How to Change Michael Pollan’s Mind:
A critical analysis of ‘addiction’, spirituality, and psychedelics
Submitted in partial fulfillment of the requirements
for the Bachelor of Arts degree in the Independent Program at Vassar College
Advisor, Eileen Leonard
Table of Contents:
Chapter 2: Buddhism and spirituality as offering the conceptual and practical tools to address ‘addiction’
I would like to first give a special thanks to my advisers, for both my major and my thesis: Prof. Eileen Leonard of the Sociology Department at Vassar College and Prof. Randolph Cornelius of the Psychology Department at Vassar College. I am so indebted to both of you, for all of the wonderful hours in class and meetings with you, for all of your feedback and advice on matters of academia but even more so on matters of life. I would not be who I am today without both of you. I would also like to thank Prof. Robert McAuley of the Sociology Department at Vassar for aiding my in my intellectual development and offering me feedback on my thesis, far beyond what was required of you as a professor. I am grateful to Prof. Luke Harris of the Political Science Department at Vassar, Prof. Jasmine Syedullah and Prof. Bill Hoynes of the Sociology Department, Jeffrey Golden, and Prof. Caroline Palmer of the Psychology Department for providing me with the creative and intellectual space to explore the topics discussed in this thesis, and for being wonderful and supportive teachers. I will always remember my conversations with Rev. Sam Speers about spirituality which helped me not only in developing this thesis but also, and more importantly, in developing my own spiritual practice.
I am so appreciative of my loving parents for providing me with the means and support to pursue my education and my goals. I could not have accomplished this project without the support of my friends, many of whom I discussed this thesis or related topics with, and many of whom simply provided me with a gift far greater: the support and love of friendship.I would also like to thank those who I have discussed this thesis with, or, more broadly, drug policy in general. I would like to give a big shout out to Students for Sensible Drug Policy (SSDP) for the amazing work they do and their annual conferences which inspired me to engage in this work. I have met so many wonderful people through SSDP, and I hope to connect with as many people within the SSDP family as I can. Thank you Rena Blumenthal for mulling over these topics with me. Thank you Bett Williams for giving me advice and encouragement on my thesis.
Psychedelics have recently become all the rage among … prestigious, white lab-coat, mainstream academics and researchers. Wait, what? Once the icon of the illegitimate, disruptive, hedonistic counterculture, psychedelic drugs are witnessing newfound interest and respect among reputable circles of scientists. Recent clinical trials at universities such as New York University, Johns Hopkins University, the University of New Mexico, and the University of California, Los Angeles represent psychedelic drugs’ foray into the mainstream as these drugs are explored for their therapeutic potential for a wide range of conditions, from depression to addiction to end-of-life anxiety in terminally ill patients. These studies have found significant success in the use of psychedelic-assisted therapies for these conditions (Bogenschutz et al., 2015; Robin L. Carhart-Harris et al., 2016; Roland R. Griffiths et al., 2016; Johnson, Garcia-Romeu, & Griffiths, 2017).
These trials represent not only the burgeoning acceptance of psychedelics into mainstream science and clinical practice, but also the resurfacing of attempts to explore psychological questions of philosophy and subjectivity in the era following the decade of the brain. In contrast to these inquiries, the Decade of the Brain – bestowed by President George H.W. Bush and referring to support for brain research in the 1990s – represented an almost unparalleled praise for reductionism and technological authority in psychology in its emphasis on neuroscience. In 2006, a paper was published in the peer-reviewed scientific journal Psychopharmacology, titled “Psilocybin Can Occasion Mystical-Type Experiences Having Substantial and Sustained Personal Meaning and Spiritual Significance” (R. R. Griffiths, Richards, McCann, & Jesse, 2006) The title conveyed the beginning of the fusion of two distant worlds: “science and spirituality.” (Pollan, 2018, p. 10). Such an attempt to reconcile these two worlds represents a return to the original, and yet still unaddressed, questions and paradoxes of psychology. These inquiries were initially explored by William James yet reliably left unexplored by mainstream psychology since: studying “people in their totality” and searching for scientific truths while also recognizing the messiness of human existence (Grogan, 2013, p. 33). This new field of psychedelic science, often termed the third wave of psychedelics1, is promoting new frontiers in science such as the legitimizing of the placebo effect with respect to more mainstream therapies (such as institutionalized therapy or pharmacological medicine) through its reframing as “meaning response” – a capacity of the mind to engage in healing through the construction of meaning (Hartogsohn, 2018; Moerman, 2002).
At the same time that psychedelic science is flourishing, the overdose crisis continues to increase its death toll, and mass incarceration remains as the dominant public policy promoted by those in power to address drug use (M. Alexander, 2012; Rajagopalan, 2018a). Beyond opioids, ‘addiction’2 plagues U.S. society through a myriad of forms including substances such as cocaine, alcohol, nicotine, and meth, but is certainly not limited to psychoactive compounds. ‘Addiction’ is increasingly understood as a generalized disorder across a range of behaviors such as gambling, eating, and the acquisition of power or wealth (B. Alexander, 2010b). Such an understanding contrasts with dominant treatments and understandings of substance use disorders, which fixate on substance use itself and are often obsessively concerned with abstinence. The pervasiveness of ‘addiction’ across the United States suggests that ‘addiction’ cannot be merely understood at the level of the individual. Rather than pathologizing unhealthy behaviors in the individual, we should continue to help those suffering while relocating the basis of pathology within society itself.
In Chapter 1, I will explore how the biomedical emphasis of dominant paradigms for understanding ‘addiction’ distract from social and cultural explanations, such as intersectional oppression, cultures and forces of isolation and disconnection, or an existential meaninglessness felt by many in highly industrialized nations. The biomedical framing of ‘addiction’ as a disease represents the pathologizing of the individual manifestation of sociocultural and political forces. The pathologization of the individual is guilty of similar consequences and rests upon the same, flawed, core ideological assumptions as the criminalization model, which has ruined so many lives through mass incarceration and the War on Drugs. For example, Angela Garcia, in her work exploring heroin use along the Rio Grande, examines the paradoxical relationship between the criminal and medical paradigms for addressing substance use in which people who use drugs are caught between the roles of patient and prisoner (Garcia, 2010). Garcia highlights how the medical paradigm removes agency from people who use drugs through either its emphasis on neurobiological determinism or though its moral degradation through the underlying connotations of terms such as “relapse” as indicating a personal failure. Although the medical model is a primary focus of this paper, such a paradigm must be considered in the context of its interaction with the criminalization of people who use drugs, as these two paradigms are intertwined.
Both paradigms depend upon a conceptualization of the atomized, disconnected, independent, entrepreneurial individual: the Western self. The criminalization paradigm accuses people who use drugs of a moral failing, of choosing to ignore standards of behavior. The medical paradigm asserts that people’s brains are to blame, yet still locates the realm of concern, the issue to be fixed, within the individual. The field of psychology, operating under the medical paradigm through clinical psychology, has been similarly critiqued for its fixation on the individual and its subsequent disregard for the illuminations provided by broader perspectives (Parker, 2015). Dr. Peter Cohen at the University of Amsterdam convincingly argues that “the concept of ‘addiction’ is an inevitable by-product of the concept of the individual” (P. D. A. Cohen, 2000). “It is, of course, a fiction that individual persons steer themselves … our ‘personal’ steering is a socially developed, relational, and cultural ability that allows a few variations” (P. D. A. Cohen, 2000). Cohen highlights how our fixation on these variations overemphasize individual responsibility, control, motivation, and ethical purpose, while neglecting a more interconnected understanding of human behavior, one that is common to not only sociology but also spiritual traditions such as Buddhism and earth-based spiritualities.
A critique of the medical paradigm, manifesting in an emphasis on illness as individual pathology, and a discussion of its similarities to the criminalization paradigm is not at all meant to suggest these two approaches are equal in their shortcomings. To even refer to consequences of the criminalization of people who use drugs as “shortcomings” is to underemphasize the horrors that have and continue to occur in the name of “justice.” However, we must remind ourselves that the medical paradigm has, too, manifested its own horrors. The medical paradigm, like the criminalization paradigm, serves to dehumanize people who use drugs and remove their sense of agency over their lives (P. Cohen, 2009).
In contrast to these models, in Chapter 2, I will explore spiritual approaches to ‘addiction’ which incorporate radically different perceptions of the self and approaches to pathology and healing. Definitions of spirituality can be vague and varied. The spiritual approaches in this exploration will focus primarily on contemporary Buddhist understandings. These approaches remain at the center of this inquiry for a variety of reasons. There exists a deep cultural history between psychedelics in the United States and Buddhism, a history which represents both justification for inquiry as well as material to draw upon. Buddhism’s teachings, particularly the Four Noble Truths and the Eightfold Path, also offer insight into our desires and our suffering and serve as tools to cultivating healthier behaviors and relationships with substances. Buddhist principles of mindfulness, self-forgiveness, lovingkindness, and compassion have been incorporated into recovery programs that speak directly to what people who use drugs need and often what the medical model is missing (Oliver, 2014). Finally, contemporary Buddhist practices – Thich Nhat Hanh’s Engaged Buddhism and Radical Dharma – demonstrate socially engaged spiritual practice, which I contrast with the contemporary mainstream psychedelic movement3. Socially engaged practices of Buddhism offer us a framework for interpreting the interconnectedness at the heart of psychedelic experiences. I believe that Buddhist approaches to ‘addiction’ offer tools and frameworks that would prove fruitful for moving forward in progressive approaches to ‘addiction.’4 In particular, Buddhism incorporates teachings of non-dual consciousness.
Non-duality is defined by experiences of interconnectedness, as a dissolution of the illusion of separateness (Evans, 2018). That is to say that Buddhism challenges the hyper-individualization and disconnectedness at the heart of the medical paradigm and instead promotes a paradigm of interconnectedness that illuminates much that the dominant medical paradigm fails to acknowledge. Buddhism also has a drastically different approach to pathology and healing, recognizing suffering as an integral part of the human condition and itself a path to greater wellbeing. This understanding is encapsulated in the phrase: “no mud, no lotus” (Nhat Hanh, 2014). Buddhism teaches us to sit with rather than suppress our suffering, and in doing so offers radically different opportunities to not only work through our suffering but also to understand our suffering, particularly its roots. The medicalization of suffering seeks to eradicate it, and in doing so, obscures its causes (A. K. Williams, Owens, & Syedullah, 2016). Upon considering and exploring Buddhist understandings of substance use, pathology, and healing, we must ask these questions: Do these spiritual paradigms seem to conflict with a medical model or are they complementary? Do these paradigms address the flaws and shortcomings of the medical model?
Recent studies in psychedelic science present the perfect opportunity for exploring these inquiries, which I will explore in Chapter 3. The emphasis on mystical experience as a crucial mechanism of action for the treatment of addiction with psychedelic-assisted therapies, in the studies conducted by Johnson et. al (2014) and Bogenschutz et al. (2015), emerges as an opportune point of departure for exploring how these recent developments in the field of psychedelic science relate to spiritual and medical paradigmatic understandings of and treatments for substance use disorders (Bogenschutz et al., 2015; Johnson, Garcia-Romeu, Cosimano, & Griffiths, 2014). The efficacy of these treatments across a range of substance use disorders (from tobacco to alcohol), as well as the prominent role of mystical experience as a mechanism of action, suggests a common component of spiritual deprivation that is pervasive across substance use disorders (B. Alexander, 2010b; Miller, 2014). I wish to explore the validity of this underlying mechanism as well as its implications for the dominant medical paradigm.
Mystical experience, as a component of spirituality, seems, at face-value, to conflict with the dominant medical model approach to understanding and treating substance use disorders, an approach which rests upon a basis of materialism, pathologization, and individualism. Mystical and material philosophies have long been understood as mutually exclusive and conflicting. Many in the new field of psychedelic science argue that the movement represents a long overdue synthesis of the two. However, can other core elements of these two paradigms, particularly their conflicting approaches to pathology and healing, ever be reconciled in a synthesis of the two? If so, are these trials doing so? If not, which paradigm remains dominant?
Spirituality is, in many regards, in conflict with a medical model approach to illness. Particularly, the pathologizing, stigmatizing, and individualizing of the medical model directly conflicts with a spiritual approach to suffering. To what extent do these studies replicate the shortcomings of the medical model? To what extent do these studies approach the inclusion of a more engaged spirituality? I will seek to answer these questions by examining the ideological frameworks that inform the studies and compare these with my explorations of the spiritual and medical paradigms. My overarching argument seeks to highlight and critique the individualization of medical paradigms (Chapter 1) while praising the interconnectedness, self-empowerment, and potential for social justice of spiritual paradigms (Chapter 2). I then seek to situate psychedelic therapies within these discussions (Chapter 3), exploring the limitations of these supposed radical medicines under the current mainstream movement to legitimize and legalize psychedelic therapies. I hope to highlight the pervasiveness of medical paradigms of ‘addiction’ and the overall trends of the psychedelic renaissance – that is, the continuation of depoliticized, colorblind, individual approaches to psychiatric conditions. If psychedelics do not challenge the individualization and depoliticization of the dominant paradigms for addiction then they do not offer radical new routes of healing but rather perpetuate systems of oppression that actually exacerbate the causes of ‘addiction.’
In highlighting the capacity for individual agency and self-determination of spirituality, I realize that a paradox arises in that I seem to praise that which I so heavily critique in my first chapter (Ch. 1) on the dominant narratives of ‘addiction.’ I believe there to be some fundamental differences between the secular and spiritual conceptualizations and practices of agency. The secular model is based on a distinction between individual and environment that sees the two as fundamentally separate. Agency is a means by which blame, judgment, and individualization are manifested. In contrast, spiritual practices of agency promotes empowerment and liberation; they are situated within an understanding of interconnectedness that promotes love and understanding, striving towards collective growth. The capacity for our minds to shape our realities is a core component of the teachings of mystical experiences and relates back to the legitimization of the ‘placebo effect’ in its reframing as ‘meaning response.’ We will return to this interaction between our minds and reality throughout this thesis; this interaction is at the heart of the integrative approach of this thesis that seeks to highlight critical perspectives in conversation with spiritual wisdom.
In this light, I hope to challenge the mystical-material dichotomy that rejects either the materialism of Western science or the mysticism of Eastern and indigenous spiritualities. I maintain that consciousness, the mind itself, is a supernatural entity and we need not move beyond the bidirectional causal relationship of mind-brain (or more accurately, mind-body) to enter the realm of mystics. The mind itself manifests our realities. Seeking to understand the capacity of reality-manifesting practices opens up collective potential for social justice and cultural transformation.
Finally, in my Conclusion chapter, I will conclude with a discussion of what the psychedelic movement should be. The interconnectedness of non-dual philosophies and experiences, as well as the ethical frameworks and practices of Buddhism, a religion centered around non-dual experiences, suggest that non-duality has the potential to inspire a sociological imagination and inform and motivate practices of transformative justice. I will briefly explore the possibility of psychedelic-assisted therapies under a critical psychology framework, as a practice of transformative justice and liberation psychology. A discussion of a politics of love and intersectionality will highlight the limitations of the current, mainstream field of clinical treatment in providing the solutions necessary to truly help people who use drugs, such as inclusive policies and practices of harm reduction including safe consumption spaces – places for people who use drugs to consume substances with medical supervision, without judgment or fear of incarceration.
My interest in these topics is intellectual, personal, spiritual, and political. As someone committed to a future career in social work, the healing potentials of psychedelics, and the progression of social justice demands for equality, this thesis feels intensely personal. Furthermore, my experience in drug policy reform and harm reduction on campus at Vassar College – through Students for Sensible Drug Policy – has shaped and motivated my attempts to support and humanize people who use drugs. I also wish to situate my thesis in my experiences this past summer, when I was working at a nature-based therapy summer camp for neurodivergent children in Oakland and living in a student-based affordable housing cooperative in Berkeley.
The contrast between diverse Oakland and “hippie” Berkeley was exemplified by my experience attending Michael Pollan’s lecture in Berkeley on How To Change Your Mind, his new book on psychedelics, while I was also working at this summer camp. **TRIGGER WARNING** (ableist language). He spoke of his experiences and knowledge of psychedelics, using terms such as “love” and “unity” while also referring to himself in a highly problematic phrase: “spiritually retarded.” After attending the lecture, I began to read a copy of his book that I received at the talk. While reading this book written by a formerly “spiritually retarded” white, middle-class cishet male, I was working one-on-one as a social aid to a child of color with autism, actually striving to practice the “love” and “compassion” that Pollan had said he experienced through psychedelics, yet undermined in his derogatory phrase. I began to see the disconnect between what many in the psychedelic field were preaching, and what the movement was actually accomplishing.
A sociological critique of medical paradigms of ‘addiction’
“Keep Your Brain Healthy. Don’t Use Drugs” - the National Institute of Drug Abuse’s Media Campaign (2000)
This chapter will highlight an overview of Western discourses around addiction, including dominant medical and critical approaches. First , I will highlight the individualization that is at the core of secular science and medicine (Section 1.1). I will then discuss the brain-disease paradigm that represents the dominant understanding of medical approaches to ‘addiction’ (Section 1.2). Such a paradigm is limited in its neurobiological reductionism that reduces complex phenomena to the brain, thereby limiting an understanding of people as social and cultural organisms with lived subjective experiences that influence their realities.
Although neurobiological perspectives on addiction do acknowledge the role of ‘environmental’ factors in contributing to the pathology of addiction, medical paradigm’s emphasis on individual agency depoliticizes the conversations about and treatments for addiction by shifting attention away from sociocultural flaws. Furthermore, the reduction of agency, framed in a medical light as a consequence of disease, limits people who use drugs in their capacity for self-directed growth beyond self-destructive cycles and enforces anti-democratic language and perceptions of dependency upon medical structures.
I then look to Western medicine more generally to understand the limitations of medicalization (beyond just neuroscientific paradigms), especially within the prevailing context of criminalization that surrounds drug use globally (Section 1.3 and 1.4). I will argue that medical approaches are depoliticized and decontextualized in their promotion of ‘objectivity’ and individualism that in actuality promotes neoliberal conceptualizations and perpetuates colorblind structures of medicine that lack an intersectional approach. These medical approaches perpetuate systems of oppression and fail to more meaningfully incorporate sociocultural and identity-sensitive perspectives into diagnosis, treatment, and policy. Medical paradigms fail to acknowledge and emphasize collective and cultural causes, instead focusing on the level of the individual.
If medical models do not challenge the individualization of addiction paradigms then they do not represent radical and progressive departures from criminalization approaches to addiction. That is to say that medical and criminalization approaches can, and often do, coexist. The intersectional oppression and individualism integral to criminalization approaches are not inherently challenged by medical approaches, which are often seen as promoting alternative, non-criminal approaches to drug use. I will discuss later in this chapter the whiteness of medical and public health approaches to ‘addiction’ that not only coincides with the racist drug war but also perpetuates criminalization structures in that it further separates white policies from those applied to people of color.
In contrast, social and cultural models provide radical, critical, and cultural approaches for conceptualizing ‘addiction’ and highlight limitations of current medical models (Section 1.5). The insights of sociocultural and critical approaches are discussed in this chapter, while the following chapter (Ch. 2) provides direction for incorporating the practicality of medical approaches with the necessary critical insight of socio-cultural approaches. Far from rejecting the dominant brain disease paradigm and its foundational knowledge altogether, critical perspectives that emphasize the social, cultural, and political conceptualizations of addiction must incorporate a “consideration of the physiology, biochemistry, and neurobiology” of addiction in order to transcend the “biology/culture dualism” (Dunbar, Kushner, & Vrecko, 2010, p. 2). Critiques of the dominant medical paradigms of addiction should not dismiss the genuine – if not entirely successful – efforts within medicalization to destigmatize substance use and promote harm reduction.
1.1 - Individualization and Atomization
We can understand the atomization of drug use as rooted in our conceptualization of the individual. Dr. Peter Cohen roots these conceptualizations in the social history of Protestantism which supplanted the power of the Church with notions of individual responsibility as a means of direct accountability to God. Similarly, the individual accountability, morality, and entrepreneurial spirit at the heart of Western, capitalist societies was famously analyzed by Max Weber (Weber, 2013). The conceptualization of the individual promoted by the Protestant Reformation demanded personal responsibility in new ways. “The structuring of right and wrong became more of an individual activity than ever before,” as one’s reliance upon the Church or priests diffused into personal responsibility (P. D. A. Cohen, 2000). The autonomous individual was born.
Such beliefs about individuality persist, deeply ingrained into the ways we see the world, the ways we design our public policies, the ways we judge and understand the behavior of others. That is to say, that individuality is at the heart of dominant paradigms in the United States. “We have beliefs about individual responsibility, about how we are motivated to act, and to what good purposes individual capacities should be used” (P. D. A. Cohen, 2000). Conceptualizations of the individual promote beliefs about entrepreneurialism and our ability and responsibility to develop “navigational powers that reside inside the person, powers we need in order to develop the self in an aggressive and chaotic world” (emphasis added) (P. D. A. Cohen, 2000).
The dominant paradigm within ‘addiction’ studies is known as the NIDA (National Institute on Drug Abuse) paradigm for NIDA’s role in advancing this paradigm in both research and policy. Through its location of ‘addiction’ within the individual brain, the NIDA paradigm fails to question the roots of its underlying assumptions of individuality that are the foundation of the paradigm. These unquestioned assumptions fundamentally undermine the supposed objectivity of its scientific research and claims. As Peter Cohen (2000) points out, these assumptions, rather than stemming from “objective” understandings,
are inherited from the Reformation and its Renaissance roots. It is, of course, a fiction that individual persons steer themselves, as if an inner compass were installed in each of us. Our ‘personal’ steering is a socially developed, relational and cultural ability that allows a few variations, although for us it seem as if this variation constitutes the summit of individuality. The steering forces that shape [people] and move them in relation to each other (history, role, climate, economic conditions, etc.) are so inherent to location, cultures of upbringing, and period in which a person develops, that the imprints they make determine human beings at least as much and probably much more than the differences between them. True, no two waves in the sea are the same, but how important are these differences to understand the phenomenon of waves (P. D. A. Cohen, 2000)Importantly, Cohen does not dismiss entirely the possibility of variation and self-determinism, but rather stresses that the dominant and limited conceptualizations of the individual overemphasize such possibilities, to the point of viewing them as the entirety of the picture rather than a very small part. The possibility of variation, through self-determinism, will re-emerge as an important consideration in later discussions on spiritual understandings of and approaches to addiction. Although the medical model attempts to move beyond the moral baggage of individualism and choice, it nevertheless remains rooted in the individual as the supreme basis of choice, locating limitations to choice primarily within the individual brain rather than external forces. In maintaining a focus on the individual, medical models fail to subvert the moral weight of ‘addiction’ paradigms. Although many advocates of the medical model emphasize that acknowledging ‘addiction’ as a brain disease results in the destigmatization of ‘addiction’ struggles, the inability to move beyond individualist models obstructs progress away from the moralization of ‘addiction’. We can understand limited or unsuccessful efforts at destigmatization as failures to adequately promote collective understandings of ‘addiction’ that relocate the primary focus of concern outside of the individual.
1.2 - Addiction as brain disease: the NIDA paradigm
The dominant medical model of addiction promoted by the National Institute on Drug Abuse (NIDA) – referred to henceforth as the NIDA paradigm – conceptualizes addiction as a brain disorder (Dunbar et al., 2010). This paradigm, which underlies the NIDA’s research and funding programs, assumes and perpetuates atomistic understandings of substance use that parallel neo-liberal conceptualizations of individualism, rational actors, personal responsibility, and individual autonomy (P. D. A. Cohen, 2000; Hunt, Milhet, Bergeron, & Moloney, 2016; Netherland, 2012). Such atomistic understandings underlie the pathologization of substance use which locate the causes of addiction within the individual. The pathologization of substance use as individual disease located within the brain serves to depoliticize addiction discourse and treatment, decontextualizing people’s substance use from the sources of their suffering, including intersectional oppression and cultural malaise. By doing so, the dominant paradigms of addiction, in their efforts to treat the biological aspects of addiction, actually serve to perpetuate the social, collective causes of the suffering that underlie addiction.
Furthermore, the NIDA paradigm fails to destigmatize and de-moralize addiction and removes agency from and disempowers people who use drugs; the NIDA paradigm, far from the lofty and idealistic goals of medicalization –- such as the restoration of basic dignities to people who use drugs in the eyes of society – functions to dehumanize people who use drugs and acts as a form of social control. The failed potentials of medicalization are discussed later on this chapter in Section 1.4. The dominant medical model of addiction does not rebuke or deny such atomistic understandings of autonomy, but rather seeks to remove the burdens of agency and responsibility by locating pathology in the brain. In doing so, medical models actually undermine the capacity for self-determination and healing from within – capacities that I find emphasized in Buddhist and spiritual approaches, as discussed in the next chapter (Ch. 2) (P. Cohen, 2009). Medicalization seeks to move away from the moralization of choices but still emphasizes the individuality and importance of choice.
The NIDA paradigm is further plagued by its almost exclusive and reductionist reliance upon paradigms of epidemiology, psychiatry, and neurobiology and its uncritical promotion of pharmaceuticalization. The NIDA paradigm emphasizes a loss of autonomy as resulting from neurophysiological changes in the brain and the psychopharmacological cravings stemming from drug use. In doing so, the medical model constructs social realities and personal narratives of relapse that manifest as self-fulfilling prophecies. The consequences of these paradigms centered in biological determinism function to disempower people who use drugs and reinforce the inevitability of relapse (P. Cohen, 2009); even more progressive paradigms of medicalization that seek to promote harm reduction and depathologization – such as therapeutic orientations of pain medicine and psychology –- fall prey to the individualization that perpetuates collective causes. I do not mean to suggest that these functions are whatsoever the aims of medical professionals but rather the consequences of medical paradigms.
The NIDA paradigm is a continuation of atomistic understandings of drug use and personhood through its emphasis on pathologizing addiction within the individual brain. By doing so, the medicalization of substance use, of which the NIDA paradigm is merely the latest iteration, removes agency from people who use drugs akin to the removal of agency from incarcerated people through the punitive criminal justice system. The connections between the medicalization and incarceration of drug use are explored later in this chapter in Section 1.5. “Currently, the neurochemical thinking that dominates addiction produces craving and relapse as the primary objects of explanation rather than other aspects of the addictive experience” (Keane & Hamill, 2010, p. 53). The dominant conceptualizations of addiction fail to incorporate more in-depth understandings of craving and relapse as situated within deeply complex life histories, themselves embedded within sociocultural and historical contexts.
Instead, deterministic models of addiction reduce addicts to their brain; the discourse of the NIDA paradigm emphasizes neurochemical and physiological processes that are viewed as “fundamental and persistent neuroadaptive changes,” in the words of Alan Leshner, former head of the NIDA (Keane & Hamill, 2010, p. 53). Addicts are indoctrinated into addiction paradigms that emphasize the inevitability of relapse by reducing choice to acts of compulsion determined by neurophysiological processes in the brain. Addiction is not a disease that can be simply ‘cured,’ and by reducing relapse to biological processes, addiction paradigms frame relapse as a function of forces beyond one’s control, yet firmly within oneself. The cultural prominence and political power of the NIDA paradigm can be most recently attributed to the rise of neuroscience and the Decade of the Brain which paved the way for an emphasis on the “cellular and molecular mechanisms that mediate the transition from occasional, controlled drug use to the loss of behavioral control over drug-seeking and drug-taking that defines chronic addiction” (Netherland, 2012, p. 16). Such narratives of chronic relapse and loss of control limit the potential for self-determinism and recovery, as witnessed by an emphasis on total-abstinence and a disbelief in the ability for ‘addicts’ to return to non-problematic drug use (Keane & Hamill, 2010, p. 54; Leshner, 2001).5
Rather than destigmatizing and demoralizing addition through a neural understanding of addiction as “an anomaly in the dopamine reward system, … neural explanations continue to pathologize drug use and people who use drugs by constructing drugs as agents of disease that inexorably produce brain dysfunction” (Keane & Hamill, 2010, p. 65). Medical paradigms of addiction fixate on neuro-pharmaco-biochemical effects and epidemiological and psychiatric approaches to research and treatment6. These intertwined scientific fields – neuroscience, pharmacology, biochemistry – contribute to reductionist understandings of and treatments for addiction “in which the role of the user [(personality, system of beliefs and values, the personal function of the substance)] and the role of the social setting become underexposed” (Decorte, 2016, p. 37; Morgan & Zimmer, 1997; Reinarman, Murphy, & Waldorf, 1994; Zinberg, 1984).
The current biological trends to understand drug use and construct treatments and therapies through neuropharmacology and genetics – as a means of understanding and predicting risk factors – highlight the reductionist paradigms that frame addiction as a brain disease and direct research, health-care, and policy. Decorte and Cohen highlight the inadequacies and blind spots of neuroscientific paradigms:
Human beings are more complex, more subtle, richer and more incomprehensible than the molecules in our brains … We cannot reduce everything that bears meaning in life (including substances to a user), and the possible problems of the mind or soul, to processes in the human brain. (Decorte, 2016, p. 37)Neuroscientific paradigms fail to acknowledge that “there is little knowledge of how molecular events translate into cellular interactions and ultimately into complex social behaviors” (Netherland, 2012, p. 19). Neuroscientific knowledge does little to highlight the validity of our concepts of addiction (relapse, craving, self-destructive behavior) but rather operates on the basis of assuming rather than exploring the empirical or lived truth of these concepts (P. Cohen, 2009; P. D. A. Cohen, 2000).
Keane and Hamill note how the molecular biological approaches that underlie the neuroscientific paradigm of addiction as a brain disease represents what Nikolas Rose refers to as a scientific shift to a “molecular style of thought” (Keane & Hamill, 2010, p. 52). The neuroscientific paradigms establish “what it is to explain and what there is to explain; it ‘shapes and establishes the very object of explanation’” (Keane & Hamill, 2010). In other words, the neuroscientific or brain disease paradigm of addiction is accepted as fact rather than “belief, ideology, or assertion” (Netherland, 2012, p. 7). Rather than acknowledging the complexity of human beings, this paradigm represents a “molecular style of seeing, thinking, and acting [which] has modified objects such as the brain and the gene so ‘that they appear in a new way, with new properties, and new relations and distinctions with other objects’” (Keane & Hamill, 2010, p. 53; Rose, 2007, p. 12). Nancy D. Campbell in her elaboration on the medicalization and biomedicalization of addiction refers to the work of Jellinek – who ran the Yale Center of Alcohol Studies – who references Immanuel Kant: “A formal definition is one which not only clarifies a concept but at the same time establishes its objective reality” (Jellinek, 1960, p. 35; Netherland, 2012, p. 12). In this regard, we can understand neuroscientific paradigms in the context of power dynamics that shape the ‘truths’ that emerge from empirical science, truths that shape public policy and perceptions.
1.3 - An overall critique of medicalization: non-neuroscientific paradigms and the limitations of medicalization within a context of criminalization
American Studies scholar and licensed psychotherapist Jessica Grogan similarly highlights such a critique as emblematic of the field of psychology –- overall and historically – as shying away from the complexities of the human mind, thereby leaving much left unknown and many false claims of assuredness (Grogan, 2013). Grogan, in her exploration of the Humanistic Psychology movement, notes how reductionist paradigms are fueled by a scientific and political bias towards quantification that are ill equipped “to study people in their totality, seeking to arrive at scientific truths without running away from the full complexity of the human organism” (Grogan, 2013, p. 33). Such an emphasis on quantification is witnessed within pathology-oriented epidemiological models (NIDA paradigm) of addiction that emphasize evidence-based paradigms.
Understanding the pervasiveness of the ideas underlying the shortcomings of dominant addiction paradigms highlights the deeply ingrained paradigms that are at work here. Furthermore, psychology is a particular interesting point of discussion, for mainstream psychology serves as a means of further individualizing addiction through therapeutic treatments. Conceptualizing ‘addiction’ as psychic dependence still emphasizes an understanding of ‘addiction’ and suffering as located primarily within the individual, given the lense of mainstream psychology. In the next chapter (Ch. 2), Buddhism will be discussed for its capacity to center ‘addiction’ in experiences of subjectivity (or psychic dependence), yet through a lense of interconnectedness and a normalizing and destigmatizing understanding of craving and desire.
We can further understand the limitation of medical paradigms – with the NIDA case as the latest iteration –- through the unsuccessful medicalization of addiction within an overarching context of criminalization, the differential applications of medical paradigms, and the disconnect between theory and policy. Keane and Hamill note that, in theory medicalization can promote therapeutic over punitive responses and can assist in the stigmatization and humanization of ‘addicts’:
The formulation of addiction as a chronic and relapsing brain disease certainly suggests that responses to drug problems should be less punitive and more therapeutic than is the norm (see (Kuhar, 2010)). By couching addiction as a medical disorder rather than a moral failing, addicts are refigured as suffering and vulnerable individuals who have a right to humane and effective treatment. Moreover, by proposing that addiction results from an ecologically necessary capacity of the brain to remember and learn from pleasurable experiences, these theories suggest that losing control over consumptive behaviour is not an experience alien to normal human functioning but a side effect of human evolution (Koob, 2006). (Keane & Hamill, 2010, p. 53)“Nevertheless, in the neurochemistry of addiction, the molecular is routinely translated back into the familiar figure of the disordered drug abuser” (Keane & Hamill, 2010, p. 53). The former head of NIDA (the National Institute on Drug Abuse) emphasizes the ‘fundamental and persistent neuroadaptive changes’ of drug use, distinctively marking the habitual use of drugs as universally abnormal. “Leshner’s conception of a person with a substance use disorder as a subject marked by an objective, universal and permanent difference from the normal individual reflects a robust pre-existing discourse of addiction as a moral as well as a biological condition” (Keane & Hamill, 2010, p. 53). Leshner portrays a paradoxical image of people who use drugs in which the initial voluntary consumption of drugs – an intensely morally charged act – is contrasted with neuropharmacological explanations: “the construction of the addict as a physically, psychologically and morally pathological subject coexists with the molecular discourse of neural anomaly” (Keane & Hamill, 2010, p. 53). Although medical discourse is claimed as promoting the destigmatization and depathologization of ‘addicts,’ such efforts do not challenge but rather exist alongside the intense moral atmosphere of drug use. The pathological and immoral portrayals of drug use are rooted in previously discussed secular conceptualizations of the individual as self-steering and autonomous. Furthermore, the overarching criminal culture, which is certainly still the dominant paradigm for addressing drug use, limits the destigmatization and depathologization of ‘addicts.’ Alongside promoting public health perspectives, Leshner also adamantly argues that such approaches “must be combined with continued efforts to control the supply of drugs, which he describes as the agents in the spread of drug abuse” (Keane & Hamill, 2010, p. 54). Paradoxically, the individualization at the heart of our punitive criminal justice system – that Leshner is promoting through supporting the War on Drugs through the criminalization of suppliers – directly undermines potential collective, public health or community psychology approaches to ‘addiction’
Although the NIDA paradigm represents the dominant paradigm within ‘addiction’ studies and is the driving force in policy and research, I also wish to highlight the reductionism of other medical models, particularly those more involved with actual treatment programs such as pain medicine and psychotherapy. Keane and Hamill contrast the limitations of neuroscientific paradigms of ‘addiction’ with the field of pain medicine which promotes a more therapeutic, psychological approach aimed at reducing suffering and addressing destructive behaviors (Keane & Hamill, 2010, p. 53). In the case of opioids, pain management approaches emphasize the “low morbidity (compared with other analgesics), a low addiction potential and an ability to enhance quality of life when used appropriately” (Aronoff, 2000; Keane & Hamill, 2010). Pain management perspectives emphasize the capacity of drug use to enable “normal functioning in the presence of intractable and disabling pain,” thereby seeking to provide a destigmatizing lense for understanding and relating to drug use (Keane & Hamill, 2010, p. 58).
Thus, pain medicine carefully separates the physiological and neural changes of long-term drug use from the psychological condition of ‘true addiction,’ which is characterized by the aberrant behavior, craving and loss of control. In a field where the use of opiates is normalized, identification of the addict is based on a global evaluation of conduct, personality, and past history rather than the process of neuroadaptation.Pain medicine focuses on and accepts the subjective nature of drug use (Seymour, Clark, & Winslow, 2005). The emphasis on psychological manifestation of ‘addiction’ challenges the neurobiological reductionism of brain-based paradigms – which lack a more nuanced understanding of the complexity between neuropharmacological action and psychological manifestation of ‘disorder’ that cannot simply be reduced to the causal forces of neuropharmacology. Furthermore, pain management approaches are supported by findings that demonstrate that “no more than 10 percent of those taking opioids for pain get addicted (it’s less than 1 per cent for those with no history of dependent drug use) and of those who do get addicted, about half quit within four to five years, and almost everyone quits eventually” (Blanco et al., 2013; Lewis & Shelly, 2017; McKenna, 2016; Vowles et al., 2015). Pain management theory emphasizes the differences between physical dependence – seen not as inherently a problem but a very manageable outcome of long-term opioid pain management – and psychological addiction – seen as problematic, self-destructive, and to be treated. (Keane & Hamill, 2010)
Despite these supposed benefits, pain medicine still operates to stigmatize and marginalize ‘addicts.’ Pain management functions to stigmatize and marginalize addiction by separation ‘addiction,’ thereby “[excluding addiction] from moral concern” (Bell & Salmon, 2009; Keane & Hamill, 2010, p. 60).
By defining pain as an experience that has an intrinsic emotional and affective component, pain medicine legitimizes psychological investigation and intervention as part of its practice. However, it avoids the suggestion that emotional distress, anxiety and depression are causes of pain as such claims could easily re-invoke the belief that causes of persistent pain without evidence of organic pathology can be dismissed as imaginary … Although it endorses an understanding of the psychology of pain as necessary for an effective therapeutic response, its object of concern is physical pain. Although recent research on grief, rejection and exclusion suggests that social pain and physical pain operate through common physiological and psychological mechanisms, the realm of emotional hurt is not addressed in standard pain texts (MacDonald & Leary, 2005). Thus, like addiction science, pain medicine has a complex relationship to the binary categories of the physical and the psychological, simultaneously disavowing and relying on the dualist distinction.(Keane & Hamill, 2010, p. 61)We can understand the limitations of pain medicine then, as attempting to address psychological, subjective pain yet remaining committed to an exclusively materialist worldview that rejects the legitimacy of psychological suffering and also fails to acknowledge the material and collective causes of psychological suffering.
1.4 - Depoliticization: neoliberal privatization, colorblind medicine, and a lack of intersectionality
Individualist paradigms – common to Western, secular, medical approaches to ‘addiction’ – obscure collective causes and thereby perpetuate ‘addiction’. To the extent that they recognize the effects of collective causes, they do so in a way that still emphasizes the manifestation of suffering within the individual, stressing the ways in which the individual can navigate these forces rather than challenging the status quo of culture and society. The atomized individual at the heart of our understandings of addiction are inherent to neoliberal conceptualizations, criminal models, and pathology paradigms. The pathologization and even medicalization of substance use firmly locates the basis of illness within the individual, specifically within the brain in the case of the NIDA paradigm. “Contemporary constructions of addiction that locate the causes of addiction pathology within the individual (and often within the individual brain) also reinforce neoliberal ideals about individualism and personal responsibility” (Netherland, 2012, p. xix). Atomized conceptualizations of the individual, rooted in Protestant ideology, persist to this day in the pervasiveness of neoliberalism. Neoliberal paradigms interact with not only conceptualizations of drug use and ‘addiction’, but also exacerbate drug problems themselves.
The pathologization of substance use not only depends upon neoliberal understandings of the individual but also distracts discourse, treatment, and policies away from questioning and challenging the neoliberal structures and ideologies that exacerbate drug problems. “The neoliberal culture underpinning drug policies contributes to the reproduction and worsening of social deprivation and poverty, which themselves are key determinants of the precarious drug user … Personal suffering is politically structured often based on puritanically inspired traditions of righteous individualism that define poverty to be a moral failing of the individual.” (Hunt et al., 2016, p. 10). Medical approaches to ‘addiction’ fail to question the systems of power – such as neoliberal capitalism, white supremacy, or heteropatriarchy – that shape our lives.
We can also witness this decontextualization of suffering in the “hegemonic, White U.S. mental health care system,” which is emblematic of the field of medicine overall. The promotion of individualized and ‘objective’ medical understandings systematically fails to to grapple with the inherent whiteness at the heart of these conceptualizations and medical structures and the effect of intersectional identities on the manifestation and treatment of medical disorders. There exists “long-standing economic barriers to psychological treatments for minorities and a shameful history of the medical establishment subjecting minorities to significant harm as a direct result of medical research participations” (Katz et al., 2006; Michaels, Purdon, Collins, & Williams, 2018, p. 3; Mojtabai et al., 2011; Youman, Drapalski, Stuewig, Bagley, & Tangney, 2010). Scholar Harriet A. Washington has discussed the systematic medical exploitation of Black people as a form of “medical apartheid” (Washington, 2006). Like our white medical structures, the War on Drugs is an inherently racist tactic (Diaz-Cotto, 2005; “Race and the Drug War,” n.d.). Public health approaches to ‘addiction’ not only fail to challenge structures of racism and other identity-related oppressions but also promote the criminalization of drug supply. “Although Black Americans are no more likely than Whites to use illicit drugs, they are 6-10 times more likely to be incarcerated for drug offenses” (Netherland & Hansen, 2017, p. 1). Public health approaches that fail to challenge narratives of choice, especially the ways in which such narratives are differentially applied to white and Black people (‘addiction’ vs. criminalization), uphold systems of oppression and thereby perpetuate the causes of ‘addiction’. Netherland and Hansen articulate the racism inherent to the ‘addiction’ treatment and the surrounding drug policy, highlighting
four ‘technologies of whiteness’ (neuroscience, pharmaceutical technology, legislative innovation, and marketing)” [to understand how the] ‘White drug war’ has carved out a less punitive, clinical realm for Whites their drug use is decriminalized, treated primarily as a biomedical disease, and where their whiteness is preserved, leaving intact more punitive systems that govern the drug use of people of color (Netherland & Hansen, 2017)The decontextualization of medical paradigms of ‘addiction’ can be understood as a tool of white supremacy; in their capacity to decontextualize white ‘addiction’ and treat white people as individuals, biomedical approaches promote an ignorance of the contexts of racism that perpetuate the War on Drugs and deprive people of color of more humane, medical treatment. It is vitally necessary to consider how our models of ‘addiction’ uphold white supremacist, heteropatriarchal systems of oppression that criminalize people of color for their drug use. Although harm-reduction movements promoting public health approaches to addiction are rooted in white privilege – as white people are offered treatment while people of color are criminalized – our approaches to addiction still significantly affect people of color in that they are informed by and perpetuate the same models of individual choice that are used to maintain systems of incarceration. Furthermore, the criminalization of people of color under the War on Drugs only further exacerbates the need for more progressive and intersectional treatments for addiction. As Julia Sudbury notes in Interrupted LIfe: Experiences of Incarcerated Women in the United States:
Because the war on drugs has played such a huge role in the boom in imprisonment, strategies to tackle substance abuse and addiction must play a critical role in any abolitionist vision. The recovery movement, a user-led mental health and addiction movement, offers an important alternative to the criminalization of drug and alcohol abuse. (Sudbury, 2010, p. 22)
Although I highlight the role of race in the criminalization of drug use, I also wish to draw attention to the vital necessity of an intersectional approach that acknowledges people’s multiplicity of identities and the compounding effects of marginalization. Patricia Hill Collins and Sirma Bilge define intersectionality as
a way of understanding and analyzing the complexity in the world, in people, and in human experiences. The events and conditions of social and political life and the self can seldom be understood as shaped by one factor. They are generally shaped by many factors in diverse and mutually influencing ways (Collins & Bilge, 2016, p. 2).Intersectionality emerged as a paradigm for understanding and articulating the ways in which multiple systems of power, such as white supremacy and the patriarchy, act upon people’s lives in ways that cannot be separated – for instance how Black women’s concerns, needs, and narratives are often excluded by the anti-racism efforts led by Black men or the feminist efforts led by white women. For the purposes of this thesis, we can also understand intersectionality as an attempt to grapple with the complexity of lived experience in a manner that stands in stark contrast to medical models.
Medical paradigms of ‘addiction’ lack a systemic critique of the status quo, and instead seek to rehabilitate individuals to fundamentally flawed social structures. The effects of medical paradigms disproportionately affect marginalized groups; the limitations of depoliticization and individualization highlighted throughout this chapter are compounded by intersectional oppressions that limit access to healthcare, trap people of color between medical and criminal structures, and exacerbate suffering (understood as an individualized source of ‘addiction’). The comorbidity of mental illness and addiction should be further highlighted in politicized, contextualized approaches that acknowledge the collective causes of mental illness. Although such discussions are beyond the scope of this paper, critical race, feminist, and other critical approaches have emerged that could serve to contextualize substance use disorders in the lived experiences of intersectional oppression (Parker, 2015; Salter & Adams, 2013). Important to the treatment of ‘addiction’, “the invalidation and avoidance of racial-cultural issues by clinicians has had detrimental consequences on relationships between mental health practitioners and their patients or clients of color” (Michaels et al., 2018, p. 3). Practitioners’ lack of sociocultural sensitivity can actually result in a therapeutic experience that does more harm than good.
1.5 - Social, cultural, and political conceptualizations of ‘addiction’
Social, cultural, and political perspectives engage with alternative conceptualizations of addiction and are highlighted by labelling theory, social models of disability, and socio-somatic and biocultural perspectives. A full discussion of all of these approaches are beyond the scope of this project. The importance of these frameworks lies in their capacity to identify the causes of addiction outside of the individual and to shift away from models of individual pathology to reorient our focuses on social pathology, diagnosing and treating the ways in which society itself is deeply sick and in need of ‘treatment.’ Furthermore, these approaches highlight the power dynamics at play in conceptualizations of and treatments for ‘addiction,’ challenging the objectivity of biological and psychological approaches at the heart of medical models. “In contrast to the brain disease model, historians, sociologists, and anthropologists of addiction have suggested that the classification of certain substances as illicit or licit tells us more about social norms and power relationships than about the psychopharmacological properties of the substances themselves” (Kushner, 2010, p. 8). Social paradigms of drug use affirm that the effects of drug use are highly contingent upon the contexts of their use (such as race and class), rooted in the exploration of what Peter Berger and Thomas Luckmann termed the “social construction of reality” (Berger & Luckmann, 1966; Kaye, n.d., p. 32). Howard Becker pioneered a labelling theory approach termed the symbolic interactionist approach which “suggests that our experiences are fundamentally shaped by the labels we use to identify those experiences and that by shifting the labels we can profoundly shift those experiences” (Kaye, n.d., p. 32). He famously argued his perspective in his essay “Becoming a Marijuana User” which explored the ways in which the experience of a drug’s effects must be learned and is therefore shaped by predispositions that shape such an experience and influence the construction of personal meaning (Becker, 1963).
Thomas Szasz is likely the most famous advocate of social constructivist approaches to psychiatric conditions. His anti-psychiatry theories rejected psychiatric diseases as real and conceptualized ‘crazy’ people as “simply individuals who lived ‘outside the box’ and who were being oppressed by society’s rigid definitions of normality. Psychiatry here appears as a form of social domination, with the label of ‘disease’ acting as a mechanism of normalization’” (Kaye, n.d., p. 33; Szasz, 1961). Szasz’s criticisms question the very nature of maladjustment paradigms of pathologization. Peter Conrad’s work on the medicalization of deviance further highlights how the social construction of addiction is rooted in the pathologizing of non-normative, ‘deviant’ behavior (Conrad, 1975, 1976). .
Although Szasz’s criticism holds great significance in affirming the validity of social construction and labelling theory, questioning the claims and assumptions of the medical model, and challenging the hegemonic, normalizing goals of powerful institutions of medicine, we should resist the “trap of cultural determinism” (in the words of feminist Judith Butler) – just as we reject the reductionism of biological determinism (Butler, 1993, p. x). “Questioning the medical model doesn’t mean mental illness is a myth. Far from it. People’s distress is very real” (Sheikh, 2015). With respect to ‘addiction’ as a mental illness, there is certainly a material basis of the effects of drugs, rooted in neuropharmacology. “The question then, is not whether or not some sort of material reality exists – generally speaking, ‘drugs’ have a different action on the brain than does broccoli – but how to conceive of our relationship, as both symbolic and material creatures, with that reality” (Kaye, n.d., p. 33). I would also add we must conceive of our relationship with reality as creatures with free will and agency – of course, within and affected by infinite and often overwhelming external forces/factors.
Kaye, in his chapter in Critical Perspectives on Addiction titled “De-Medicalizing Addiction: Toward Biocultural Understandings,” highlights the importance of acknowledging the social processes and dynamics of power at play in the social construction of addiction. He refers to Donna Haraway’s understanding that “facts are theory laden, theories are value laden, and values are history laden” and her “material-semiotic” approach which describes the synthesis of the “imaginary and the real” into “facts” (Haraway, 1981, p. 477, 1997; Kaye, n.d.). STS (Science, technology, and society) scholars have come to similar conclusions. “All of these approaches essentially acknowledge that there is such a thing as a real world, but argue that there is no way to say anything about it outside of culture and politics” (Kaye, n.d., p. 34).
Theories of social disability are particularly illuminating when used to further understand conceptualizations of ‘addiction’. The discipline of disability studies is rooted in questions of the medicine and the body and in a commitment to a politicization of these matters. “It is thus not solely the physical condition of the body alone that defines impairment/disability but the interaction of this materiality with a society’s norms and functional demands that create ‘disability’ among those who ‘fail’ in some way or another” (L. J. Davis, 1997; Ingstad & Whyte, 1995; Kaye, n.d., p. 35; Shakespeare, 1998). Gareth Williams, disability theorist, notes that disability is not solely dependent upon or reducible to biology or society but rather is a product of both – an emergent phenomenon that cannot be understood as simply the sum of its parts (G. Williams, 1998). ‘Disability’ provides a framework to understand ‘addiction’ as a failure to conform to societal norms and responses to ‘addiction’ – including medical and criminal policies and interventions – as an attempt to exclude, fix, or punish deviant people. “All diseases and disabilities are thus socio-somatic in that they first arise from tasks and norms established by society, and are only then seen ‘in the body’ in terms of a failure to accomplish those (now taken-for-granted) ideals” (Kaye, n.d., p. 36). The pathologization of ‘addiction’ as a biocultural condition can best understood in the contexts of societal norms and the labelling of deviant behavior.
1.6 - Transition into Buddhism and spirituality
Evaluating the significance of these discussions, we can ask ourselves a few questions moving forward in our explorations of ‘addiction.’ In considering Buddhist, spiritual, and psychedelic approaches to ‘addiction,’ we will explore whether they:
- Challenge us to move beyond – without rejecting – the neurobiological reductionism of the brain-disease paradigm
- Challenge the underlying ideological frameworks – of choice, individualism, materialism, and moralization – and hegemonic, oppressive consequences of medical paradigms more generally
- Incorporate social and cultural perspectives while also providing concrete tools for healing
Buddhism and spirituality as offering the conceptual and practical tools to address ‘addiction’
Buddhist thought and practices can respond to flaws in medical paradigms. Specifically, Buddhist-inspired recovery practices and Buddhist philosophy address the limitations of medical paradigms: individualization, biological/neuroscientific reductionism, and depoliticization. Buddhist approaches/thought offer insight into the subjective experiences of addiction, rooted in craving, suffering, relief, pleasure, and consciousness. This lense of consciousness provides further insight into biocultural paradigms, highlighting the limitations of secular approaches and the need for transcending not only the biocultural divide but also the mystical-material dichotomy. Engaged and political practices of spirituality, rooted in yet not limited to Buddhism, are discussed as vitally and inherently necessary to honor the lived truth of interconnectedness which lies at the heart of Buddhist philosophy. Socially-engaged Buddhist approaches are just one example of how spirituality can address the need to acknowledge both individual and collective suffering, to promote healing at both levels through facilitating awareness. The discussions of Buddhism throughout this chapter are most significantly inspired by the socially-engaged practices of Buddhism taught by Thich Nhat Hanh and discussed in Radical Dharma. I do not claim to be an expert on Buddhism nor do I claim that these discussions of Buddhism are representative of the entire religion.
In response to the questions highlighted at the end of the last chapter, Buddhism is congruent with neuroscience – as demonstrated by the numerous studies exploring the overlap between Buddhist insight into meditation and neurological changes shown through fMRI’s – but emphasizes subjective experience of consciousness that moves beyond the neurobiological and materialist reductionism of brain-based and pain-management paradigms. We can understand Buddhist practices, and spiritual practices more generally, as practices of self-determining liberation that seek to combat deterministic causal relationships with material forces (both external and internal).
Buddhism also challenges the ideological frameworks of medical paradigms: an emphasis on choice, individualism, and moralization. Buddhism emphasizes the interconnected nature of everything without reducing the potential for choice. Buddhism holds the capacity for choice within an understanding of the contexts of collective, external forces that are beyond individual control, thereby combatting the moral weight placed upon the actions of people who use drugs yet also providing the tools (cultivation of mindfulness through meditation) to expand the capacity for choice. Buddhism also promotes an understanding of interconnectedness and non-duality and emphasizes the role of community (sangha) in spiritual practice. Furthermore, the Buddhist concept of lovingkindness as a deep compassionate understanding of oneself and others emerges as an inherent consequence of the recognition of interconnectedness.
Socially-engaged Buddhism combats hegemonic oppression and collective suffering through an incorporation of socio-cultural perspectives, anti-oppression work, and healing practices; Engaged Buddhism, as taught by Buddhist monk Thich Nhat Hanh, emphasizes the need to expand Buddhist practice to include insight outside of the traditional Buddhist canon so as to achieve the ultimate goals of Buddhism, to transform suffering. The Buddhist concept of the Hungry Ghost and the Buddhist emphasis on understanding suffering allow us to shift our pathologization from the individual to society and culture. By expanding our spiritual reach beyond Buddhism, we can look to practices of healing and transformative justice that aim to transform society and culture yet also promote healing in the here and now.
As author, scholar, and activist Ann Cvetkovich notes in her book, Depression: a public feeling, “my own aim is to make conceptual space for accounts of depression that can embrace alternative medicine and healing practices as well as alternative ways of understanding depression (including other vocabularies) as the product of a sick culture” (Cvetkovich, 2012, p. 102). She also notes that spiritual approaches offer “another holistic perspective on feelings as the intersection of mind and body, and nature and culture,” thereby challenging the mystical-material dichotomy. (Cvetkovich, 2012, p. 104).
First, in Section 2.1, I will discuss the interconnectedness at the heart of Buddhism teachings. Then, I will discuss Buddhist-inspired approaches to ‘addiction’ in Section 2.2. Section 2.3 includes core teachings of Buddhism, which I then relate to understanding and treating ‘addiction.’ Section 2.4 discusses the Buddhist practices of Meditation and mindfulness, which are integral to Buddhist-approaches to ‘addiction.’ Section 2.5 discusses the restorative justice implications of the Buddhist recognition of interconnectedness – lovingkindness and non-judgment. I then contextualize Buddhism as situated within practices of community – sangha – in Section 2.6. Section 2.7 includes a discussion of efforts to adapt Buddhism to address the suffering of the contemporary world. Finally, I conclude in Section 2.8 with a discussion of spirituality more generally as a politicized practice of interconnectedness which stands in direct contrast to the depoliticized, individualized practices of medical approaches.
2.1- Interconnectedness and non-duality: emptiness, interbeing, nonself, and interdependent co-arising
My focus on non-duality (non-separateness, interconnectedness) stems from the potential for the dissolution of the illusion of separateness to challenge the hyper-individualization and disconnectedness that I, and many others, find at the heart of our collective suffering and instead promote paradigms of interconnectedness that illuminate paths towards liberation. The interconnectedness of non-dual experiences and practices suggest that spiritual practices and teachings rooted in non-duality have the potential to inspire a sociological imagination and inform and motivate practices of transformative justice.
Thich Nhat Hanh describes our interconnectedness through the Buddhist liberation teaching on emptiness. He notes that “emptiness is not a philosophy, it is a description of reality” (Hanh, Hanh, & Lion’s Roar Staff, 2016). Rather than a metaphysical belief, the Buddhist teaching of emptiness is a grounded and accessible reflection of the nature of reality. Hanh describes interconnectedness with the simple yet profound statement that the entire universe is present within a flower, for a flower cannot exist separate from the forces of the universe that give rise to it.
When we look into a beautiful chrysanthemum, we see that everything in the cosmos is present in that flower – clouds, sunshine, soil, minerals, space, and time. The flower can’t exist by itself alone. The glass, the flower, everything inside us and around us, and we ourselves are only empty of one thing: a separate independent existence. (Hanh et al., 2016).
This Buddhist teaching of emptiness is also known as interbeing, in the sense that all things that exist are in existence together with one another in the fabric of reality and cannot be separated from that fabric. Hanh notes that the nature of emptiness is also called nonself. Nonself does not deny the existence of a self, but rather challenges the notion that this “self” exists as autonomous and separate from everything else that is.
The interconnectedness of all things is further conveyed by the teaching of interdependent co-arising which both describes the causal nature of all things yet also critiques the unidirectional understanding of causal relationships. “According to the teaching of Interdependent Co-Arising, cause and effect co-arise (samutpada) and everything is a result of multiple causes and conditions” (Hanh, 1999, p. 206). I perceive the Buddhist teaching of Interdependent Co-Arising as seeking to understand and communicate the interconnectedness and complexity that is the truth of reality. In this regard, the Buddhist Teaching of Interdependent Co-Arising seems highly resonant with intersectionality as well as the core sociological concept of the sociological imagination and the famous political slogan of 1960s feminists: “the personal is political” (Crow, 2000; Wright Mills, 2001). This resonance will be discussed later on this chapter in an elaboration upon the inherent collective and political implications of a Buddhist understanding of existence as interdependent. Hanh gives this example to illustrate the teaching of interdependent co-arising:
For a table to exist, we need wood, a carpenter, time, skillfulness, and many other causes. And each of these causes needs other causes to be. The wood needs the forest, the sunshine, the rain, and so on. The carpenter needs his parents, breakfast, fresh air, and so on. And each of those things, in turn, has to be brought aby by other conditions. If we continue to look in this way, we’ll see that nothing has been left out. Everything in the cosmos has come together to bring us this table. Looking deeply at the sunshine, the leaves of the tree, and the clouds, we can see the table. The one can be seen in the all, and the all can be seen in the one. One cause is never enough to bring about an effect. A cause must, at the same time, be an effect, and every effect must also be the cause of something else. Cause and effect inter-are.(Nhat Hanh, 1998, pp. 206–207)
The Buddhist teaching of interdependence highlights the interconnectedness of all things, urging us to consider ‘addiction’ as merely one component of infinite phenomena. We are therefore drawn away from fixating on the single phenomenon of ‘addiction,’ but rather compelled to understand the complex web that surrounds ‘addiction.’
2.2 - Buddhism and addiction: cycles of suffering and craving
Beyond challenging the individualization inherent to medical paradigms, Buddhism also offers insight into ‘addiction’ itself. Buddhism can be understood as a practice of suffering, in contrast to a medical model which can be seen as a practice attempting to eliminate suffering. Rather, Buddhism teaches us how to sit with our suffering, how to intimately know and face our suffering. In this regard, Buddhism embodies an inherent curiosity in its approach to addiction, a humanizing curiosity that seeks to understand lived experiences of addiction in personal narratives of suffering. As Buddhist monk Thich Nhat Hanh says:
For forty-five years, the Buddha said, over and over again, “I teach only suffering and the transformation of suffering.” When we recognize and acknowledge our own suffering, the Buddha –- which means the Buddha in us – will look at it, discover what has brought it about, and prescribe a course of action that can transform it into peace, joy, and liberation. Suffering is the means the Buddha used to liberate himself, and it is also the means by which we can become free. (Nhat Hanh, 1998, p. 3)
If you have experienced hunger, you know that having food is a miracle. If you have suffered from the cold, you know the preciousness of warmth. When you have suffered, you know how to appreciate the elements of paradise that are present. (Nhat Hanh, 1998, p. 4)
Hanh’s description of Buddhism, as practices of suffering and joy, relates directly to the Buddhist-inspired approach to addiction Refuge Recovery7 which notes that recovery entails finding “healthy ways to enjoy life” and recovering from the suffering of ‘addiction’ and learning “to appreciate and enjoy the simple joys of sobriety” (Levine, 2014a, p. 14). Although Refuge Recovery advocates total abstinence, I believe that Buddhist approaches to ‘addiction’ offer space for non-normative recovery routes in which recovery is framed more so in terms of one’s psychological relationship to craving and drug use, rather than only in terms of drug use vs. abstinence. Buddhism’s emphasis on holding space for the negativity in life as significant opportunities for learning, growth, and reflection further challenge the notion put forth by medical models of the totality of relapse as failure rather than as potentially a step along one’s spiritual path.
The work of Buddhist monk Thich Nhat Hanh provides us with distillations of essential Buddhist teachings that prove useful in reconceptualizing addiction outside of medical paradigms. Refuge Recovery interprets struggles with ‘addiction’ as responses to suffering fueled by cycles of craving. Yet, importantly it is not “craving itself that’s the problem. [Craving] is just a natural phenomenon of the conditioned heart-mind. No, the problem lies in our addiction to satisfying the Craving. We all experience craving” (Levine, 2014a, p. 94). Medical paradigms fixate upon eliminating or only addressing the addicts experience of craving without developing an in depth understanding of what craving means in the context of our experiences of consciousness and suffering.
Of concern to the person who use drugs is not craving itself but their relationship to craving. Buddhism teaches us to be honest (and non-judgmental) with ourselves about our craving, and then teaches us skills to navigate our urges through our meditation practice, through observation, through the development and practice of awareness. Furthermore, by centering a Buddhist understanding of craving and suffering at the center of addiction, these approaches achieve greater strides in achieving the destigmatizing goals of medicalization. “We all experience craving. When we have a pleasant experience we crave more of it – we wish for it to increase or at least to last. When we have an unpleasant experience, we crave for it to go away. We feel the need to escape from pain, to destroy it and to replace it with pleasure ”(Levine, 2014a, p. 94). Buddhist understandings of addiction as rooted in a universal human propensity for craving are also supported by the recent expansion of addiction studies into gambling, food, sex, and video games. Understanding ‘addiction’ as rooted in consciousness further highlights the reductionist flaws of the brain disease paradigm which emphasizes the neuropharmacological action of drugs and subsequent neurological changes as the primary causal factors, designating the subsequent subjective experiences and our relationship to these experiences as secondary considerations, if at all.
To understand and develop this relationship one must understand the object of craving and the root of that craving: suffering. In the words of Ram Dass, “in meditation we can watch the itch instead of scratching it.” Importantly, Buddhism is not only a practice in suffering but also a practice in joy and pleasure. “It is true that the Buddha taught the truth of suffering, but he also taught the truth of ‘dwelling happily in things as they are’ (drishta dharma sukha viharin)” (Hanh, 1999, p. 22). Buddhism also teaches us how to resist grasping onto pleasurable, positive experiences, how to simply be present in them without developing an unhealthy relationship to them. The teachings of Buddhism and the practices of mindfulness and loving kindness offer us the conceptual and practical tools for addressing our capacities for addiction.
2.3 - Core teachings of Buddhism: The middle way, the four noble truths and the eightfold path
Thich Nhat Hanh describes three original or core teachings of the Buddha as encompassed within the sutra on the Discourse on Turning the Wheel of Dharma. The first teaching is that of the Middle Way
The Buddha wanted his five friends to be free from the idea that austerity is the only correct practice. He had learned firsthand that if you destroy your health, you have no energy left to realize the path. The other extreme to be avoided, he said, is indulgence in sensual pleasures – being possessed by sexual desire, running after fame, eating immoderately, sleeping too much, or chasing after possessions. (Nhat Hanh, 1998, p. 7)I find that the Buddhist teachings of mindfulness and the Middle Way highlight a paradox of drug use. Buddhism emphasizes mindful appreciation of the present, for the present moment is all our lives will ever be. Drug highs and intoxication can paradoxically be an impetus to focus on the present moment, in a myriad of different and complex ways. Yet, ‘addiction’ can be a painful struggle that removes one away from mindful appreciation of the present through craving and suffering. The Buddhist teaching of Middle Way, in my opinion, challenges total abstinence approaches as the only valid approaches by highlighting the potential for healthy relationships with pleasurable experiences as a middle path. I do not mean to reject total abstinence approaches, for they certainly are beneficial and appropriate for some, but rather highlight the validity of other approaches, particularly in the context of the failures of total-abstinence approaches for many people in recovery. Although Buddhist teachings, specifically the Fifth Precept, emphasize sobriety, a Tibetan Buddhist nun – who has been practicing for decades under the guidance of Venerable Khenpo Kalsan Gyaltsen at the Tsechen Kunchab Ling, the seat of His Holiness the Sakya Trizin, third in the Tibet Buddhist hierarchy (which is led by the Dalai Lama) – recently told me that such directives are mostly intended for those engaged in Buddhist monastic life and that Buddhism as a spiritual practice has different applications for lay people. Nuanced perspectives on the Fifth Precept are also expressed in Zig Zag Zen in relation to Buddhist practice and the use of psychedelic drugs (Badiner & Grey, 2015). The Fifth Precept can be understood as emphasizing abstinence specifically from drugs that disrupt one spiritual journey, yet certain drugs – such as psychedelics – can be seen as congruent with such a path. Moving beyond the Middle Path, Thich Nhat Hanh introduces us to the core Buddhist teachings of suffering and liberation.
The second teaching is that of the Four Noble Truths, not only a teaching but also a practice of suffering.
The First Noble Truth is suffering (dukkha). We all suffer to some extent. We have some malaise in our body and our mind. We have to recognize and acknowledge the presence of suffering and touch it. To do so, we may need the help of a teacher and a Sangha, friends in the practice.
The Second Noble Truth is the origin, roots, nature, creation, or arising (samudaya) of suffering. After we touch our suffering, we need to look deeply into it to see how it came to be. We need to recognize and identify the spiritual and material foods we have ingested that are causing us to suffer.
The Third Noble Truth is the cessation (nirodha) of creating suffering by refraining from doing the things that make us suffer. The Third Truth is that healing is possible.
The Fourth Noble Truth is the path (marga) that leads to refraining from doing the things that cause us to suffer. The Buddha called it the Noble Eightfold Path. (Nhat Hanh, 1998, pp. 9–11)
The Four Noble Truths of Buddhism highlight the universality of suffering. Thich Nhat Hanh notes two common misunderstandings or misinterpretations of the Buddha’s teachings on suffering: the notion that Buddhism teaches that all life is suffering or the claim that all of our suffering is caused by craving. “The Buddha taught us how to recognize and acknowledge the presence of suffering, but he also taught the cessation of suffering. If there were no possibility of cessation, what is the use of practicing?” (Hanh, 1999, p. 11). Far from an esoteric tradition aimed at transcending the body and rejecting the material world, Buddhism is a deeply grounded practice that is engaged with the very real healing and suffering in the here and now. Furthermore, Buddhism recognizes the myriad roots of suffering, not just craving but also “anger, ignorance, suspicion, arrogance, and wrong views” (Hanh, 1999, p. 21). We must move beyond understanding ‘addiction’ as merely resulting from the craving to escape from suffering but also understand the many other roots of suffering.
The third teaching of the Buddha is one of active engagement with the world, known as the Eightfold Path. “The teachings of the Buddha were not to escape from life, but to help us relate to ourselves and the world as thoroughly as possible” (Hanh, 1999, p. 8). Buddhist approaches to suffering and addiction are inextricably intertwined within a social justice context, for Buddhism seeks to not only recognize the sources of suffering and the potential for liberation within ourselves (our minds, our consciousness) but also within the world. The Eightfold Path includes Right View, Right Thinking, Right Mindfulness, Right Speech, Right Diligence, Right Concentration, and Right Livelihood. (Nhat Hanh, 1998)
The Four Noble Truths of Buddhism and the accompanying practices of the Eightfold Path seem quite resonant with modern psychotherapeutic methods of inquiry into the root of suffering, such as therapeutic treatments for addiction. Despite many parallels and points of agreement, Buddhism differs in a few regards. First, Buddhism recognizes the capacity for suffering and craving as inherent in all people8, thereby challenging the pathologizing or maladjustment paradigms of medicine. Buddhism sees the potential for addiction in all of us, as rooted in the universality of suffering, and thereby blurs the lines between “addict” and “non-addict.” Furthermore, Buddhism stresses that one practice the Four Noble Truths and commit to the Eightfold Path in community with a sangha, challenging the individualized modes of care common to medicine. Buddhism as a source of community and in relation to community psychology will be discussed later on in comparison with the Oxford House approach to addressing ‘addiction.’ Finally, The Eightfold Path is an ethical path of engagement. Buddhism is not healing for the sake of isolated refuge or blissful escape. For instance, Engaged Buddhism and the tradition of Radical Dharma acknowledge that the path to liberation from one’s own suffering is intertwined within collective systems and cycles and thereby stresses one’s own liberation in the context of engaging with the world (Hanh, Hanh, & Lion’s Roar Staff, 2017; A. K. Williams et al., 2016).