I’m lying in bed when I hear the commotion. I peer through the doorway of my room, and right outside, the new guy is getting in Ruiz’s face. There’s a phone right outside the door, one of those sturdy metal payphones like one you’d see on a street corner, and Ruiz, a gentle older man with shoulders stooped by the demoralisation of his nth relapse and hospitalisation, is just trying to talk to his family. But the new guy has been manic and pacing since he arrived a few hours ago, and he won’t take no for an answer.
I watch the new guy stalk the other way across the doorway, muttering to himself, menacing even in retreat. Then a warning shout echoes from much too far in the distance, and he appears once again – flying, near horizontal – to tackle Ruiz, dragging him off the phone.
The staff quickly take him down; thankfully, no one is seriously hurt. Shaken, I try to focus on my journal, but my mind races. I’m 29 years old, writing notes in a sloppy felt-tip pen (no ballpoints are allowed), trying to understand how I went from being a newly minted doctor in a psychiatry residency programme at Columbia University in New York to a psychiatric patient at Bellevue, the city’s notorious public hospital.
Bellevue is synonymous with the most challenging cases of mental illness, and now I’m locked on the dual-diagnosis ward on the 20th floor, near the top of the building, where they put people who have substance use problems alongside other mental disorders. I’ve already recognised some of the faculty from when I applied here for residency, and I know from the tour I took as an applicant that the special prison ward, protected by a guardhouse with bulletproof glass and thickly barred gates, is one floor below us.
I need the phone those two men have been fighting over. It’s my only way to reach the outside world, that other plane of reality where I was once a psychiatry resident. I’m having trouble accepting that I belong here. Day by day, it seems more likely that what the doctors have been telling me is correct – that, just like the new guy, I too have had a manic episode, in my case induced by weeks of stimulants and alcohol. But I’m still not sure what I should do.
The next day, I meet with the whole treatment team – half a dozen psychiatrists, therapists and counsellors facing me across a massive table in one of those windowless hospital conference rooms. For the first time, I truly let my guard down and recount my whole drinking history. How I grew up with two alcoholic parents and swore to myself I’d never be like them. How, even as I finished medical school at Columbia, I had the creeping sense that my drinking was out of control. How the blackouts got more and more frequent, but I didn’t reach out for help, and I didn’t accept the help that friends, colleagues and supervisors had all offered, then implored me to take.
I tell them everything, even about the time I woke up on the floor of the hallway in my building, shirtless, my skin sticking to the tacky linoleum, locked out of my own apartment. It was only by getting up to the roof and climbing down the fire escape that I made it in to work that day at all. I was late again, and so ashamed and scared by what it said about me. It was obvious that something was wrong, but I never told anyone about it, because to do so would be to acknowledge what I had long suspected.
They ask me about my family, and I tell them about my father’s four stints in rehab and the bottles of wine my mother secreted around the house. I describe my parents as alcoholics, as I usually do, but I also finally give voice to that dangerous suspicion about myself: “I’m starting to realise that I’m an alcoholic, too,” I say, and then break down crying.
Later that weekend, I call my friend Ravi from that payphone, looking down the disorientingly long hallway that stretches the length of the ward. He’s helping me with all the logistics, setting up disability insurance, getting my rent paid and generally making it possible for me to go to rehab – a place I don’t quite want to go to, but am told that I need.
We talk about how it’ll be good for me, and how I’ve struggled for so long. His voice is strained. It’s clear he’s worried about me. So I hesitate for a moment – I have the clear sense of telling myself that this is a truly ridiculous question, that I shouldn’t ask him this – but then ask him anyway, even as I keep one eye down the hallway for any potential assailants: “Do you really think I can never drink again?”
I’m supposed to be going to some specialised rehab for doctors, but I know nothing about it. I want to go, but not really. I need help, but maybe I can do it on my own, or at least find a better way. Why is this so hard?
Addiction is a terrifying breakdown of reason. People struggling with addiction say they want to stop, but, even with the obliterated nasal passages, scarred livers, overdoses, court cases, lost jobs and lost families, they are confused, incredulous and, above all, afraid. They are afraid because they cannot seem to change, despite the fact that they so often watch themselves, clear-eyed, do the very things they don’t want to do.
Addiction is often explained in terms of a dichotomy of free choice v total compulsion. By claiming that addictive behaviours are simply a kind of choice, people have justified punitive measures for centuries, from putting drunkards in the stocks to imprisoning people for drug possession. If their drug use is a free choice like any other, the argument goes, people should accept responsibility for their behaviour, including punishment. The opposite view, which these days is commonly presented as a compassionate counter-argument by neuroscientists and advocates, is that addictive behaviours are involuntary and uncontrollable compulsions, and thus people with addiction deserve compassion and treatment, rather than punishment.
But this dichotomy between choice and compulsion is unsatisfying. Lived experience contradicts such a stark binary, and many people with addiction feel themselves occupying a confusing middle ground. The thing that is terrifying to most people with addiction is that they watch themselves making a choice even while feeling there is something wrong with the choosing. It is, in other words, an issue of disordered choice: a problem with choice, choice gone awry.
The ancient Greeks had a word for this experience of acting against your present judgment: akrasia, often translated as “weakness of the will”. Akrasia isn’t just doing something that is arguably harmful, like eating too much pie or spending too much money on clothes. Everyone indulges, even though indulgence is rarely the best option according to a cold, utilitarian calculus. Akrasia is doing something even though you truly believe it would be better not to, of recognising in the moment that you are acting against your better judgment.
Aristotle was deeply invested in the idea of akrasia. To him, it was self-evident that people sometimes acted against their better judgment. He saw more nuance in the notion of choice, and he believed there were various ways that internal conflict might interfere with that choice. Surely, he asked, emotions or misguided reason can often get in the way of one’s better judgment?
Plato arrived at a different point of view. He understood the problem of self-control partly as the result of a divided and conflicted self, one he illustrated through the famous metaphor of the chariot: the intellect is the charioteer attempting to wrangle the two horses of positive moral impulses and irrational, passionate drives. The notion is also found widely in classical narrative, such as Medea’s psychological struggle in Ovid’s Metamorphoses, torn between love and duty: “But a strange power attracts me against my will – desire urges one thing, reason another.”
In the study of addiction today, the divided self is a prominent explanation of how choice can be disordered. For example, behavioural economics research describes the psychological feature of “delay discounting”, in which smaller but more immediate rewards are favoured over larger, delayed ones – this process is universal to humankind, but more pronounced in addiction. Immediate rewards are grossly overvalued, causing extreme impulsivity that feels like loss of control.
Nudging these types of choices can be a highly effective component of addiction treatment. The most obvious example originates from the 1980s, when Stephen Higgins, a psychologist at the University of Vermont, developed a “contingency management” programme to treat people with cocaine addiction. In addition to counselling, Higgins used a voucher system that gave people small rewards, such as sports equipment and movie passes, for cocaine-negative urine samples, and gave them a bonus for longer stretches of abstinence. This strategy was highly successful. One of the early experiments found that 55% of the voucher subjects were continuously drug-free for 10 weeks, compared with fewer than 15% of subjects receiving the usual treatment. After decades’ more research, contingency management now has strong evidence in its favour, especially for stimulant problems, for which there aren’t good medication treatments.
After my time at Bellevue, I did go to rehab, and in time, I returned to the residency programme at Columbia. For years afterward, I was in supervised treatment. At a moment’s notice, I had to be prepared to run across the medical centre or across town to my “urine monitor”, a woman who would watch me urinate to make sure I didn’t try to pass off someone else’s bodily fluids as my own. My monitored treatment was a form of negative contingency management. I wasn’t totally committed to abstinence at first, but my medical licence was on the line, so I chose not to drink. This powerful contingency is, in large part, why these physician health programmes have extraordinary five-year success rates of 75% or higher, eclipsing the effectiveness of essentially all other addiction treatments.
Yet some people don’t stop, no matter what the cost. There is still that nagging 25% of people who don’t make it to the five-year mark, for example. Some of my friends and colleagues from the physician health programme did relapse, and they were trying their best – none thought in the moment that it would be better to start drinking or using again. Those outcomes are a testament, I think, not to the power of a simplistic compulsion, but to the complexity of the internal forces that lie beneath the stereotype.
As I was researching the subject of addiction, my mother was slowly wasting away from lung cancer. During her illness she told me about how her own father, a Swedish immigrant, fell into a severe depression every winter. He would remember his happy childhood in Stockholm and compare it with their life in Newark: no hot water, working the night shift at a bottling plant, never seeing his wife, who worked an opposite shift on a different assembly line. Though he tried not to drink, he’d always relapse on alcohol as Christmas approached, and for months my mother, still a young girl, would be sent out into the Newark winters to trudge from bar to bar to find him so he could get a few precious hours of sleep before his next shift. From an early age, she was taught that alcohol was a way to cope with a difficult world.
I don’t intend to diagnose my parents or grandparents. It is rarely useful to attempt to arrive at one major “cause” of anyone’s addiction – genes, environment, trauma, the trauma of everyday life. But it has helped me immensely to see their addictions at least in part as a function of their unprocessed pain. Like everyone else, they were drinking and smoking for a reason: because those substances did something for them. Sadly, their use simultaneously helped them to cope and made their problems much worse, perpetuating a vicious spiral.
This is the core of the addiction-as-dislocation theory. Beyond soothing the concrete effects of physical dislocation, people use drugs to address an alienation from cultural supports. This kind of alienation is what Émile Durkheim, the founder of modern sociology, called anomie: the social condition of a breakdown of norms and values, resulting in an existential lack of connection to meaning and purpose. This sense of dislocation, some scholars argue, is one of the core drivers of today’s opioid epidemic.
Epidemics are never caused solely by some inherent power of the drugs themselves. There is often, if not always, social wounding underneath, driving the substance use. In 2014, the Princeton economists Anne Case and Angus Deaton (the latter of whom won a Nobel prize the next year) happened upon an unexpected finding: a significant uptick in the number of suicides among middle-aged white Americans.
Case and Deaton found that death rates from three causes – suicides, drug overdoses, and alcoholic liver disease – were rising rapidly, and the increases were almost all among people without a college degree. In their subsequent analyses, Case and Deaton connected these deaths to a rot at the core of today’s societal structure. True, these working-class whites were suffering some concrete losses from the globalising economy, such as worse jobs with lower wages, but beyond that, work had become far less meaningful. People no longer had a real connection to their jobs – they were less likely to belong to a union and less likely to have any stability or structure in their work. Beyond that, there were plenty more reasons for despair. Marriage rates were declining, and religious participation was falling. More people were living alone than at any time in recorded human history.
All these dislocations were fatally exacerbated by the US’s stark inequality – the highest income inequality of all the G7 nations – combined with what is objectively the worst-performing healthcare system in the developed world, with its bloated costs and inefficiencies holding down wages and destroying jobs. Case and Deaton labeled these deaths from suicides, drug overdoses, and alcoholic liver disease “deaths of despair”. In 2017 alone, there were more than 150,000 deaths of despair in the US, and many of them among people between 20 and 50.
It’s crucial to note that all these white people – my family and myself included – were spared from other, more direct forces of oppression and racism that have driven deaths from addiction in Black and Brown communities for decades, even centuries. Persistent health inequities by race and social class have long dwarfed the white working-class deaths of despair identified by Case and Deaton. The “deaths of despair” narrative should not enable an exclusive focus on white problems; to do so would draw a false distinction between this epidemic, populated by images of white middle-class users who are portrayed as blameless victims, and the ongoing crisis of substance-related deaths driven by structural issues such as poverty, trauma, concentrated disadvantage and hopelessness. In reality, these crises are deeply intertwined. The point, rather, is that the psychological dislocation driving addiction is powerful enough to reach into all corners of human society, and it is not limited to concrete, material resources.
One of the first patients in my internal medicine rotation during medical school was a rail-thin man with a heroin addiction who had a tumour the size of a melon sticking out of his jaw. He had tried to get a little nodule on his tongue checked out a few months earlier, but the clinic doctors didn’t have a lot of patience for his drug use and “noncompliance”, and he had quickly fallen out of care. Now his family had brought him to the medical centre to die.
It was four years before my breakdown, and I was in the middle of the third year of medical school – the dreaded “clinical year”, when students rotate through different specialties as part of the teams directly caring for patients – and it was wearing on me. That man seemed to embody everything wrong with modern medicine: not our inability to cure the cancer, but how easily patients could be left by the wayside. The churn of the system was demoralising. We’d patch up acute conditions and dump people back into nursing homes or even on to the streets, with little opportunity for working with the human problems so often at the root of unhealthy behaviour. As the winter rolled on, I got tired of waking up at 4am just to tackle checklists of tasks that didn’t seem to be helping anyone.
I started drinking more – much more. I started crying unexpectedly. I met with a bushy-bearded psychoanalyst in a cramped cinder-block office at the medical centre, though at first I hid the extent of my distress behind safe, professional language, claiming I was there because I wanted to develop as a future psychiatrist and learn about myself.
I limped through the year of clinical rotations and took a research fellowship, but even during the comparatively relaxed research year, my drinking got progressively worse. I set countless limits for myself, then immediately violated them. After telling myself I wouldn’t drink at a scientific conference in Miami, I passed out against a palm tree and then puked in a cab. I wondered if I was an alcoholic, but I quickly dismissed the possibility.
I had gone to an Alcoholics Anonymous (AA) meeting as a med student – we were all required to go as an educational exercise – and it seemed clear that I wasn’t like those people, or my parents. My problem, I thought, was more sophisticated, something more complex and existential than a “disease” like alcoholism or a psychiatric disorder like suicidal depression or debilitating OCD. Patients facing those conditions were the ones really suffering; they were the ones who needed treatment. I just needed to grow up.
And yet, as the consequences mounted, I started to believe that I might have a problem. My psychiatrist fired me as a patient because of all the sessions I missed, and I poured a full bottle of gin down the sink and swore to myself that I’d really cut down this time. I didn’t realise then, but I do now, that I was doing the same thing I had tried with my parents once I got old enough to recognise just how bad their drinking was: searching the house for hidden bottles and pouring them out in front of them. It worked just as well.
In the end, it was the mixed amphetamines of Adderall that tipped me over the edge into a complete breakdown. I had accessed the drug easily, because it was an entitlement for a white and privileged user like me. I got it through medical channels, paid for it with medical insurance and, most of the time, used it in a relatively sanctioned way. It is the kind of drug that preserves and supports the existing social order; stimulants get you to work, after all. Not long after it was in my hands, though, I began using Adderall dangerously, and the combination of alcohol, amphetamines and days of sleeplessness combined to put me into a drug-induced manic episode.
At first, it was glorious. I felt the total dissolution of my ego and a lucid clarity, a taste of an imminent and transcendent mystical experience. Then the delusions set in. I understood that I had got wrapped up in a spiritual war of good versus evil. At times I did wonder whether the drugs had caused a psychotic mania, but I could no longer identify reality, as all those thoughts and feelings and fears came rushing in at once. We describe mental illness as if it’s an entity, a clearly demarcated state, or at least a state with some sort of checkpoint or transition, but I passed no such gate. I felt like I was straddling the gap between sanity and insanity, or, perhaps better put, inhabiting the quantum uncertainty of both at the same time, multiple states of being flashing through my disordered mind.
A few days later, it was getting harder to deny to myself how bad things had got, but in my mind I still protested. I started whispering the same phrase over and over to myself: “I know what crazy is, and this is not it. I know what crazy is, and this is not it.” For just one precious moment, I saw just how wrong I was, and, realising that I couldn’t do it myself, I screamed out for help. My neighbour called the police.
On my second day in rehab, almost two weeks after I was taken to Bellevue, I was summoned to meet the medical director, Dr Summers, in his office for my intake interview. I had heard that he would probably have the final say over my case, and I had been watching him closely as he stalked the hallways with an impatient, kinetic energy. This I could work with. I had spent my entire career sucking up to older doctors.
As soon as I sat down in his office, he scowled and began to interrogate me. How much had I been drinking, exactly? What else was I using? Was I sure? My hopes withered, but I tried to stay positive and calmly presented my case: young man with binge drinking exacerbated by Adderall and occasionally cocaine, in the context of overwork and burnout. Far from healthy, but now highly motivated. I could really do this as an outpatient. I had learned my lesson and wanted to get better.
I watched his face for any signs of an opening. Instead, after a long pause, he leaned across the table and told me that he’d be testing my hair for drugs.
“Tell me now,” he asked portentously, “what will we find?”
At first, I was confused – I had just told him everything I’d been taking – but then the realisation landed: I wasn’t a colleague or a trainee any more, not to him. I was an addicted doctor, the worst kind of patient, perfectly equipped to massage my story and maintain my denial. In Bellevue I had also been a patient, but treated with respect, even like a colleague. Here, though, I was just a liar, and apparently I had to be broken down and reformed.
During the nine weeks I was in rehab, I saw things in the programme that seemed wrong, if not downright harmful, and which fed my resistance. A sense of fear and surveillance permeated the group I was in, all of us health professionals. A flirtatious surgeon was “therapeutically discharged” because he wouldn’t stop talking to female patients; he was transferred to a long-term care programme in Mississippi that would, we were told, break down the entrenched personality issues standing in the way of his recovery.
In a regular group exercise titled Responsible Concerns, we called out other people for troubling behaviour, such as expressing any doubts about treatment or AA. A family practice physician – older than most of us, and gentle, but quietly, awkwardly obstinate – refused to stop pointing out the elements of AA that he thought were illogical, so he was given a pamphlet titled King Baby, which described how his resistance was just a symptom of his own immaturity. It all felt crazy to me. The targets of their interventions were sweeping – people’s very personality and character – and in psychiatry, we would never set out to engineer a fundamental character reconstruction in the space of a few weeks or months.
To this day, I am not entirely sure how to think about that rehab programme. Was it too harsh, or did I need to be challenged? Was all their focus on character and personality rehabilitation overkill? I am convinced that I did need to be coerced, in the sense of being faced with a hard choice. Most people going to addiction treatment are going with some form of coercion – at least informal coercion, from family and friends – and I was there because I had to be, at least if I wanted to practice medicine anytime soon. I am glad that I was coerced in that sense; if I hadn’t had the monitoring programme in place, I might not have stuck with treatment and entered recovery, and I could have harmed other people, or died myself. Still, I’d like to believe that whatever deeper rehabilitation I experienced had more to do with connection than confrontation. I didn’t really need to be broken down, and the most meaningful and transformative experiences were less about the formal treatment and more about being put in a situation where mutual help could take hold and do its work.
After residency, I devoted a year to training in forensic psychiatry. I spent one day a week at New York State’s maximum-security prison for women, and it seemed as though every patient sent to our psychiatric clinic had both a low-level drug offence and trauma history. Many of them jockeyed to get time off their sentences by going to tough-love boot camps, where their heads were shaved and they did push-ups in the snow while staff screamed at them. I couldn’t shake their stories. The injustice of how, if not for an accident of birth, my own story could have been entirely different. The NYPD chose to take me, a white guy living in an upscale Manhattan neighbourhood, to a hospital rather than booking me. If I’d been a person of colour in a different neighbourhood, I could have been imprisoned, like so many of the people who populate our current system of mass incarceration, or even shot and killed.
Disparity in access to medical treatment remains one of the strongest examples we have of the stark racial disparities in the understanding and treatment of addiction. Black and Brown people have long had to fight for treatment. Addiction in communities of colour, perennially a major problem, is too often explained in a stigmatised way that justifies prohibitionist approaches: portrayed as self chosen and irresponsible. On a structural level, addiction is explained away as the intractable effect of poverty or other root causes, treated as inevitable and expected, and thus left to the criminal legal system.
In my psychiatry practice, I see “non-addicted” people struggling with food, work, cheating, power, money or anger all the time. One psychotherapy patient of mine uses compulsive bingeing and purging as a way of managing negative emotions such as fear and shame. Another cannot put down his phone or stop checking his email – despite his clear intentions and plans to do so, and despite the fact that it causes real problems in his marriage – because of a crushing need for external validation from his work. I don’t insist that they call themselves addicted, and in general I don’t assume that the roots of my own addiction are similar to others’, or that others need what I have needed to recover. But I also don’t see a tremendous division between me and them. We all suffer from a divided self, and we all have too much confidence in our judgment and our ability to exert power over our environments and ourselves. And in that, I think we share a fellowship, in that addiction is simultaneously a tremendous problem that causes unthinkable suffering, and something contiguous with all of human suffering.
This is an edited extract from The Urge: Our History of Addiction by Carl Erik Fisher, published by Scribe and available at guardianbookshop.com