Mixed Bag #12: Carl Erik Fisher on Addiction

“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab

---

Carl Erik Fisher, MD is an addiction psychiatrist, bioethics scholar, author, and person in recovery. He is an assistant professor of clinical psychiatry at Columbia University, where he works on law, ethics, and policy relating to psychiatry and neuroscience, especially issues related to substance use disorders and other addictive behaviors. He is the author of the 2022 nonfiction book The Urge: Our History of Addiction, selected as a “best book of the year” by The New Yorker and The Boston Globe and translated into half a dozen languages. The book is an intellectual and cultural history of addiction, interwoven with his own experiences as an addiction psychiatrist at Columbia and as someone in recovery himself. He hosts an interview podcast focused on addiction and recovery, Flourishing After Addiction, featuring discussions with scholars, writers, artists, people with lived experience, and more.  You can find him at his website.

---

Fisher: I’m delighted to be participating in this series. I’ve loved Psychiatry at the Margins so far, and I’m especially glad to find points of connection between the fields of addiction and “general” psychiatry—the separation of which simply doesn’t make sense and causes a lot of harm. There’s much in the critical and philosophical debates around psychiatry that would be fruitful to apply to addiction studies, and, I hope, vice versa. So first and foremost, in writing this blog entry, I’m thinking about people who know and read a lot about the conceptual basis of “general” psychology and psychiatry but who perhaps are less familiar with addiction as such. This work matters a great deal—we’re still in the midst of a horrific overdose crisis, and many of the harms of substance problems continue to increase more and more each year, even though public interest seems to have waned since the onset of COVID—so clear thinking about this topic is quite literally a matter of life and death.

In choosing my 5 items, I tried to imagine what you, the reader, might find useful as departure points today—no doubt with some recency bias on my part. I have also hewed closer to the fundamental conceptual views relating to what I see as one good core question: “What is addiction?” There is also an essential and even bigger conversation about the connections between addiction and questions of justice, power, racism, oppression, and colonization, which I know will be important to many readers of PaTM, but frankly, I think those topics are better addressed at length, which is in part what my book is trying to do.

Surprise item – The vibhidaka nut

Fisher: I’m starting with the surprise item instead of saving it for the end. In researching my book, the oldest example of addiction that I was able to find was not a substance but a gambling problem. In the Rig Veda, an ancient compilation of Vedic Sanskrit hymns from India, there is an evocative account called “The Gambler’s Lament.” The poem describes a man who struggles unsuccessfully against his desire to play dice. We feel his body aflame and see the dice exerting their own power over him. At times he feels compelled, at other times he is able to exercise some agency, all the while feeling mystified by the ambiguity.

Yet ancient Indian “dicing” was different than what we think of today. Usually “dice” is the word used in these translations, but the gamblers were actually pulling small brown vibhidaka nuts out of a hollow in the ground. This evokes for me the slippery nature of the concepts and terms we apply to addiction, and the benefits and challenges alike of tracing mental phenomena through history. I write “dice” and I suppose you imagine something you’d see on a Vegas craps table, and perhaps that discrepancy doesn’t matter all that much to the core conceptual questions associated with psychological issues caused by high-stakes games of chance. On the other hand, perhaps we should not be too quick to assume our present concepts and terms map so neatly onto the past. To do so would risk a misleading kind of essentialism.

The eminent scholar Robin Room has described “the dance between concept and terms”: “addiction” as a word existed prior to our contemporary concepts, with a different set of meanings than the modern use. Those older definitions influenced the development of the modern concept of addiction, and, notably, that modern conception of the addiction phenomenon actually preceded the use of the term “addiction” for that concept. In other words, there’s a tangled and multidirectional interplay between the concept and the term across medical, popular, and cross-cultural understandings. We should not assume that what we call “addiction” neatly maps onto what people in other times called inebriety, or habitual drunkenness, or whatever.

I say all this at the beginning of this “mixed bag” to explicitly call out the challenges of tracing concepts and terms about psychology and psychiatry throughout history. I believe history matters and has a great deal to offer us, but I am also no essentialist and I try to be very careful about falling into ahistorical assumptions. Put another way, I believe addiction exists, but I also think we should not hold onto the idea too tightly.

Book — Evaluating the Brain Disease Model of Addiction. Edited By Nick Heather, Matt Field, Antony Moss, Sally Satel. Routledge, 2022.

Fisher: I’m cheating here, in a way, by selecting a book that in actuality is a collection of different articles across a diversity of viewpoints. The “disease” and “brain disease” debates are not all that interesting in their own rights, IMHO, but they open the door to important questions across several different fields. So, I heartily recommend this book as an excellent starting point; it is probably the best recent sampling we have of serious, contemporary, interdisciplinary work on addiction.

For example, in the conceptual realm, the philosopher Hannah Pickard—who has done excellent work on “responsibility without blame” in other contexts—provides a useful application of the conceptual distinction between “strong” and “minimal” concepts of disease: the former means pathological states in the body that cause syndromes, while the latter means signs and symptoms may hang together as syndromes without any particular arguments about underlying causes. In a more sociological vein, Helen Keane and coauthors describe how narratives of addiction are in relationship to and enmeshed with “the rise of liberal and neo-liberal conceptions of freedom.” Bruce Alexander of “rat park” fame discusses the geopolitical function of brain-based explanations as a starting point for arguing against multifactorial explanations and instead for a more fundamental, culturally situated paradigm shift. Many others debate the finer points of brain science and the actual, practical effects of such science on people with addiction, clinically speaking and otherwise. So, again, there’s no single grand synthesis here, but many worthy attempts at integration and synthesis.

Article — Owen Flanagan, “The Shame of Addiction,” (2013) Frontiers in Psychiatry.

Fisher: Owen Flanagan also belongs among the essential contemporary philosophers of addiction. He draws on his own experience as a person in recovery: in 2008, well after having established himself as a leading philosopher of mind, he disclosed his own addiction history to a large audience of his colleagues at the Society for Philosophy and Psychology with a talk, later adapted into his article, “What Is it Like to Be an Addict?” Since this “coming out” moment, he has been regularly publishing thoughtful and insightful articles about addiction, which I think will be collected into a book pretty soon, so keep an eye out.

In the meantime, this article, “The Shame of Addiction,” is as good a starting point as any. On my reading, he provides a compassionate yet provocative and rigorous account of why practical ethics matters in the case of addiction. Allow me to quote his abstract at length:

“Addiction is a person-level phenomenon that involves twin normative failures. A failure of normal rational effective agency or self-control with respect to the substance; and shame at both this failure, and the failure to live up to the standards for a good life that the addict himself acknowledges and aspires to. Feeling shame for addiction is not a mistake. It is part of the shape of addiction, part of the normal phenomenology of addiction, and often a source of motivation for the addict to heal.”

Person – William White

Fisher: Perhaps because the study and care of addiction is in many ways separated from the rest of psychiatric treatment and research, there is a thriving tradition of independent scholars who have done excellent work. For example, the best book about the actual formation of Alcoholics Anonymous, the rigorous and skeptical Writing the Big Book, comes from William H. Schaberg, a scholar and rare book dealer. Hundreds of articles are collected on https://silkworth.net/.

I could go on. But unquestionably first among these folks is William White, a person in recovery, counselor, and self-trained historian who has doggedly tracked down rare books and obscure articles and interviewed countless participants to construct the definitive history of addiction in America: Slaying the Dragon. His background is unconventional (street worker, counselor, clinical director, trainer, and research associate), but I’ve spoken with some of the leading mainstream contemporary historians of addiction, and they acknowledge, sometimes with grudging respect and a bit of wonder, the quality of White’s work. In addition to Slaying the Dragon, which clocks in at about 550 hefty pages, he’s published more than 400 articles and 16 other books. Many of these, plus interviews, blog posts, and more, are available for free on his website. He’s also a great pre-Substack example of an independent scholar making a difference outside of the academy.

Concept — Recovery

Fisher: I’ve used this term “recovery” several times so far, but I have to acknowledge that this too is a contested term that has had multiple concepts attached to it over the years. People in traditional, 12-step recovery have debated for decades whether they qualify as “recoverED” or “recoverING,” and if the latter, what does it mean to be continually engaged in an ongoing process of change, long after the “symptoms” or problems of substance addiction have resolved? (Following Leslie Jamison, I believe that recovery cliches contain a lot of wisdom, including the old AA chestnut: “I came for my drinking and stayed for my thinking.”) And 12-step is not the only game in town. Increasingly, people who do not identify with traditional 12-step practices are shaping recovery identities of their own. There are many pathways to recovery, but what is it? Why do people stick around in communities of recovery for 5, 10, 20 years or more, and what exactly are they doing? What are the necessary and sufficient conditions for recovery? Is recovery any different from positive psychology or any other attempt at human flourishing and freedom from suffering?

There are straightforward definitional questions here too: what is our starting point; how do we define recovery? A consensus panel convened by the Betty Ford Institute (hence, more 12-step flavored) came up with one influential wording a few years ago: “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” The researcher Katie Witkiewitz and coauthors have more recently proposed a broader conception: “an ongoing dynamic process of behavior change characterized by relatively stable improvements in biopsychosocial functioning and purpose in life,” in part as an attempt to better reflect the multidimensional and heterogeneous pathways to recovery; provocatively, they argue that recovery does not necessarily require complete abstinence (Also worth noting here is John Kelly and Bettina Hoeppner’s “A Biaxial Formulation of the Recovery Construct,” in Addiction Research & Theory).

“Recovery research” into these components of well-being and positive functioning is still in its infancy. I’m eagerly looking forward to more work on this topic, which is necessarily intertwined with normative questions—it’s not just a question of identifying the “active ingredients” in some sort of reductive psychological sense. Consider, for example, that the commonly identified dimensions of change in recovery invoke not just things like physical health and material resources but also practical ethics, interconnectedness, meaning and purpose in life, service, and spiritual/self-transcendent elements and practices. I do think there’s hope that this kind of work might inform a more nuanced conception of flourishing. But to do so we have to be very clear and careful in examining our assumptions about ideas like “addiction,” “recovery,” and the like, as they come burdened with an extraordinary amount of historical and folk psychological baggage.

---

See previous posts in the “Mixed Bag” series

---