About a year ago, I attended a meeting of Narcotics Anonymous (NA) as part of an assignment for a class on addictions counseling I’d been taking in the Master’s in Counseling Program at Felician University.[1] Struck by the philosophical richness of what I’d encountered at the meeting, I thought I’d reproduce a version of my report on it here in case readers found it of any interest. In the interests of preserving the confidentiality of the group’s members, I’ve omitted any identifying features of the meeting with respect to time, place, and the identity of those present, describing the event only in the most general way. My aim here is to reflect on matters of general principle, not to dwell on the particulars of anyone’s life.

The meeting, which took place in a room at the back of a church, was attended by about a dozen people, both men and women, ranging in age from their 20s to their late 50s. Chairs were arranged in a circle with a table at one end; two individuals seated at the table functioned as officers for the group and informally ran the meeting.

To describe the group’s demographics in a generic way: Some of the attendees were well off; the others ranged from long-term unemployed to lower middle class. All were either white or Hispanic; there were no African American attendees, and I was the only Asian American in the room. Most were from the immediate area; one was from farther away but happened to be in the area at the time of the meeting, and one had spent several hours on mass transit to get there. It was difficult to learn much about their educational level, but regardless of their level of formal education, all struck me as highly intelligent and well-spoken.

One of the group’s leaders opened the meeting by welcoming everyone and reading the group’s rules, which seemed familiar to most if not all of the attendees. There were a lot of rules, hard to remember in retrospect, but a few stood out: attendees were not to bring drugs or weapons to the meeting, and were not to attend the meeting within 24 hours of using an illicit substance.[2] Attendees were instructed to turn off their electronic devices, a rule followed as much in the breach as in the observance: two attendees spent most of the meeting on their phones. Attendees were also assured that the contents of the meeting were entirely confidential, that participants were not under police surveillance, and that NA was an independent organization without a commercial or political agenda. Two signs on the wall listed the twelve steps of NA, which were described as fixed absolutes demanding adherence by all participants; unfortunately, I wasn’t able to make the rules out from my seat, and didn’t get a chance to get up and read them. (They’re available online.)

After spending maybe ten or fifteen minutes on procedural matters, participants were then asked to introduce themselves. The format of the introductions was to introduce oneself by first name, followed by one’s status as either an “addict” or a “supporter.” The format implicitly suggested that “addict” functioned as a substitute last or family name: it was often impossible to tell the difference between “John, addict” and “John Addict.” Whether intended or not, the implication seemed to be that “addict” was a kind of fixed, inherited identity, and perhaps that those with the name “Addict” all bore a quasi-family relation to one another, possibly stronger than the one offered by their birth families.

Participants were then asked to read passages from cards that had been handed out ahead of time, inscribed with what were in effect statements of NA’s creed. Though not religious in a specifically sectarian sense, the statements were still religious in a strongly theistic sense: each praised abstinence while recommending reliance on a Higher Power to that end. Early on in the meeting, participants recited the famous “Serenity Prayer” associated with Reinhold Niebuhr and Alcoholics Anonymous (Shapiro 2014);[3] the same prayer was recited at the end of the meeting, with participants facing each another in a circle, arms around one another. It was hard to miss the proselytizing posters and literature in the room, all expressing the theological commitments of the church in which the meeting was taking place.

The centerpiece of the meeting was a harrowing story told by one of the attendees concerning his childhood trauma, addiction, and recovery. Other attendees shared similar stories, not quite as extreme as the main speaker’s, but each affecting in its own way.

The overarching patterns of each story were similar. In every case, personal difficulties of some kind led to drug use, conceived of as a cure-all for those difficulties, and eventually, to addiction. Most stories described broken families, and many described sexual assault,[4] homelessness, run-ins with the law, and attachment difficulties, whether preceding addiction or following in its wake. Almost all participants described a constant craving for their substance of choice (heroin in all cases but one, marijuana being the one exception), as well as the shame, lack of self-esteem, money and employment problems, and propensity toward petty crime produced by their addiction.

It was clear that attendees’ involvement in NA meant a great deal to them, and had done a lot for them. That said, participants differed as to whether their coming to terms with addiction was more a solitary or more a group endeavor; some acknowledged the value of group solidarity but stressed the essentially solitary nature of the recovery enterprise, while others conceived recovery as a social accomplishment through and through.

I was faced with something of a dilemma in figuring out how to present myself to the group. I was unable to contact the group ahead of time to tell them that I’d be there to observe as a counselor-in-training. On arriving at the meeting site, it struck me as awkward or incongruous to describe myself as a mere observer; it was also unclear until the meeting began which of the participants was the group’s leader. Since the meeting was described as “open,” I was at least technically permitted to attend as an observer, but decided at the last minute to participate as an “addict.”

Actually, by this particular group’s definition (though not necessarily NA’s or anyone else’s), I am an addict, so no one was misled by my disclosure. For about eight months, from about August  2013 to February 2014, I was addicted to Ambien, during which time I had three emergency medical episodes (two at work), and was twice taken to the hospital by ambulance. I got the Ambien by prescription from my primary care physician during a bout of insomnia and depression following a divorce; he prescribed 90 tablets at the maximum dose of 12.5 mg controlled release, adding three refills for good measure. After three weeks of daily 12.5 mg doses, the initial effect began to wear off, and I started doubling the dose. By the fourth week of constant use, there were nights when I was taking 37.5 mg of Ambien a night–once, I believe, with a dose of Nyquil, 10% alcohol by volume (a huge amount for someone who doesn’t otherwise consume alcohol).

After about three or four months of use, it finally occurred to me that I was addicted, and had to get off.  To that end, I put myself on a “do it yourself” taper regimen (naturally, I Googled it) which induced extreme withdrawal symptoms, including nightmares, hallucinations, paranoia, vertigo, panic attacks, and various adverse physical effects. I eventually got off Ambien, and was forced to deal with the insomnia that had provoked it, partly but not entirely resolving it over the next few years.

Arguably, I might still be said to abuse sedatives from time to time; though I happen to lack access to Ambien, I have access to other things, and will occasionally wash something down on a bad night to induce sleep. Though I don’t consider myself an addict, the NA group’s conception of addiction seemed to imply that once a person is an addict, he remains one essentially for life. Accepting the assumption for the purposes of the meeting, I introduced myself as an addict, and acted as though I was one. That said, though I was tempted to tell my own story in the “sharing” period, I ended up not doing so.

The members of the group were warm, friendly, and deeply passionate about their involvement in NA. They treated me with extraordinary kindness, and did their best to welcome me to the meeting and to show their support for one another. Their stories were moving, and their disclosures were often painfully honest—many of them paradoxically enough confessions of acts of personal dishonesty motivated by the need to acquire drugs. I was struck by participants’ emotional intensity, their authenticity, their maturity, and their engagement with one another. I also got the impression that despite their situation, they seemed to have a wisdom or self-knowledge missing in a lot of casual drug users I know—though I’d be hard pressed to explain to an epistemologist exactly how I got this impression, what special knowledge I took them to have, or how I’d prove their possession of it.

Though I found the participants admirable, a few aspects of the meeting struck me as problematic or questionable. All of them had to do with the quasi-religious character of the group.

I was, for one thing, somewhat uncomfortable with the ritualistic features of the meeting. Every individual who spoke at the meeting was obliged to recite his or her name, along with her addiction status, every time she spoke. Every spoken statement was met with ritualistic approval, regardless of its content. Every speaker was thanked “for sharing” once her account was over, with participants using that exact phrase in unison after every speech. The result was a (to me) uneasy blend of evangelical church service and ordinary conversation when I’d expected more of the latter. That said, something similar might be said of, say, a traditional Okinawan karate dojo, or of any conventional religious service of any denomination: the rituals of either thing would strike newcomers as weird. (Personally, I’d say the same of a bar or a football game.) Of course, neither karate nor a religious service is primarily therapeutic or discursive in nature; a rehab program is. So I’m not sure how much the dojo/church service/NA meeting comparison really helps. It could be that the initial strangeness of NA’s rituals wears off after extended exposure to them, and it could be that the rigidity involved is necessary to provide structure, but I personally found it wearing.

The group’s ritualism seemed loosely connected with a sort of theology that I also found discomfiting–more discomfiting than the rituals. Commitment to belief in a “Higher Power” appears to be a condition of participating in NA. The role of this “Higher Power” is specified in the Serenity Prayer, which attendees seemed to take literally. The assumption seemed to be that one’s mental states are a gift from God, as are the circumstances of one’s life, whether good or bad. Listening to some participants, a listener might be led to believe that virtually everything they felt and did, and everything that happened to them, took the form it did because God had specifically willed it.

Though there’s obvious value in believing in a natural world that transcends human will, the insistence on a personal Power transcending this world seems to me to lend itself to a kind of “magical thinking” in participants at odds with NA’s apparent commitment to personal responsibility and a disease-based conception of addiction. It’s not clear how an individual addict can be responsible for anything if God or a Higher Power is responsible for everything. It’s also not clear how addiction can at once be a natural condition, and a condition whose vicissitudes are micro-managed by a supernatural deity.[5]

The most problematic issue, for me, was the group’s implicit definition or understanding of “addiction,” which appeared to be based on three core assumptions, to the effect that addiction is…

(1)  a label that applies to an addict over the whole of his lifetime, regardless of his actual patterns of use or physical dependence;

(2) a lifelong disease or illness, like diabetes or hepatitis B; and

(3) a condition that is fundamentally the addict’s own responsibility and fault.

An initial problem concerns the apparent incoherence of the beliefs taken as a set: belief (2) seems in tension with belief (3). Though not a literal contradiction, it confuses things to say that addiction is a disease and that it’s the addict’s own fault. A disease is usually a condition whose etiology is not within the patient’s control; by contrast, control seems to be a necessary condition for blame. There may be exceptions to the general rule that disease-etiologies are are outside of the agent’s control (or that control is necessary for fault or blame), but the exceptional nature of these cases calls for comment and explanation, something that didn’t come up even by implication.

In fairness to the group’s participants, they seemed less committed to (3) than they did to (1) and (2), but they were sufficiently committed to (3) to speak of addiction as something the addict just about always brings on herself. There was little consideration of the possibility that addiction can arise through the acts of a third party.  This is obvious in the case of an infant born with an addiction, but it’s also true of someone who becomes physically dependent on a drug either through the error of the physician who prescribes it, or through the intense pressure and/or deceptions of a seller who pushes it on a relatively unwitting buyer. In short, NA’s worldview doesn’t seem to allow even for the possibility of involuntary, iatrogenic addiction. Put another way, it allows for little nuance in the ascription of responsibility for addiction: the addict is pictured as either responsible for the whole of his condition in all of its ramifications, or is thought to be left off the hook for any of it.

Coming the other way around, and contrary to (2), it seems dogmatic to insist that addiction is always a disease. A disease is a disorder of the anatomical or physiological structures/functions of the body, not a pathology of choice. But addictions can be chosen, and choice is not obviously or clearly an anatomical or a physiological structure/function of the body. A choice can lead to a disease (such as when the choice of a bad diet leads to heart disease), but the choice is not itself part of the disease. Choice, however, can be an essential part of addiction, not just something that leads to addiction. If and when addiction includes the choice to become addicted, addiction cannot itself be a disease; in those cases (however frequent or infrequent they are), addiction is more plausibly regarded as a pathology of choice. The group’s insistence on viewing addiction as a “disease” tended to obscure the role of choice even in cases where an individual speaker wanted to stress the role of choice. The more they described the addiction as a disease, the less clear it became how choice could be involved.

Belief (1) struck me as the most problematic of the set. It’s not clear what sense it makes, or what purpose is served, in claiming that people lacking physical dependence on a substance, and abstinent from it for months, years, or even decades, are still “addicts,” and will remain addicts until death, whether they use drugs or not. The plausibility in this claim seems to derive from two assumptions:

• that erstwhile addicts have a strong propensity to relapse, and
• that the craving for addictive substances persists indefinitely.

Both things may be true, but neither or both imply that addiction persists indefinitely. A propensity to relapse, however strong, isn’t actually a relapse. And a craving for a substance, however strong, isn’t actually a case of substance use until it leads to relapse, if it does. And it need not.

To think of addiction according to (1)-(3) above is to treat it as something akin to an incurable disease, or else to a moral-legal condition requiring lifelong stigma or punishment. A person with hepatitis B will always have hepatitis B, even if he’s asymptomatic; a one-time murderer may never outgrow that label in later life, even if he refrains from murdering again. It only makes sense to describe addiction in the same way if addiction is demonstrably like hepatitis B or a capital offense.

But is it? There is no addiction virus or bacterium that stays with the addict-as-host, and though genetic factors matter, there is no “addiction gene” common to and explanatory of all and only cases of addiction. Nor is addiction so willfully evil an act that it taints the addict’s character forever in the way that murder might.

It seems more plausible to think that addiction requires physical dependence on a substance that can in principle diminish and vanish with time. Likewise, in many cases addiction involves a craving that seems ungovernable but isn’t literally ungovernable. At a minimum: it’s implausible (even absurd) to say that every erstwhile addict remains an addict for life, even if she’s been clean for ten or twenty years and lacks a craving for the relevant substance. But the case in which the one-time addict is clean for decades and retains a craving for the substance is still not obviously a case of addiction. No matter what we say about it, the case of {long-term craving & long-term abstinence} still has to be distinguished from the case in which long-term craving leads to frequent use. The first person strikes me as being at risk of addiction; the second is a user and likely an addict. But they’re obviously not in the same condition.

So contrary to my claims at the NA session, I don’t think it makes sense to call me an addict simply because I once was one. I say this despite frankly acknowledging an occasional tendency to abuse sedatives. An occasional tendency to abuse a substance may (or may not) eventually cause an addiction, but is not itself a case of addiction. Maybe I’m at risk for addiction; maybe I have an addiction-prone personality. But if I’m not physically dependent, and wouldn’t suffer withdrawal from abstinence, I don’t see the rationale for calling me an addict. From the NA group’s perspective, my insistence would probably come across as denial; from my perspective, their contrary insistence comes across as quixotic.

My guess is that the practice of referring to oneself as forever an addict arises from the need of one-time addicts to stress their solidarity with current addicts, and/or to throw cold water on the idea that one-time addicts deserve individual credit for having overcome their addiction. For obvious reasons, if you take the group’s theology literally, it’s unclear how anyone gets credit for anything.  “There but for the grace of the Higher Power go I.” But while I see the rationale, the claim itself seems counter-productive. After all, if every addict is always an addict, the only reason to go clean is to become less of an addict than you already are. But if you can never escape addiction, it’s unclear what motivating power there is in decreasing the degree to which you’re an addict. It’s as though Sisphyus had been told that each successive trip up the mountain would get him closer to a peak he’d never reach.

So far, I’ve been focusing on what, for lack of a better term, might be called the phenomenology of an NA meeting. But the meeting would have been of relatively modest philosophical interest if a visitor got nothing out of it but immersion in a semi-exotic phenomenology. Somehow–I’m not sure how–immersion in the meeting focused my mind in a more-urgent-than-usual way on three matters of philosophical principle.

The role of coercion in moral rehabilitation. What role should coercion play in the rehabilitation of addicts? At one extreme, the answer is “none.” At the other, the answer is “a huge role unconstrained by any determinate boundaries.” My own tentative conclusion is something like “ideally none, but if some, then one sharply constrained by clear-cut boundaries.”

One basic lesson of NA is one about the powers of moral regeneration under conditions of freedom. People enslaved by addiction can free themselves from it, but only if they’re left free to do so. Yes, they need help in getting clear, but it’s not obvious they need coercion. And to some degree, it’s obvious that they don’t need it. An addict voluntarily has to regard himself as an addict, voluntarily has to want to change his situation, voluntarily has to elect to change his situation, and voluntarily has to sustain a commitment to change. None of those things can literally be forced on anyone, and the attempt to try it is bound to be counter-productive.

Actually, “voluntarily have to sustain a commitment to change” is a rather bloodless way of putting things. I can say from even the mildest experience with addiction that the prospect of withdrawal upon abstinence or dose reduction is a terrifying thing. And the prospect is terrifying because the thing itself is. If you can’t supply the motivation to endure it from within, no one can do it for you. The point is not so much that addicts have to “hit rock bottom” in order to rebound from it as that they fully and voluntarily have to grasp the nature of the situation they face from an authentically first-person perspective, something that can’t be forced on them.

From that perspective, a war on drugs paternalistically aimed at moral restoration is a blatant, obvious, egregious contradiction in terms: there is no such thing as a war waged for the good of those targeted by it. And war is no metaphor in this context. There’s a good reason why NA meetings and rehab facilities are sanctuaries from law enforcement. You couldn’t conduct such a meeting or engage in rehab with a narc in the room and a SWAT team at the door.

That said, it would be a mistake to infer too quickly that no coercion is ever involved in successful cases of drug rehabilitation. Whether it has to be involved or not is a separate matter, as is whether outcomes would be improved if coercion were drastically scaled back or eliminated. But the fact remains that many addicts praise the cops who arrest them, and praise the drug courts that involuntarily put them in drug counseling. Law enforcement agencies now brag about having become de facto social service organizations–tough love enforced with a gun, a badge, and some Narcan. If not for the initial coercion that pushed them into the system (some addicts say) they’d never have seen the light, never have gotten off of drugs, and would be worse off than they are. I heard this over and over at the meeting I attended, and it would have been facile to dismiss it as self-deception or false consciousness.

As a general proposition, there are cases where the use of coercion in drug cases seems plausible, whether on paternalistic or rights-based grounds. There are times when addicts, like psychotics, are too out of their minds to make even minimally autonomous decisions, in which case it doesn’t seem wrong coerce them out of harm’s way for the day when they can make the relevant decision. And like it or not, drug addiction is closely connected with rights-violations: whether we explain this behavior by way of the drug war or not, drug addicts tend by their own admission to lie, cheat, steal, rob, and assault people in order to get their fix. They also abuse or neglect their families, drive under the influence, and free ride at work. Something similar might be said of drug pushers. And what can be said of “drug pushers” in the stereotypical sense can also be said of a lot of respectable MDs with prescription pads: both doctors and pushers play fast and loose with the law in harmful or fraudulent ways that might justify coercive responses.

It’s not clear that every one of these problems requires a coercive response, but if not, it’s not clear how to draw the line between a tough response that falls short of coercion, and a response that literally initiates coercion. Drawing that line is a philosophical matter with enormous practical consequences. Our war on drugs is a crazy, immoral idea that involves the functional equivalent of an addiction to coercion. The problem is, it’s not clear whether our addiction to coercion can really be cured by a cold-turkey remedy. And just as addiction doesn’t quite prove that substance use is wrong in all cases, the malfeasances of the war on drugs don’t quite prove that paternalistic coercion is wrong in all cases. What those malfeasances prove is that coercion has to be ratcheted way back, and radically reconceived with more sensitivity to realities on the ground. No drug counselor could do her job effectively by assuming a priori that coercion was utterly off the table for every case she confronted. On the other hand, no society can function justly if it treats the use of coercion as just another “tool in our toolbox.” The jury is out on how to draw the line between tough persuasion and coercion, and also whether that line does all or only some of the relevant normative work. But a line has to be drawn.

Defining “addiction.” Paradoxically, a second philosophical issue worth getting straight on is the definition of “addiction.” NA’s to my mind confused conception of it is just one instance of more widespread confusion. Some conceptions of addiction insist on physical dependence, others insist on craving, others still on hyperbolic discounting. Some claim that you can only be addicted to substances; others say you can be addicted to behaviors as well. Some say that addictions are always harmful; others distinguish harmful and innocuous brands of addiction. But most conceptions put the etiology of addiction squarely on the addict; few definitions of “addiction” that I’ve seen take iatrogenic addiction particularly seriously, something that may or may not be explained by the fact that those doing the defining are most vulnerable to the charge of iatrogenesis. This is a huge topic I can’t do justice to here; suffice it to say that like obscenity and terrorism, more people are against addiction than know, or at least can say, what it is.  Beware of anyone who wants to go to war against a moving target.

Moral double standards. A final point. Sitting at the NA meeting, I couldn’t help reflecting on an odd, offensive incongruity in American conceptions of “law” and “sanctuary.” When it comes to drug addiction, there seems to be a growing consensus despite the war on drugs that “offenders”–users who violate the drug laws–deserve sanctuary and amnesty, at least if they’re citizens. But when it comes to immigrants, no such dispensation is thought appropriate: “sanctuary” and “amnesty” are axioms in the one context, and fighting words in the other.

Citizen drug offenders attend NA meetings, freely confess their moral and legal transgressions, are offered counseling, go back into the world, are expected to relapse, do relapse, are forgiven for having relapsed, and then repeat the cycle almost as often as necessary. The expectation is that we’re to forgive them their transgressions and fuck-ups as a natural part of the process of healing. I have no problem with that, but if it isn’t sanctuary and amnesty, what is it?

As far as immigrants are concerned, the expectation seems to be that the smallest transgression of the law, no matter how venial or ancient, should spell legalized doom: the same drug possession that leads in one case to an NA meeting leads in the other to imprisonment, deportation, and family break-up. I’m not quick to want to haul out the “racism” card, but if that isn’t racism, it sure is an odd double standard oddly adjacent to ethnicity. If it isn’t racism, it’d be nice to have an alternative word for it.

Anyway, to make a long story short, I learned more from a bunch of drug addicts than I thought I would. Maybe you have, too.

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References

Rand, Ayn. (1990). Introduction to Objectivist Epistemology. Expanded Second Edition. New York: Signet.

Rand, Ayn. (1982). The Metaphysical Versus the Man-Made, in Philosophy: Who Needs It. New York: Signet.

Shapiro, Fred. (2014). Who wrote the Serenity Prayer? Chronicle of Higher Education (April 28).

 

Notes

[1] Though the group is called “Narcotics Anonymous,” our group leader made clear that he regarded alcohol as a narcotic, making no distinction between illegal narcotic substances and legal ones.

[2] Whatever its merits, I’m inclined to think that this rule incentivizes lying about how long one has been sober. It was often difficult to get clear in any given case on how long a speaker had been sober, and some just came out and admitted to having lied about the subject, at least in past meetings.

[3] “God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”

[4] Virtually all of the women in the group reported cases of sexual assault, at least one of them a longstanding case that started in childhood and lasted for years. All were remarkably matter-of-fact, even nonchalant, about the assaults they’d suffered, almost self-consciously contrasting their own settled attitudes with the breathless ones being reported on the news in connection with the Ford-Kavanaugh hearings.

[5] Rand 1982 contains an interesting discussion of AA and the Serenity Prayer associated with it. She writes:  “…omitting the form of a prayer, i.e., the implication that one’s mental-intellectual states are a gift from God, [the Serenity Prayer] is profoundly true, as a summary and a guideline: it names the mental attitude which a rational man must seek to achieve” (Rand 1982, 31).

It’s worth emphasizing that as an organization, NA does not “omit the form of a prayer” in invoking the Serenity Prayer, and probably would not tolerate the attempt to do so in its members. It’s essential to the group’s understanding of the Serenity Prayer that God grants the serenity, courage, and wisdom mentioned in the prayer; the latter attitudes are not, on NA’s conception, to be understood as effects of the agent’s own agency. On NA’s conception, serenity requires surrender to a Higher Power (“Your heart, mind and will take action by surrendering to this Higher Power”); though Rand sometimes writes of “surrender,” she does so in very different contexts. Indeed, Rand’s conception of mental states as essentially active makes it difficult to see how she could regard serenity, conceived of as a state of passive surrender or acceptance, as metaphysically possible (Rand 1990, 5).

In this light, Rand’s praise for AA is misconceived: “In view of the fact that today’s social-psychological theories stress emotional, not intellectual, needs and frustrations as the cause of human suffering (e.g., the lack of ‘love’), that organization deserves credit for discovering that such a prayer is relevant to the problems of alcoholics…” (Rand 1982, 31-32). Contrary to Rand, NA’s conception of the prayer refers at least implicitly to the love of a Higher Power, attributing drug addiction to alienation from the will of that Power. In any case, there is no clear sense in which serenity and courage as NA understands them are intellectual rather than emotional states, or in general that NA adopts the intellectualized conception of the Prayer that Rand has in mind. Rand’s attempt to naturalize the Serenity Prayer is interesting and ingenious, but more revisionary than she admits.