Incompatible Knots in Harm Reduction: Part 2 (Collectivism)

Harm reduction proponents often profess that their approach has ‘roots in humanitarianism and libertarianism’ (Newcombe 1992: 1), which place primary emphasis on individual liberty and individualism, yet there is also a tendency by many of them to adhere to social justice ideology (Pauly 2008; Friedman 1998; Graham 2014) which inherently favours collectivist values and epistemology. For example, groups like the Harm Reduction Coalition identify as a ‘movement for social justice’ (Greig & Kershnar 2002: 365). Social justice can be defined a position that aims for the eradication of all forms of social oppression, inequality and, frequently, for one form or other of economic redistribution (Feagin 2001). A harm reduction approach that is informed both by a collectivist value of a social justice orientation and the individualist values of libertarianism can become internally inconsistent.

There can be detrimental consequences when harm reduction policies are geared towards collectivist instead of individualist aims. The influence of social justice activists has moved the aim of harm reduction away from helping the individual towards that of the ‘common good’. Mugford (1993) points to the self-contradictory nature of harm reduction’s adherence to its utilitarianism (informed by collectivist values, through which Draconian anti-Drug strategies have been defended) and its liberal values (based on humanistic and libertarian perspectives, the protection of civil liberties and human rights). Miller’s (2001) view is that the primary impulses of harm reduction programmes have not been out of concern for the individual drug user, but rather for the benefit or protection of the ‘general public’ and the reduction of health care costs. Indeed, for some harm reduction organisations and activist groups, syringe exchange is merely a means to an end, a political activity and not a value-neutral healthcare intervention. In extreme cases, harm reduction threatens to become a ‘holy cause’, a kind of mirror to the moral righteousness behind the politics driving the ‘war against drugs’. As Eric Hoffer, author of The True Believer (1951) reminds us

The burning conviction that we have a holy duty toward others is often a way of attaching our drowning selves to a passing raft. What looks like giving a hand is often a holding on for dear life. Take away our holy duties and you leave our lives puny and meaningless. There is no doubt that in exchanging a self-centred for a selfless life we gain enormously in self-esteem. The vanity of the selfless, even those who practice utmost humility, is boundless (p. 23).

The bias of an overly collectivist approach to addiction is also exemplified in research, where nearly all attention has focused on indicators of change that are observable and socially desirable (e.g., abstaining from drugs, avoiding criminal activity, gainful employment). It frequently neglects other, more functional, indicators (e.g. quality of life, satisfaction with treatment) that bear more importance to drug users themselves (Fischer et al 2001). And, perhaps most crucially, rarely have studies explored the congruence of these outcomes with the perspectives of drug users (Fischer et al 2001). The currently available instruments (e.g. the generic Nottingham Health Profile) were developed for and by professionals without input from drug users or their families and caregivers (Fischer et al 2001). Their viewpoints are notably missing from the literature (Drumm et al 2003). According to Saleebey (1996: 301) oppressed or marginalised populations typically have ‘[their] stories buried under the forces of ignorance and stereotype.’ In the context of this essay, I would argue that drug users often have ‘their stories buried under the forces of ignorance and stereotype’ (Saleebey, 1996: 301) of collectivist thinking.

Harm reduction approaches should not be driven by political agendas, and we do not need more ‘true believers’. Social justice activism is a political project and not an evidence-based scientific activity, and it is concerning how social justice-orientated harm reduction proponents assume the self-evident truth of this position, considering the complex philosophical or political debates and critiques that underpin collectivist ideology (see Strang 1993, Psychoactive drugs and harm reduction: From faith to science). Instead, we require the perspectives of people who identify as addicts, empirical research, clinical experience, concern for drug users as individuals and pragmatic health aims.

References to be found in: Du Plessis, G. P. (in Press) Some Incompatible Knots in Harm Reduction, in Let’s Talk About Opioids and Harm Reduction in South Africa. HSRC Press (Edited Volume).

Incompatible Knots in Harm Reduction: Part 1 (Relativism)

Since the introduction of the harm reduction paradigm in the 1980s, it has almost universally been presented as the ‘self-evidently correct’ and ‘rational’ approach to the problems associated with drug use (Erickson 1995; Weatherburn 2009; Single 1995; Roe 2005). It frequently pits itself against recovery orientated paradigms, characterising them as punitive, narrow in perspective and ‘rooted in punitive law enforcement models and in medical and religious paternalism’ (Newcombe 1992: 1), or as undermining the freedom, dignity or positive self-image of individuals with substance use disorders (Ezard 2001; Zajdow 2005). Instead, harm reduction is often presented as a humane, value-neutral, pragmatic, and scientific alternative, and is, thus, often accepted uncritically as an obvious and unqualified good (Souleymanov & Allman 2016; Marlatt 1998).

Yet, harm reduction proponents are frequently ill-informed of some of the social and ontological assumptions that underlie their concepts. When these assumptions are accepted as ‘self-evident’, harm reduction can become beleaguered with internal inconsistencies and uncertainties in its core goal (Mugford 1993; Weatherburn 2009; Keane 2003). An internally contradictory position within harm reduction theory and practice can create a ‘double bind’, that results in what existential psychiatrist R. D. Laing (1960) refers to as an ‘incompatible knot’.

In the follow three blog posts, informed by critical hermeneutics (Roberge 2011; Ricoeur 1981, 1986; Gadamer 1975), I provide a brief critical evaluation of some of the foundational suppositions that often underlie harm reduction theories and interventions. I deliberately take on the ‘strong’ versions of these suppositions in order better to reveal what I consider to be at stake. I will limit my focus to three theoretical orientations (or ‘-isms’), often advanced by harm reduction proponents, which contribute to its ‘incompatible knots’. These are: 1) relativism, which leads to conflation of drug use and addiction as concepts and to conflation of ‘drugs’ in general; 2) collectivism, which prioritizes the common good over that of the individual; and 3) determinism, which represents people with addiction as victims with limited agency.

Relativism
It is common for harm reduction proponents to conflate the behaviour of drug use and the condition of addiction (Davies 1997; Peralta & Jauk 2011), and to minimize the distinctions between medications commonly prescribed by the health care system and those (such as the opioids) that are diverted into non-medical economies for their intoxicant and dependency-producing properties. I will make a distinction between ‘categorical conflation’ and ‘continuum conflation’. Categorical conflation (which will be my focus here) can be considered as denying any categorical difference between drug use and addiction, whereas continuum conflation acknowledges some differences but assigns enough similarity to place it on an ontological continuum (The DSM-5’s (APA 2013) sub-categories of substance use disorders as mild, moderate or severe runs a risk of continuum conflation). I argue that both these types of conflation of drug use and addiction are serious conceptual errors that lead to deleterious consequences for the design and sustainability of harm reduction policy.

Comparing drug use to addiction is like ‘comparing apples and oranges’. Drug use and addiction are distinct phenomena and harm reduction interventions for drug use and addiction should be fundamentally different. Makings claims whether drug use is good or bad is a normative statement and stating whether someone is an addict or not (and how to treat it) is a descriptive or positive statement. This is similar argument to Hume’s law which states that we cannot derive normative statements (how we ought to act) from descriptive statements (what is) because there is a fundamental difference between how we should act morally and how the world factually is (Hume 1739). Addiction is not morally good or bad, it just is – it is a scientific concept, whether it is present or not is a descriptive/positive statement. Normative conflation of drug use and addiction returns us to a moral model of addiction (Pickard et al. 2015). This model applied a normative orientation to both drug use and addiction and concluded that both are moral failings and should be judged and treated accordingly (Mugford & Cohen, 1988). ‘The parallel would be with theorising alcohol usage in general on the basis of what is known about institutionalised alcoholics’ (Mugford & OMally 1999: 27)

One of the primary reasons that many harm reduction proponents conflate drug use and addiction is because they tend to have a have a relativist view of drug use and addiction, influenced by radical social constructionist perspectives (Dingelstad et al 1996; Davies 1997). ‘Strong’ social constructionism as a philosophical approach tends to suggest that “the natural world has a small or non-existent role in the construction of scientific knowledge’ (Collins 1981: 3). Applied here, it proposes that addiction exists as a dominant and historically produced narrative, which would cease to exist if we thought, wrote and spoke about it differently (Davies 1997). Weak social constructionism proposes that many of the concepts and approaches to addiction are socially constructed but concedes that there is an underlying reality to some of them, and is perhaps best defined as epistemological pluralism. Proponents of a social constructionist position call addiction a ‘myth’, a phenomenon that does not really ‘exist’ outside our collective perception and even that ‘drugs’ are social constructions (Davies 1997; Hammersley & Reid 2002). Jacque Derrida (1995), for example, concluded that ‘the concept of drugs is a non-scientific concept, that it is instituted on the basis of moral or political evaluations: it carries in itself norm or prohibition, and allows no possibility of description or certification…’ (p. 229). While (as other contributors to this volume have discussed) the concept of ‘drug’ carries ambiguities and social meanings that impact policy, the differing chemical nature of psychoactive substances and their potential bioactive consequences on a body and psyche must be recognised and respected.

Although there is a cornucopia of perspectives on addiction which makes a unified understanding a challenging prospect, it is nonetheless erroneous to deny the ontological realities of drug use and addiction through adopting an position of relativism. There are certainly ways to maintain epistemological plurality while not holding to a strictly realistic metaphysics. Adopting a form of critical or pragmatic realism (Harre & Moghaddam 2012; Bhaskar 1997) conceptualises addiction without submitting to judgemental relativism (giving equal voice or weight to multiple theories or interpretations). In the trenches of the therapist working with addicted populations, and parents who have addicted children, a radically relativist perspective of addiction has little value and purchase, and can even be harmful.

References to be found in: Du Plessis, G. P. (in Press) Some Incompatible Knots in Harm Reduction, in Let’s Talk About Opioids and Harm Reduction in South Africa. HSRC Press (Edited Volume).

Archaic Narcissism, Ideology Addiction and Political Ideology

In previous blog posts I have proposed that ideologies are psychoactive and potentially addictive. I suggested that ‘ideology addiction’ can be understood as a type of ideological possession and zealotry, with deleterious consequences for the individual and society. An individual in the grips of an ideology addiction exhibits psychological and behavioral patterns common to all addicted populations (It must be noted that I am not proposing that all individuals that adhere to an ideological system are ‘ideologically possessed’, but instead am referring to an extreme position of ideological belief).

From a psychodynamic perspective, ideology addiction can be understood as the result of a narcissistic disturbance of self experience and deficits in self capabilities. Simply put, ideology addiction can be understood as a pathological relationship with an ideology that provides a misguided solution to narcissistic injury and shame. Consequently, the activism of an ideology addict is fundamentally a narcissistic project. A misguided attempt at self repair and satisfaction of archaic narcissistic needs, and seldom motivated by the ideals of the ideology. From a self psychology perspective, narcissistic injury can lead to porous or scant psychic structure that is in constant threat of psychic fragmentation or annihilation. The individual with narcissistic injury often seeks self-objects that provide psychic scaffolding (Kohut, 1977). Ideology can be understood as a self-object that provides much needed psychic structure for such individuals, and transports them in a transmogrified fantasy world. The individual who is ideologically possessed is a “narcissist in wonderland” under the influence of “intoxicating fantasies” (Ulman & Paul, 2000) that presents a danger to him or herself and society.

In the context of the extreme political ideologies I will argue that there is narcissistic transference (Idealized, Mirroring and Twinship Transference) at play as a causal factor in determining an individual’s choice of extreme political positions. For example although extreme ‘left’ political ideologies, like Communism, and extreme ‘right’ political ideologies, like National Socialism, presents itself conceptually as two opposing ideological positions, from a psychological perspective I will argue that the logical and conceptual content of these ideological positions are superfluous, as the psychological dynamics that motivates both its adherents are similar. At the roots lies a form or archaic narcissism that leads to the mode-of-being of “ressentiment” (in the Nietzschean sense) and a yearning for a future utopia, and what distinguishes the extreme left from the extreme right is the type of narcissistic transference each applies to sooth their unstable inner worlds.

There are many typological perspectives that can be applied in the context of addiction. One example is that of feminine and masculine types. “When we speak of ‘masculine’ and ‘feminine’ we are not necessarily speaking of biological ‘male’ or ‘female’, but rather referring to a spectrum of attitudes, behaviors, and cognitive styles. I have proposed that psychoactive substances can be classified according to a masculine or feminine typology (Du Plessis, 2018). Depressants or downers such as tranquilizers, and heroin can be classified as ‘feminine psychoactive substances’. And stimulants or uppers such as cocaine and methamphetamine can be classified as ‘masculine psychoactive substances’ (Du Plessis, 2010, 2012a).

I will argue that that extreme left and right political ideologies can also be classified according to a similar typological continuum. For example on the one side of the continuum we have extreme the extreme left wing ideology of Communism on the one side and on the other side we have extreme right wing ideology of National Socialism. Although they represent two extreme poles on the political spectrum, there are more similarities than differences. As Sir Rodger Scruton (2016) states in his book Fools, Frauds and Firebrands that “the public ideology of communism is one of equality and emancipation, while that of fascism [for example National Socialism] emphasizes distinction and triumph. But the two systems resemble each other in all other aspects…” (p. 200). I will classify extreme left ideologies like communist as a ‘pathological feminine ideology’ of “equality and emancipation” and extreme right ideologies like fascism as a ‘pathological masculine ideology’ of “distinction and triumph”. Like Scruton (2016) I will argue that there is a “deep structural similarity between communism and fascism, both as theory and as practice” and to think otherwise “is to betray the most superficial understanding of modern history…Communism, like fascism, involved the attempt to create a mass popular movement and a state bound together under the rule of a single party, in which there will be total cohesion around a common goal…Both aimed to achieve a new kind of social order, unmediated by institutions, displaying an immediate and fraternal cohesiveness (p. 200–201).

To elucidate a typology perspective of substance use disorders and ideology addiction I will apply the bioself-psychological typology of addiction of Ulman and Paul (2006). Kohut, (as cited in Ulman and Paul, 2006) stated: “The self should be conceptualized as a lifelong arc linking two polar sets of experiences: on one side, a pole of ambitions related to the original grandiosity [feminine] as it was affirmed by the mirroring self-object, more often the mother; on the other side, a pole of idealizations [masculine], the person’s realized goals, which, particularly in the boy though not always, are laid down from the original relationship to the self-object that is represented by the father and his greatness” (p. 30). In Ulman and Paul’s bioself-psychological typology, addiction is understood as a psychological end result of developmental arrest in the bipolarity of the formation of the self. Biological psychiatrists, in their conception of bipolar spectrum disorder, devote considerable attention to depression and mania as they manifest in this disorder. These mood disorders correlate with disorders of the bipolar self as understood by Kohut. He stated, “In general, a disturbance in the pole of grandiosity [feminine] may find expression in either an empty, depleted depression or, in contrast, in over-expansive and over-exuberant mania or hypomania; whereas a disturbance in the pole of omnipotence [masculine] may appear in either depressive disillusionment and disappointment in the idealized or, in contrast, in manic (or hypomanic) delusions of superhuman physical and/or mental powers. We maintain that an individual maybe subject to specific outcomes resulting from a disturbance in either or both of these poles of the self” (in Ulman & Paul, pp. 395–396). Owing to the specific accompanying mood disorder of each of the possible disturbances of the poles of the self, individuals will be attracted to certain psychoactive substances and ideologies, which can be understood as an attempt at rectifying a specific deficit in self and coping style (Ulman & Paul, 2006).

Therefore, by using the masculine and feminine typology, we could propose that the psychopharmacological properties of certain classes of psychoactive substances and the psychoactive effect of ideologies correlate with masculine and feminine typologies (i.e., depressant psychoactive substances and extreme left ideologies of “equality and emancipation” with the feminine, and stimulant psychoactive substances and extreme right ideologies of “distinction and triumph” with the masculine), and how Kohut’s (1977) poles of the self can also be classified within a masculine and feminine typology (pole of grandiosity/feminine and pole of omnipotence/masculine).We can, therefore, see how certain masculine/feminine psychoactive substances and masculine/feminine ideologies act as a structural prosthesis and a narcissistic object for transference in an attempt to rectify dysfunctional masculine and/or feminine poles of the self and coping styles. In short, extreme left ideologies of “equality and emancipation” (feminine) is a source for mirroring transference, and extreme right ideologies of “distinction and triumph” (masculine) is a source for idealized transference, and both provide a source for twinship transference.

According to Scruton the “[m]ost important is the way in which ideology of the kind I discuss [in Fools, Frauds and Firebrands] insulates itself against criticism, regards non-believers as a threat, and refuses to examine evidence coming from outside the closed circle of gratifying ideas” (personal communication, 5 August 2018). I would ascribe that “burying one’s head in the sand” phenomenon (so typical of the ideologically possessed) as a protective mechanism against ‘narcissistic mortification’. For this type of narcissistically disturbed individual the ideology serves the dynamic function of a ‘psychic prosthesis’ for a feeble and unstable self, and therefore a threat to the coherence of the ideology is experienced as an direct attack on the self, and conjures up powerful archaic fears of psychic fragmentation and annihilation. Therefore, to maintain psychic homeostasis the ideologically possessed individual must do everything in his power to refute these “attacks of reality” and eliminate the threat (often violently), or face a profoundly disturbing and frightening emotional experience (which perhaps could help explain the bizarre and elaborate mental gymnastics performed by many radical leftist “intellectuals” in their defence of Communist dictators like Lenin, Stalin, Mao even after these dictators were clearly exposed as brutal mass murderers).

(This blog post is based on section in a draft essay about applying Logic-Based Therapy in dealing with existential issues arising in the treatment of substance abuse disorders.)

References

Du Plessis G. P. (2018) An Integral Foundation of Addiction and its Treatment: Beyond the Biopsychosocial Model. Integral Publishers: AZ, Tuscan.

Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. New York, NY: International University Press.

Kohut, H. (1977). The restoration of self. New York, NY: International University Press.

Scruton, R. (2016). Fools, Frauds and Firebrands: Thinkers of the New Left. London: Bloomsbury Publishing.

Ulman, R. B., & Paul, H. (2006) The self psychology of addiction and its treatment: Narcissus in wonderland. New York, NY: Routledge.

Basic Existential Needs and Addiction

In the following blog post I explore addiction and recovery from the perspective of basic existential needs. When basic existential needs are understood as ontological (i.e. inherent and not socially constucted), drug abuse and addiction could be interpreted as pathological satisfiers of fundamental human needs.

From this premise it follows that a recovery process should then be understood not as “curing the addiction” or “treating the disease”, but rather as a lifestyle approach geared towards finding healthy satisfiers, which consequently would alleviate the need to rely on destructive satisfiers (i.e. drugs). This idea would support a community-orientated system of care in contrast to a top-down medical/psychiatric system of care.

Although addiction is related to the reward system of the brain, which can be hijacked, this should first and for mostly be framed through an understanding of basic existential needs as ontological. Simply put, from this perpesctive the “craving’ for the drug is not so much the craving for the pharmacological agent but rather a craving for the unmet need that the drug attempts to satisfy. Therefore addiction can be seen as a pathological relationship with a substance or behavior that attempts to satisfy ontological (not socially constructed) needs.

Chilean economist, Alfred Max-Neef (1991), who developed the theory of human scale development, stated that “[f]undamental human needs [basic existential needs] are finite, few and classifiable and are the same in all cultures and in all historical periods. What changes, both over time and through cultures, is the way or the means by which the needs are satisfied” (p. 18). He went on to say that: “Each economic, social and political system adopts different methods for the satisfaction of the same fundamental human needs. In every system, they are satisfied (or not satisfied) through the generation (or non-generation) of different types of satisfiers [the object or process used to satisfy a need]. We may go as far as to say that one of the aspects that define a culture is its choice of satisfiers…In short: What is culturally determined are not the fundamental human needs, but the satisfiers for those needs” (p. 18).

According to the theory of human scale development, an individual’s quality of life is correlated with the actualization of nine classes of interrelated ontological needs. In this model “no hierarchies exist within the system [as opposed to Maslow’s model]. On the contrary, simultaneities, complementarities and trade-offs are characteristics of the process of needs satisfaction” (Max-Need, 1991, p. 17). According to Max-Neef, (1991) any “fundamental human need not adequately satisfied generates a pathology” (p. 22). In Max-Neef’s model, satisfiers refers to the method of having a basic existential need met (satisfying the need), and various groups of satisfiers are proposed. Five types of satisfiers are suggested: violators or destroyers, pseudo-satisfiers, inhibiting satisfiers, singular satisfiers, and synergic satisfiers.

Violators or destroyers are paradoxical in nature because when they are applied to satisfy a need, “not only do they annihilate the possibility of its satisfaction over time, but they also impair the adequate satisfaction of other needs” (Max-Neef, 1991, p. 31). Pseudo-satisfiers “generate a false sense of satisfaction of a given need. Although not endowed with the aggressiveness of violators or destroyers, they may on occasion annul, in the not too long term, the possibility of satisfying the need they were originally aimed at fulfilling” (Max-Neef, 1991, p. 31). Inhibiting satisfiers tend to over-satisfy a given need, consequently, limiting the possibility of other needs being satisfied. Singular satisfiers tend to satisfy one specific need. They are neutral in relation to the satisfaction of other needs. Synergic satisfiers satisfy a given need and “simultaneously stimulating and contributing to the fulfilment of other needs” (Max-Neef, 1991, p. 34).

From the above description, it should be clear that addictive behavior can be understood as violators or destroyers, and pseudo-satisfiers. Addictive behavior is always directed at satisfying a need, but what differentiates addictive behavior (violators or destroyers) from other methods (or other satisfiers) of having needs met is that it paradoxically destroys the individual’s capacity to meet the need(s) it is attempting to satisfy, as well as the capacity to meet other needs. As an addictive lifestyle progresses, the individual’s capacity to have most of his or her needs met is diminished, until there is a near total reliance on the substance or behavior to meet most basic existential needs.

Within the context of the above discussion, it should be clear that a recovery program and lifestyle is a process of replacing destroyers/violators with synergistic and singular satisfiers.

References:

Max-Neef, M. A. (with Antonio, E., & Hopenhayn, M.). (1991). Human scale development: Conception, application and further reflections. New York, NY: Apex.

(This blog is derived from an passage in my book “An Integral Foundation for Addiction: Beyond the biopsychosocial Model.)

An Altered State of Consciousness Perspective of Addiction

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Understanding addiction and recovery from a state perspective may be one of the missing links in contemporary addiction treatment programmes’ attempts to create sustainable treatment protocols. Addicts are obviously experts on states. Using substances or engaging in any mind-altering behaviour is an attempt to create an altered state of consciousness (ASC), and the specific psychoactive effect of various drugs and mind-altering behaviour creates various types of ASCs (Milkman & Sunderwirth, 2010). It follows that viewing addiction in terms of an ASC perspective is crucial for a complete understanding of the nature of addiction (Winkelman, 2001).

Some researchers have argued that the majority of addiction treatment programs fail to integrate a huge body of literature that highlights the therapeutic benefits for addicts in experiencing ASCs. They propose that a principal reason for the high relapse rate in treatment programs is the failure of those programs to address the basic need to achieve ASCs (McPeake et al., 1991). Some scholars believe that humans have an innate drive to seek ASCs (e.g., McPeak et al. 1991; Weil, 1972; Winkelman, 2001; Ken Wilber, personal communication, January 13, 2011). They believe that addicts follow a normal human motive to achieve ASCs, but they use maladaptive methods because they are not provided with the opportunity to learn “constructive alternative methods for experiencing non-ordinary consciousness” (McPeak et al., 1991, as cited in Winkelman, 2001, p. 340). From this viewpoint, drug use and addiction are not understood as an intrinsic anomaly, but rather as a yearning for an inherent human need to be met.
In some instances the etiological roots for certain individuals’ addiction may be a dysfunctional attempt, borrowing terms from Robert Assagiloi (1975), at “self-realization”, and the consequent flawed channeling of “superconscious spiritual energies,” energies to which these individuals are often sensitive but which have not found suitable ways to be actualised. It is obvious that drug use and addiction are associated with an alteration of consciousness; however addiction has seldom been analysed from the perspective of consciousness theory or cross-cultural patterns of the use of ASC. Weil (1972) and Siegal (1984) propose that humans have an innate drive to seek ASC. From this perspective, drug use and addiction are not understood as an inherent abnormality but as a striving to meet an innate human need.

Alcoholics Anonymous (AA) acknowledges the importance of an alteration of consciousness for recovery to be effective: it calls for “a new state of consciousness and being” (Alcoholics Anonymous, 1987, p. 106) designed to replace the self-destructive pursuit of alcohol-induced states with a more healthy life-enhancing approach. AA advocates meditation, a change in consciousness, and spiritual awakening as fundamental in achieving and maintaining sobriety.

Blum (1995) believes that addicts often have a neurologically based inability to experience pleasant feelings within simple life experiences and suggests that a neurological-normalising shift may happen as a result of neurotherapy which rectifies the endless quest for neurotransmitter balance, as explained by his Reward Deficiency Syndrome Model. In Integral Theory, states refer to the various states of consciousness available at any stage of development (Wilber, 2006).

Every human being engages in various activities to feel good. Feeling good and avoiding unnecessary pain are universal needs. To feel good, we seek out activities that alter our brain chemistry. Addiction can be understood as this normal need gone awry. Milkman and Sunderwirth (2010) state, “In light of the seemingly universal need to seek out altered states, it behooves researchers, educators, parents, politicians, public health administrators, and treatment practitioners to promote healthy means to alter brain chemistry” (p. 6). Addicts have found a dysfunctional way to meet this innate need through substances or certain behaviours to which they become addicted. Addicts normally have three dominant ways of seeking comfort and altering their consciousness: “We repeatedly pursue three avenues of experience as antidotes for psychic pain. These preferred styles of coping – satiation, arousal, and fantasy – may have their origins in the first years of life. Childhood experiences combined with genetic predisposition are the foundations of adult compulsion. The drug group of choice – depressants, stimulants, or hallucinogens – is the one that best fits the individual’s characteristic way of coping with stress or feelings of unworthiness. People do not become addicted to drugs or mood-altering activities as such, but rather to the satiation, arousal, or fantasy experiences that can be achieved through them” (Milkman & Sunderwirth, 2010, p. 19).

The quotation above clearly points to the need for addicts in recovery to find healthy behaviours and activities to manifest their preferred coping style, since this preferred coping style (satiation, arousal, or fantasy) correlates with their drug of choice (Du Plessis, 2012).

References to this blog post can be found in my articles as indicated on my Publications and Research page of my website www.guyduplessis.com.

The Need for a New Ontological Foundation of Addiction

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I believe one of the central problems in addition studies is that research and theories are based on “outdated” ontological assumptions about human nature. In philosophy the term ontology is often used within the context of metaphysics, and refers to what exists or what can exist in the world. Epistemology refers to the nature of human knowledge and understanding that can be obtained through various types of investigation (Slife, 2005).

Ontological and epistemological questions often concern what is referred to as a person’s Weltanschauung or worldview. Philosophers and theoretical psychologists point out that all theories have ontological and epistemological ancestry or foundational assumptions, whether implicitly or explicitly stated (Bishop, 2007; Polkinghorn, 2004; Slife, 2005). Consequently conceptions of addiction, like conceptions in any science, are based on certain philosophical assumptions, which influence the trajectory of the development of the concept (Richardson, 2002; Bohman, 1993). In addiction science these initial assumptions often go unnoticed and consequently are uncontested once treatment methodologies are employed and made the objects of research (Hill, 2010).

For example, Ribes-Inesta (2003) commented “…psychologists have paid little attention to the nature of concepts they use, to the assumptions that underlie their theories, and the ways such concepts are applied in the study of behaviour”. Within the field of psychology there exists various ontological worldviews and hidden assumptions (Hill, 2010).Hill (2010) points out that theories about and definitions of addiction and treatment methodologies may in the same manner been influenced by ontological assumptions which often remain implicit. In his PhD dissertation, An ontological analysis of mainstream addiction theories, Hill (2010) says that there are certain (often unrecognised) ontological assumptions made by those who study addiction (or any human behaviour), and he points out that most of these assumptions are abstractionist or positivist, which he believes is problematic. The popular biopsychosocial model of addiction is such an example.

In the last ten years the field of addictionology has seen a progressive movement toward compound models of addiction (DiClemete, 2003). The integrated or compound approach to addiction is an attempt to integrate the divergent and often conflicting philosophical foundations of the biomedical, psychological, and sociological perspectives of human behaviour (Graham et al., 2008; Levant, 2004; Pilgrim, 2002; Wallace, 1993).Although the BPS model approach could be viewed as approximating a comprehensive integrated approach, there are still considerable positivistic, ontological and epistemological underpinnings and assumptions which hinder a comprehensive conceptual framework. It has been argued that the BPS model does not provide an adequate integrative conceptual framework for the many antecedent variables that it acknowledges, and for which it provides a semantic linking, at best (DiClemente, 2003; Hill, 2010; Alexander, 2008).

I proposed that that an adequate foundation can be found for addiction studies by developing an integrative meta-approach, a unifying approach – a pluralistic ontological and epistemological foundation for the study of addiction (Du Plessis, 2012, 2013, 2014). I will expand on this proposition in other blog posts.

References to this blog post can be found in my articles as indicated on my Publications and Research page of my website www.guyduplessis.com.

Myth of the brain disease model of addiction

images2The brain disease model of addiction is one of the most prevailing myths in our understanding of addiction. It is indubitable that addiction has a significant neurological component, but to reduce addition to neurophysiology is a gross error. The reason this way of thinking is so readily accepted is that it is congruent with the prevailing scientific materialistic worldview that dominates most analysis of addiction, and human behavior. Although many adherents of the brain disease model acknowledge the interplay of psychosocial factors with physiology, they nonetheless place primary emphasis on biology. Below is will briefly try and point out that viewing addiction as a brain disease is making an error in assigning addiction an ontological status, that is not befitting of its true complexity.

Integral scholar Sean Esbjörn-Hargens (2010) describes that the ontic status of a phenomena can be understood as having three potential orders of complexity, “the first order is characterized by phenomena that we can more or less ‘see’ with our own senses. The second order is the result of using various extensions of our senses (instruments, computer programs, charts) to see the phenomena … The third order cannot be seen with our senses nor indirectly by our instruments, but only by indications” (p. 159). Certain phenomena can be adequate accounted for when viewed as a first or second order ontological complexity, but certain phenomena has to be understood as a third order complexity, to avoid running the risk of developing over-simplified and reductionist understanding of the phenomenon.

At the highest level of abstraction lies the notion of an individual’s addiction-in-the-world, which is a staggeringly complex phenomenon beyond our senses or instruments. So addiction “is two steps removed from our direct experience (the first order) and our perception of it relies on many abstract indicators (the second order), which are epistemologically distant and ontologically complex” (Esbjörn-Hargens, 2010, p. 159). Therefore is best viewed as a “probability continuum” of ontological complexity, co-arising and enacted through different methodologies and worldviews. For example, a first order ontology could be the experience of being high on the drug. It is available to our senses. A second order ontology could be the pharmacological effect of a drug on neurotransmitter levels or unconscious psychological drives as risk factors to substance abuse. This we can understand only through measurement and calculations, and through a metapsychological perspective. Both these approaches can grasp only partial aspects of human existence.

When understanding addiction as a third order ontology, we begin to understand why certain models of addictions, especially the single-factor models, give rise to such partial and reductionist explanations. They are good at explaining certain “archaic features” of addiction in the realm of its enacted first or second order ontology, but methodologically and epistemologically, they are incapable of enacting addiction on a third order ontology. Technically, a third order ontology is actually the level of ontological complexity where the notion of addiction exists (a first or second order ontology cannot articulate a complex phenomenon like addiction, and can only enact “archaic-addiction” probabilities).
Most of the models of addiction have as their foundation a worldview of scientific materialism and positivistic methodology that are typically adequate for exploring phenomena existing on the first and second order of ontological complexity. However, such models are hopelessly inadequate in explaining complex phenomena such as addiction (or any human behaviour) which “exist” on the third order of ontological complexity. For example, reward deficiency syndrome (Blum, 1995) can only be understood as one of many possible physiological risks that interact with other aspects of being human, without having to reduce human behaviour and motivation to neurotransmitter levels. Simply put, even though an addict has abnormal neurotransmitter levels, at the molecular realm of brain physiology concepts such as addiction are meaningless. To talk at molecular level about addiction is like saying that an amoeba, which only primarily exists in a primitive level of ontological complexity, has abandonment issues originating from poor object relations.

Medard Boss (1983) points out that the natural scientific method has its limitations in explaining the human realm, as it originated from and is only sovereign in the non-human realm (natural sciences). Boss’s approach of Daseinsanalysis, based on Heidegger’s (1962/1927) ontology, could be described as an ontic “articulation of Heidegger’s” ontology. In our current context we could say that by using Heidegger’s method in exploring psychology and psychiatry, Boss echoes the dangers of explaining higher-order complex phenomenon (which includes any aspect of human-being-in-the-world) by using methodology (i.e. empirical observation) and epistemology (i.e. positivistic) dominant in lower orders of complexity. He believes that in Freud’s metapsychology (and most other theory of human existence) there is inevitably an abstraction and tapering from our lived engagement in-the-world (human-being-in-the-world reduced to first and second order ontology).

In summary: the phenomenon of addiction is best understood as a third order ontology, which can only be co-enacted (“brought-forth-in-the-world”) when juxtaposed with associated “methodological variety” and “epistemological depth” (Esbjörn-Hargens, 2010). The notion of epistemological distance highlights that some facts of addiction “speak louder” than others and some elements of addiction facts are only enacted within certain worldviews. Methodological variety refers to the fact that “the more epistemological distance and ontological complexity increase, the more methodological variety will increase. Thus, the more multiple an object becomes (the What), the more methods and disciplines you will need to study and make sense of it (the How), and the more perspectives there will be on what is or is not the nature of that object (the Who)” (Esbjörn-Hargens, 2010, p. 162). In short, trying to reduce any human’s being-in-the-world to a first or second order ontology, as the “brain disease” model tries to do, is fundamentally flawed. Addiction is caused by, affects and manifests in all areas of our being-in-the-world, and only paradigms (or rather meta-paradigms) that function on this level of ontological complexity may suffice, if we are ever to understand, and successfully treat this colossal nemesis.

References to this blog post can be found in my articles as indicated on my Publications and Research page of my website www.guyduplessis.com.