speaker 1: came down to how hard I tried, because I so
Speaker 1: desperately was like, please not not not abstinence, not a again,
Speaker 1: you know, And there wasn't a lot of options besides
Speaker 1: a fifteen years ago at least in Columbus, Ohio, right,
Speaker 1: and it didn't work for me. And I saw in
Speaker 1: moderation management a lot of people like me who were
Speaker 1: people who needed abstinence, who were kind of hanging on
Speaker 1: to that idea. And so I think that's partially why
Speaker 1: the moderation debate gets so heated, is because for people
Speaker 1: who need abstinence. I'm a little frightened by the moderation conversation,
Speaker 1: to be honest, because a little part of me wakes
Speaker 1: up and go, see, maybe it could be you. And
Speaker 1: so I think that's why it's difficult conversation. How do
Speaker 1: you feel about it on a personal level? Yeah, I
Speaker 1: had to write three hundred pages before I got to
Speaker 1: a point where I was comfortable engaging with it. That
Speaker 1: was part of the arc of the book was trying
Speaker 1: to make sense of my felt sense that I am
Speaker 1: a person in recovery from addiction, that there's something special
Speaker 1: about that that I have membership and then I qualify
Speaker 1: to be in this certain tribe or group of people,
Speaker 1: and at the same time that there's no essential division
Speaker 1: between addiction and the rest of the population. So how
Speaker 1: do I make sense of that, and the moderation piece
Speaker 1: goes along with that question, because if I'm not uniquely
Speaker 1: disordered in some way that crosses a very defined US
Speaker 1: them line, then there's no absolute law that says that
Speaker 1: I can or can't drink again. For me, I feel
Speaker 1: like it's enough. I've got enough data and I'm not sure,
Speaker 1: I'm not percent sure that I could never drink again safely,
Speaker 1: but it's not worth it to me, Yeah, it really is.
Speaker 1: What would I actually get from that experiment? What am
Speaker 1: I hoping to get out of it? And in fact,
Speaker 1: you know, one of the gifts of recovery for me
Speaker 1: was that I got back to something I had a
Speaker 1: real yearning for earlier in my life, but then addiction
Speaker 1: pushed me away from, which was Buddhist practice, specifically Zen practice,
Speaker 1: and I could never commit to it because you know,
Speaker 1: I would do a three weeks silent retreat and then
Speaker 1: I would leave and go straight to the bar just
Speaker 1: to eradicate all of the progress. I admit, I couldn't
Speaker 1: wake up on a Saturday morning to get to the
Speaker 1: Zen center because I was too hungover or whatnot. As
Speaker 1: a totally separate system of spiritual practice, there are precepts
Speaker 1: about taking intoxicans, and there are precepts of caution people
Speaker 1: to be really attentive to the cause and effect of
Speaker 1: what happens when I take it in toxicans. And it's
Speaker 1: very similar to what happens when I engage in anger,
Speaker 1: very similar to what happens when I engage in gossip.
Speaker 1: You know, these are similar precepts and that moral and
Speaker 1: ethical code. It's as I and again I'm not a
Speaker 1: Buddhist teacher, but as I understand it, it's not to
Speaker 1: say thou shalt not. It's to say, pay attention and
Speaker 1: see what it's like when you do this, when you
Speaker 1: do that, And it's about um training the mind. So
Speaker 1: I'm at a place right now where I don't stress
Speaker 1: about it too much. I don't see much of an
Speaker 1: advantage to intoxication. As a matter of fact, it takes
Speaker 1: me away from what one of my main purposes of
Speaker 1: spiritual practice is. As far as I understand it, and
Speaker 1: I share your fear that by talking about moderation, maybe
Speaker 1: somebody gets misled and they say, hey, some doctor said
Speaker 1: on some podcasts that some people can drink moderately. Maybe
Speaker 1: I'll try it, And then they go out and they
Speaker 1: overdose because they can supply is totally contaminated with fentanyl
Speaker 1: or whatnot. But we can't deny reality. The fact of
Speaker 1: the matter is back to the nine seventies, we had
Speaker 1: these studies saying that some people, even with severe substance
Speaker 1: use problems, can return to moderation. And I think that
Speaker 1: the forces that try to suppress and muddy up those waters,
Speaker 1: in some cases by outright suppressing those reports that did
Speaker 1: more harm than good. We're engaged in a scientific process
Speaker 1: of trying to understand psychology. We can't fight that. That's
Speaker 1: you talked about the risk of it. It made me
Speaker 1: think of Pascal's wager, which is the basic idea of like, well,
Speaker 1: if I don't believe in God, what do I get? Well,
Speaker 1: I get to maybe, you know, act bad a couple
Speaker 1: more times, and you know, but if I'm wrong about this,
Speaker 1: if I say God doesn't exist and I'm wrong, I'm
Speaker 1: talking about eternal infinity of damnation, Like, okay, it makes
Speaker 1: sense to believe, and you know, moderation is a similar
Speaker 1: thing for me. Is is that idea of like, like
Speaker 1: you said, what's the benefit? I know what the downside
Speaker 1: of it is. I've seen what it does to my life.
Speaker 1: I actually also have the additional benefit of you know,
Speaker 1: I got sober, stayed sober eight years, and then bought
Speaker 1: the moderation thing for myself. I was like, well, you know,
Speaker 1: I was twenty four. Back then, I was doing heroin,
Speaker 1: which we can all agree is a bad idea. I've
Speaker 1: been to a ton of therapy since then, Like, I
Speaker 1: think I can make good choices about it, and it
Speaker 1: turned out I couldn't. So I've already done that once,
Speaker 1: which helps me a little bit. Let's talk about zen
Speaker 1: for a minute, because I'm sort of on a Zen
Speaker 1: hiatus at the current moment, but have been a pretty
Speaker 1: dedicated Zen practitioner at different points. Is that what you're
Speaker 1: still doing is Zen practice? And if so, what's the lineage?
Speaker 1: I'm curious. It's so too zen? Okay. The Brooklyn Zen
Speaker 1: Center that I fell into, for lack of a better term,
Speaker 1: is in the same lineage as the San Francisco zenn
Speaker 1: Center from Shinryo Suzuki, and I loved it. It was
Speaker 1: what I needed. I started off Zen practice in Korea
Speaker 1: right after college, and also a very lovely style of practice,
Speaker 1: but it was very tough lots of bows, sitting very rigidly,
Speaker 1: a lot of banging sticks on the ground. Sometimes they
Speaker 1: banged the sticks on your shoulders. Yes, in a nice
Speaker 1: way and with people's permission. It wasn't abusive, but that
Speaker 1: was too much for me. That for me fed into anybody.
Speaker 1: I mean that the tougher model of zen practice, it
Speaker 1: fed into my perfectionistic notion that I should do it
Speaker 1: all perfectly and I should hold myself rigidly and it's
Speaker 1: all about Mimi me control, control, control, and the kind
Speaker 1: of spiritual practice I needed because I bounced around a
Speaker 1: little bit in recovery and otherwise sampling different traditions. What
Speaker 1: I needed was sometimes Soto Zen is called farmers inn
Speaker 1: because it's very gentle, because it's about as far as
Speaker 1: I understand it, again not a teacher, but it's about
Speaker 1: just sitting and being with reality as it presents. And
Speaker 1: one of the fundamental instructions is sit on a cushion
Speaker 1: and think, not thinking. How do you think? Not thinking?
Speaker 1: Not thinking? So to take it easy, man, is the
Speaker 1: way I interpret that. And I needed that kind of
Speaker 1: like sympathetic and calm self care and the other thing
Speaker 1: about sotos then that I really like, at least in
Speaker 1: the tradition and with the teachers that I had a
Speaker 1: good fortune of encountering, is a real focus on ethics
Speaker 1: and not just meditation as the sole aim and purpose,
Speaker 1: but how is spiritual practice connected in a community. And
Speaker 1: that's something I got out of recovery, to just the
Speaker 1: absolute necessity of recovering together and each other's practice as
Speaker 1: a mirror from one another. And uh, it's been really supportive.
Speaker 1: And you know, in Portugal there's a Grade Zen Center
Speaker 1: in a different lineage. I've started to go. I don't
Speaker 1: know Portuguese yet all that well, so it's I'm getting there.
Speaker 1: But it's such a gift to be able to sit
Speaker 1: in community with other people. Yeah, my tradition is white plum,
Speaker 1: so it's sort of a rinse I Soto combination to
Speaker 1: Zumi Roshi was a contemporary of Suzuki Roshi. You started
Speaker 1: San Francisco Zen Center. It's one of the only people
Speaker 1: that had a lineage holder in both Rinsey and Soto,
Speaker 1: so it's sort of a blend. You said something in
Speaker 1: the book about at your Buddhist center, you notice they
Speaker 1: hosted addiction recovery meetings and a different mutual help tradition
Speaker 1: that you started going to, and you've got a beautiful line.
Speaker 1: You said, I needed to find a different framework than
Speaker 1: the one initially offered to me. I think you mean
Speaker 1: different than twelve step. Only then did I get a
Speaker 1: taste of the relief these a A members that described
Speaker 1: to me earlier the feet line of being held by
Speaker 1: the earth and by something larger than myself, something that
Speaker 1: could help me make sense of suffering and be of
Speaker 1: purpose in the world. That's such a great summation of
Speaker 1: what mutual help groups can give us when they're right.
Speaker 1: Thank you, I meant to. I've seen people connect with
Speaker 1: that feeling, the leap of faith, the connection with the earth,
Speaker 1: and the profound happiness and joy that can come from
Speaker 1: being a meaningful service in the world. And for many people,
Speaker 1: I think they didn't need to try different varieties. I
Speaker 1: didn't know that there are different varieties of mutual health meetings.
Speaker 1: I fell into it by accident. Again, this is after
Speaker 1: med school, during residency and all the rest. And like you,
Speaker 1: I I tell people, try a bunch of different meetings,
Speaker 1: and that means try a bunch of different A meetings.
Speaker 1: But I think it's also useful for people to try
Speaker 1: a bunch of different recovery. Mutual health traditions is smart recovery.
Speaker 1: There is Buddhist Recovery network, They're a Christian based ones,
Speaker 1: so forth, and so on. There's so many different varieties
Speaker 1: now and there's so much more accessible now that everyone
Speaker 1: has developed zoom platforms or other sort of online platforms
Speaker 1: for connecting. Yeah. I just think that's a really powerful
Speaker 1: and hopeful element of recovery today. Yeah, I agree. I
Speaker 1: think it's a beautiful thing. I don't attend twelve step
Speaker 1: groups anymore occasionally, and I occasionally go to like a
Speaker 1: Dharma recovery meeting. I've been getting community in different places
Speaker 1: in different ways, but I'm so glad to see all
Speaker 1: the different things that are there. And part of me wonders,
Speaker 1: like what would I have been drawn to if I
Speaker 1: was coming in now, because it's a different world than
Speaker 1: it was in Columbus, Ohio, Like it's just so different. Anyway,
Speaker 1: I want to wrap up with a line that I
Speaker 1: just think we could summarize all of this with, and
Speaker 1: you say, how do people change? There is as many
Speaker 1: answers as there are people in recovery. The key is
Speaker 1: to try, I think That's the hopeful message, right is
Speaker 1: if you're in recovery or trying to get in recovery,
Speaker 1: try and keep trying. Yeah, there's so many ways that
Speaker 1: people have recovered, even across the years. That was one
Speaker 1: of the big gifts of the book, too, is to
Speaker 1: see all the different models and the different varieties that
Speaker 1: people have happened upon, whether it's spiritual practice or other
Speaker 1: community based support or otherwise. And that was daunting when
Speaker 1: I first started looking into the history of addiction, but
Speaker 1: it also gave me a a tremendous hope in a real
Speaker 1: sense of fellowship, just that we're part of this human
Speaker 1: project of trying to better understand the self so that
Speaker 1: we can live in harmony with ourselves and other people.
Speaker 1: And if anybody tells you they've got the answer for that,
Speaker 1: then run screaming in the opposite direction because they're obviously, yeah,
Speaker 1: they've got the only answer for it. Yeah, absolutely exactly, Carl.
Speaker 1: We are at the end of our time. As I said,
Speaker 1: I absolutely love the book. If you are interested in
Speaker 1: addiction and recovery, I highly recommend it. You and I
Speaker 1: are going to continue in a post show conversation where
Speaker 1: we are going to talk about Synanon, which is a
Speaker 1: crazy cult and it's impacts in recovery and treatment today.
Speaker 1: And I love the fact that the wounder had to
Speaker 1: be carried out on Shiva's regal because he was so drunk.
Speaker 1: But we'll get to that in the post show conversation. Listeners,
Speaker 1: you can get the post show conversation by going to
Speaker 1: when you feed dot net slash Join. Becoming a supporter,
Speaker 1: you get post show conversations, ad free episodes, a special
Speaker 1: episode I do called Teaching Song, and a poem, and
Speaker 1: the joy of supporting something that you love. So when
Speaker 1: you feed dot Net slash Joint, thanks again, Carl. It
Speaker 1: is such a pleasure to have been talking with you.
Speaker 1: Pleasures all my Eric. Great to meet you. If what
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