A Human Model for Substance Use and Abuse

I would like to talk today about models for substance use and abuse and start by saying that our theoretical models are not the world. An architect’s model of the Empire State Building is not only not the Empire State Building, it is not a building at all.  While many models clearly have utility, the utility does not offer itself because the model is, or describes, the truth.

Over the past thirty years, substance use and abuse have usually been described by one or a combination of three models: the epidemiological model, the social model, and the medical model.   All three models, in some contexts and for some purposes, can provide useful insight.  Epidemiology can give us indications of the who, what, where,and when and in what kinds of probable numbers.  Social models can, as one example, describe peer group dynamics that influence patterns of substance use.  The medical model – which is largely a disease, addiction, or pathology model – can describe some of the physiological or neurophysiological mechanisms of some kinds of substance use.

In my experience as a clinical psychologist all three models have only limited utility in helping people understand the human purposes and meanings of their substance use, and only limited utility in helping people change in important ways.  The epidemiological model may identify “high risk” groups, but people don’t actually do things because they are members of an epidemiologically-conceived group.  Epidemiology can talk only of associations, not causes and we do not know, as one example, if gay men have unprotected sex because they use crystal; if gay men use crystal to allow themselves otherwise forbidden unprotected sex; or if certain gay men both use crystal and have unprotected sex for other, unknown reasons – depression being one obvious example.  Social models suffer from some of the methodological limitations of epidemiology and are usually disciplinarily limited to a description of interpersonal, as opposed to intrapsychic issues.

The third of these models – the medical, disease, or addiction model – is the one I will focus on for the remainder of my talk.  Over the past thirty or so years, the medical model has become the premier model used to think about and address substance use and abuse.

Alcohol was the first substance to which a medical model became widely applied.  In the medical model’s description of alcoholism, the alcoholic is predisposed to alcohol abuse for – possibly genetically determined – physiological or neurophysiological reasons.  The disease is thus the predisposition to abuse, the famous “inability to stop after one or two drinks.”  As applied to alcoholism (and many other substances), the medical model also posits the somewhat separate idea of addiction . In a condition of addiction – to which we are predisposed by disease – the individual continues to use a substance to satisfy the physical cravings that are the hallmark of withdrawal from addiction.

Whether alcoholism is a disease in the conventional medical sense of the idea is questionable to me, but a discussion beyond the scope of this talk.  In any case, the utility of the model for specific purposes should probably decide that question.

The matter of addiction is somewhat clearer.  Addiction is a verifiable physiological process in which there is cellular adaptation to the ongoing presence of a substance; increased tolerance due to the cellular adaptation; the need for increased dosing to offset tolerance and maintain a given clinical effect; and cellular re adaptation – the withdrawal syndrome – on discontinuation of the substance.  The alcoholic or opiate user who maintains a fairly consistent substance blood level is addicted.  The binge drinker is not addicted.  And neither are the weekend crystal user, the E or K user, the sexual compulsive or the compulsive shopper.

The medical model has accomplished some important things: It has detached moral stigma from substance use – particularly the stigma of “weak character” – and it has given rise to some effective interventions that pragmatically curb or stop the abuse itself.   What the model has not done well – what it has often obstructed – is to help clarify why people use substances.  Disease in the true medical sense does not need reasons and does not have meaning in itself.  It is a physical pathology.  We do not or should not speak of the purposes of a virus in the sense of humanpurposes.  But substance use is not only a biological process, it is something that people do and something that they subjectively experience.  Because that is the case, I would like to talk about why people might do that, what their purposes and motivations – conscious and unconscious – might be in doing that, about what the human meanings of substance use might be.

As a psychologist who daily listens to gay men explicate their feelings, I am uncomfortable with the medical model’s removal of human meanings from substance use. When people do things – particularly impairing, destructive things like “careers” in crystal – it is obvious to me that there is meaning in the behavior.  An exclusive medical model to explain such behavior is a scientific reductionism that is increasingly common in our explanations of human life.  One scientific reductionism tells us that human life – including our subjective experience of consciousness – is truly nothing more than a series of biochemical events.  While true in the description of one model – that of the microbiologist – this description cannot mean that we are simply to dismiss the significance of subjective human consciousness.  Our mental lives – our thoughts, joy, and pain, or our thrill at the smell and touch of another human body – are not to be simply dismissed in the face of a microbiologist’s explanation.

If I insist that the medical model for substance use too easily eclipses the issues of meaning, what is the important meaning in drinking oneself into a stupor every evening?  Part of the answer is obvious:   We use substances to alter our consciousness, to change the way we feel .  We do that because our unaltered consciousness is too boring, too painful, too anxious, too limiting, or too isolating.  To the point of LGBT communities in 2002 – now centuries into a hateful and destructive social experience and two decades into a juggernaut of an epidemic – we both use and abuse substances because we too often feel depressed, anxious, unlovable, unloved, isolated, or alone.  As I pointed out to an astonished 28 year old psychotherapy patient who was, yet again, expressing remorse and bewilderment over his crystal use, “John, for three years you haven’t felt desirable enough to even leave your apartment on the weekend unless you were high.”

As painful as it is to acknowledge the situation of this man and thousands like him, are not some of the meanings of crystal in our lives obvious ?  Do we really not understand the substantial benefits John got from crystal?  Does the idea of addiction, disease, or simple pathology adequately describe what was going on here?   In therapy, it became clear that crystal allowed John a much more positive experience of himself and thus a connection with other men that was both essential and, without crystal, impossible for him.  In this understanding, his use of crystal was an adaptive response to emotional conflicts and limitations that he did not otherwise know how to address or resolve.  With crystal, he could emerge from an excruciating isolation and make desperately needed sexual and emotional connections with other men.

Before I continue with what may now appear an unbridled enthusiasm for the benefits of crystal, let me acknowledge the other side of the obvious:  The abuse of many substances – crystal not least among them – can, itself, grow into a substantial and crippling problem, and one that creates extremely destructive – so-called “secondary” – consequences.  It can also  become the means to avoiding any insight about anything.  It is not only the medical-model people who recognize these serious problems.  John, and most serious users, are well aware in moments of relaxed denial that they suffer negative consequences of use.  As with a majority of users, one of the most difficult problems working with John was having him acknowledge the benefits he derived from crystal.  Because of his own negative experiences with the drug – and particularly because of his assumptions about other’s expectations – he was very inclined to talk about crystal as if it were nothing more than an involuntary, addictive phenomenon that he would sooner be rid of.  How do we understand this man – having arrived at an adaptive, if deeply flawed, solution to his haunting loneliness – insisting upon the idea that the whole thing was meaningless?

If crystal provided John occasional, brief – and often unsatisfactory – respite from his depression and loneliness, it was not because he had developed insight about his self-esteem issues and interpersonal isolation and prescribed himself an antidepressant.  It was the very point of his crystal use to not experience such feelings, feelings most powerfully conscious during attempted – often aborted – connections to others.   Thus – and this is the crux of what I want to say – to acknowledge the meanings of his crystal use meant looking at the very feelings John used crystal to try and bury below conscious awareness.  Acknowledging that crystal helped him feel desirable and able to connect with others meant acknowledging his more usual feelings of being fundamentally un desirable and his feelings of almost unbearable isolation.  Here is the real danger of reductionistic models for substance use:  They too easily collude with the very process they purport to interrupt and “cure.”

So, this is my plea:  That we not simply settle for “clean and sober” if that means we do not examine the feelingsthat motivated us to get high in the first place.  As a psychotherapist, I have only occasionally felt the need to refuse someone for therapy because he was currently using.  Substance use, like any other mental or behavioral defense against psychological pain, is a perfectly appropriate matter for psychotherapeutic clarification and interpretation.  It is true that people often come into psychotherapy in hopes that the process will somehow allow them to avoid the substance issue.   People do that with all their defenses.  Certainly people do not come into therapy to give up the very things that protect them from pain or allow them connections with others.  So there is no point in jumping in at the beginning and trying to take those things away.

If the medical model has rightly extricated substance abuse from destructive moral stigma about things like “weak character,” the idea that the “disease” might express emotional needs often feels as if it pushes the substance issue right back into the province of moral issues.  Physical distress is still much more acceptable than emotional distress. Disease is still much more acceptable than feelings, and among gay men with HIV and AIDS, we have seen an acceptance by family, society, and Elizabeth Taylor that was never extended when we were merely homosexual – and often suffering quite badly in psychological ways for that.   If substance abuse is about feelings, then human complexities are reintroduced into a discussion that we hoped could be as “simple” – which is also to say as meaningless – as a broken leg.  Well, human life is about feelings. Those of us working with problematic substance use must help clarify the meanings in human life rather than dismiss them with a scientific reductionism that pursues often relatively empty behavioral change and easy social approbation.

There is a popular idea that a meaning-based, interpretive approach does not work.  This is expressed in the detox-first-and-I’ll-talk-to-you-in-six-months model.  In fact, the approach works all the time, and there are good reasons to let it work.  Our ultimate purpose in attempting to help others is not simply to stop a particular behavior. Our purpose is not to transform compulsive substance use into compulsive abstinence.  Our purpose is, or should be, to clarify the experience motivating the abuse, to understand the compulsivity, and by doing that to have the abuse – over time – become superfluous.  It is only by understanding the meanings of our substance use that we can understand the possibility of life without it.  This is the clarification that brings about real change and that helps a person find his or her sober authenticity.  It is in finding that authenticity that we find lives that feel like our own and feel reasonably fulfilling.

I would like to close with one additional thought about the medical model and its invocation in LGBT lives.  We have not only used the model to demonstrate that our substance use is without meaning.  We now invoke the model – in the form of genetic or inutero explanations – to explain why we are who we are.  I would like to offer the possibility of keeping the meaning in being lesbian, gay, bisexual, or transgendered by asserting that we have every right to be who we are – not because it’s not a choice and we can’t help it – but because we want to be who we are.  That’s the beginning of an understanding that will assist authentic self-respect and help make substance use – and especially abuse – much less a part of our lives.