Obey Your Master: A Visit with Narcotics Anonymous

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. Continue reading

Droning On

I’m teaching the issue of drone warfare and targeted killing in one of my ethics classes, the fifth or sixth semester in a row I’ve taught this material, via Kenneth Himes’s 2016 book, Drones and the Ethics of Targeted Killing. It’s been a frustrating, even despair-inducing experience: Of the 90 or so students enrolled, only half attend. Of the 45 of who attend, 40 are utterly indifferent to the material, unmoved even by the most shocking finding, revelation, or video I can throw at them.

My students–whether rich or poor, urban or suburban, black or white–simply do not care whether drones increase or decrease the incidence of terrorist attacks, much less whether their use is in any sense morally justified. Whether drones kill innocents or kill “bad guys,” whether the targets are justified in resisting U.S. policy or obliged to lie down and take it: none of this is nearly as important as whatever they’re doing on their phones. Continue reading

Questions About the Parkland Shooting (1): Whatever Happened to Patient Confidentiality?

The Parkland shooting seems to be one of those “tipping point” events that–like Ferguson in the case of the abuse of police power–may well change the trajectory of the debate over guns and gun control in the United States. At this point, it seems premature to come to any definite conclusions, whether about the shooting, or about what follows from its having happened the way it did. What seems more obvious to me is that far too many questions are going unasked. Here’s the first of several posts devoted to questions provoked by the shooting and the response to it–this first one provoked by the ease with which journalists seem to have gotten their hands on psychiatric or quasi-psychiatric reports having to do with the shooter’s state of mental health.

A question for people in social work/law enforcement: is there a legal/ethically legitimate way of getting hold of an adult welfare report by some equivalent of a Department of Children and Families as described in the article linked to just above? Or is journalistic reporting on the Florida DCF report on Nikolas Cruz based on a confidentiality-violative leak? Here’s some typical reporting on the release of the report, which is described as “confidential” in the same breath as it’s described as a matter of public record. Continue reading

“We’re Not In Wonderland Anymore, Alice” (Charles Manson)

I’ve contributed to The Health Care Blog a couple of times and follow its posts to stay on top of issues relevant to health care. Dr. Al-Agba wrote this article recently in relation to the recent shooting at Bronx-Lebanon Hospital in the Bronx (see link here). I think Manson was wrong; I think we are, indeed, still in Wonderland as it pertains to mass killings.

Dr. Al-Agba makes the very good (and one might argue rather obvious) point that organizations we work for have an obligation to take threats to our personal safety seriously. Today, if an individual threatens suicide, most people know that such threats should be investigated. Lives have been saved as a result.

Still not so with homicidal threats despite the carnage (and I’ve been maintaining this to anyone who will listen since I studied school shooters in the late 1990s while a student at John Jay College of Criminal Justice; it has been discouraging to know that not many have listened). This is the most pertinent line from Dr. Al-Agba’s article: “After his resignation, Dr. Bello warned former colleagues he would return someday to kill them.” Bronx-Lebanon did what in response to this threat? It’s not clear but so far I have found no evidence to suggest they took any action (i.e., reporting it to police? Seems like that would have been a good place to start).

Dr. David Lazala, who worked with Dr. Bello, described him as “very aggressive, talking loudly, threatening people,” and said that he had been threatened by Dr. Bello via email after Dr. Bello had been terminated. I could not find out if Dr. Lazala told Bronx Lebanon about these threats. But even if he had, consider what Bronx Lebanon would have done after you read about my experiences working as a clinician in New York City since 2003. Continue reading

Lies and Omissions of the “Opioid War”

I’ll be writing a series of little posts here about various articles in the media regarding the war on opioids, as I find that the news media often doesn’t tell the full story, and seems to be following (or promoting) a morality play or political narrative, rather than actually presenting the problem as it is.

This article from The Economist I found curious mainly because writers such as this almost always maintain — without any real attempt at argument– – that prescription opioids don’t “work” for chronic pain. As a someone who suffers from chronic pain, I can assure you that nothing could be further from the truth.

Prior to having spinal fusion in 2013, I was on a long-acting prescription opioid. Because I still had some pain, I thought the medicine wasn’t working, so I went off of it, only to become essentially nonfunctional for six weeks. I was in so much pain that I lost my wallet, my keys, my Kindle, my smart phone, and even my car all within a span of six weeks.

It was then that I discovered that my spine was essentially crumbling, that I had no disk left at L5, and that L4 wasn’t looking too much better. I needed major surgery on my lumbar (lower) spine.

If we restrict access to pain medications, the result will be more people in pain, more nonfunctional, and more on disability. Back pain is the most common cause of disability in the entire world. Restrict access to pain medications in the way that so many advocates demand, and we’ll essentially be denying needed relief to millions of people in serious pain. That relief allowed me to work. Was opioid use ideal in my case? No, it wasn’t, but it kept me working, and it’s hard to discount the importance of a paycheck.

It’s already challenging enough to get these medications, even with a prescription. In fact, I’d have to see my doctor monthly to get the relevant prescriptions in New York State, where I live. The fact that these visits are both costly and medically unnecessary seems irrelevant to politicians content to sacrifice people like me to their newfound compassion for addicts.

We can do little for addicts who refuse assistance. Some of them will die. But by indiscriminately trying to control the availability of these medications both to addicts and to those who genuinely need them, we would deprive millions of people access to the medications they need to avoid having to live a life completely in thrall to physical pain. In weighing the costs and benefits of any policy concerning pain medications, it might help to imagine what it’s like to live a lifetime in serious pain–with painkillers, and without.

D.F. Kripke on the Use of Sedative-Hypnotics: A Query

Here’s a question for any PoT readers who are physicians or who otherwise have experience prescribing sedative-hypnotics (aka, “sleeping pills”):

I’ve been working through D.F. Kripke’s paper “Mortality Risk of Hypnotics: Strengths and Limits of Evidence,” which claims that “hypnotics cause huge risks of” premature death in those who use them. In many ways, the paper strikes me as a methodological disaster area (here’s a cogent critique), but I’m curious what any physicians/prescribers out there think about two of the anecdotal claims Kripke makes about physicians who prescribe sedative-hypnotics. Continue reading

From the Nicomachean Ethics to the Grant Study

[Here as promised is a first draft of the paper I’ll be giving this Saturday at the annual conference of the Association for Core Texts and Courses in Plymouth Harbor, Massachusetts. Papers for the conference are supposed to be short, non-technical treatments of a core text or two appropriate for undergraduate teaching, along with a rationale for teaching them. This year’s theme is the relation between the arts and sciences in undergraduate education. Comments are welcome, though I probably won’t see them until next week. I’ll add hyperlinks next week as well. This discussion was quite helpful to me in thinking things through.]

Continue reading

Psychology, Psychiatry, and Moral Philosophy: An Open Thread

I’ve been working on and thinking about issues at the intersection of psychology, psychiatry, and moral philosophy lately, so this (partly but not entirely edifying) discussion-thread at BHL caught my eye. I thought I’d reproduce it here, comment on it, and then just leave the comments open indefinitely for thoughts on the matter.

The discussion arises in the context of a post by Jason Brennan on whether one should go to grad school. I don’t particularly like the self-congratulatory tone of the post, but don’t disagree with the advice he gives. Early on in the post, he addresses a frequently-asked question and offers up an answer:

I like reading and discussing economics or political philosophy. It‘s my hobby. Should I go to grad school? You can do all these things without getting a Ph.D. You won’t be as good at it, but you can read and discuss economics while holding down a job as an insurance agent, a lawyer, or a consultant. You might be able to maintain your hobby while making a lot more money.

It’s not very adeptly or tactfully put, but on the whole, I agree with Brennan. His point is not that a non-PhD. cannot in principle be as good as PhDs at philosophy. His point is that the generalization holds as a rule: generally speaking, and given current economic and institutional realities, you need a PhD to excel at philosophy. There are some notable exceptions to that rule, of course. Some of the most brilliant and successful academic philosophers got into the profession back in the day when a PhD was considered unnecessary (e.g., Alasdair MacIntyre, Colin McGinn, Saul Kripke), but no one holds not having a PhD against them. Coming the other way around, I know  non-academics out there (without PhDs) who can hold their own–and then some–with many PhD philosophers. But I think such people are the exception, not the rule. Ultimately, one has to commit the fallacy of accident to deny the truth of what Brennan is saying. We can recognize that exceptional cases exist while acknowledging the truth of the rule he’s identified.

Perhaps Brennan should have qualified what he said to accommodate the exceptional cases, but I also think it’s clear he had a very different sort of case in mind–e.g., the middle manager who wants to do philosophy on the side.  I think Brennan is correct to think that such a person will tend not to be as good at philosophy as the PhD philosopher from a top-20 school (Arizona, Princeton, Rutgers, Oxford, Pittsburgh, etc.) who is herself working at an R1 school and (therefore) doing philosophy all day. (And most would come out and admit it.)  The more invested you are in your day job, the heavier its demands. But the heavier its demands, the fewer resources you have to devote to philosophy. Given the (very) heavy demands of doing good philosophy, having fewer resources means, all things equal, you won’t do it as well as someone with more resources at her disposal. As someone who spent nine years temping and adjuncting before finding a full-time academic position, that doesn’t seem controversial to me.

It’s not much different than the situation of the guy who spends eight hours a day working assiduously on his guitar chops versus the guy who noodles a bit on his prized Gibson SG after a long day at work. The first guy might make it in the music business, if he’s lucky and other things come together; the second guy may do a gig of AC/DC covers at the local bar (if they let him in), but can’t expect to headline Met Life Stadium (capacity: 88,000), or for that matter, headline the local equivalent of the Wellmont Theater (capacity: 1,200). (Again, I should know.)

The conversation took a different (and actually, more interesting) direction after an intervention by someone named Val, a psychiatrist, who jumped in with this comment just below. Responding to the Brennan passage quoted above, he or she had this to say (sorry for the pronoun ambiguity, but “Val” could be either male or female):

Rubbish and simple minded navel-gazing. Except for the unique subspecialty of a Ph.D tenured research professor (“I’m the foremost expert on La Rochefoucauld’s writing of the year 1678!”), anyone who puts in the time and is clever can speak on intellectual issues with equal footing. You can certainly be “as good at it” in whatever interests you.

I’m a psychiatrist attached to a large research university and spend most of my day as a clinician. The philosophy professors who have careers focusing on ethics, political philosophy, or Scholasticism are barely on equal footing with the well-read clinicians who have been reading the epistemology of science for the last 25 years.

I think Val’s comment talks somewhat past Brennan’s. Yes, “anyone who puts in time” can speak with equal footing, but Brennan’s point is that if you have a day job, the better the job, the less time you’ll have to put in. The worse the job, the less sense it makes to do philosophy rather than get yourself a better job (and then do philosophy, in which case, it’s back to the first option). There are exceptions to this rule, too, but as a rule, it holds. Val’s situation is unique, and escapes Brennan’s point, but doesn’t generalize to the cases Brennan is discussing–the majority of cases.

Unfortunately, Brennan, given an opportunity to re-direct the conversation, only had this to say:

Val, I bet you just think you’re smart because of the Dunning-Kruger effect.

Clinical psych is easy as pie. It’s what people with bad GRE or MCAT scores do.

It’s a somewhat cryptic–and actually pretty stupid–response. The first sentence is just a particularly abusive instance of poisoning the well. The second sentence suggests that Brennan is under the impression that Val is a clinical psych(ologist). In other words, his implicit reasoning is:

You must be one of those dumb people who’ve opted to work in clinical psychology. Your GRE scores were probably too low to work in a difficult field, like philosophy, economics, or cognitive psychology. Your MCAT scores were probably too low to get you into a good medical school, or to get you in at all. So you opted for the easy way out–clinical psychology. And given that, you must think you’re particularly smart because you’re operating under the Dunning-Kruger effect. Being a victim of that effect, you’ve taken umbrage at my suggestions, but that’s because the effect has deluded you.

One problem here is that Val is a psychiatrist with an MD. So the GRE is irrelevant to his/her situation, and he/she obviously did well enough on the MCATs to get into med school, get an MD, go into practice, and get attached to a research university.

A second problem is that even if there was a documented correlation between low GRE/MCAT scores and the choice of clinical psychology as a profession, it wouldn’t follow that clinical psychology was “easy.” The more obvious inference would be that neither the GRE nor the MCAT was designed to test skill or aptitude in clinical psychology. A little Howard Gardner might have gone a long way here.

Personal experience might help, too. Brennan often likes to talk about his, so here’s a bit of mine. I spent part of grad school writing GRE questions for the Educational Testing Service (ETS), so I have a fairly good sense of what’s involved in designing them, including what they test and what they don’t test. There’s a lot that they don’t test, and a lot in them, methodologically and substantively, that is highly debatable, regardless of what ETS’s in-house psychometricians will tell you. Keith Stanovich’s work is relevant here.

It’s a great irony, by the way, that a large number of the item writers for the GRE (and personnel at ETS generally) are people who, by Brennan’s standards, are academic failures–i.e., grad students, often at Rutgers, Princeton, Temple, or Penn, who’ll never get a tenure track R1 job, or grad students (Rutgers, Princeton, Temple, Penn) who never finished their programs. So lots of Brennanite “failures” end up being the gate-keepers for the Brennanite “winners.” Something similar is true of the PRAXIS exam: I wrote items for PRAXIS at a time when, as a doctoral student without a teaching certificate, I was writing exam questions for a profession I wasn’t permitted to enter–and the questions I wrote were for an exam involving the very credential I lacked for purposes of entry!

A bit of advice, then: Brennan tells people who might want to go to grad school, but shouldn’t, to get a job at GEICO. I would say, instead: get a job at ETS. I worked there as a part-timer for almost six years before I got a full time academic position. It was a good place to work. Not my first preference, but still.

Incidentally, if I were Jerry Springer, at this point I would say that one important lesson we learn here is not to accuse someone of being a victim of the Dunning Kruger effect, accuse him/her of bombing the GRE, and misread what he/she wrote all in the same comment.

Anyway, back to Val’s comment. I sort of agreed, sort of disagreed. So here’s what I said:

I’m a PhD philosopher working on a master’s degree in counseling psych. I spend a fair bit of time discussing philosophy vs clinical psychology and/or psychiatry with people in those fields. I see where you’re coming from, but don’t agree with you (not that I agree with Brennan’s comment below*).

An enormous amount of the literature in both clinical psychology and psychiatry strikes me as methodologically weak and substantively trivial. (Much of it also makes huge, unwitting assumptions about difficult issues in the philosophy of mind.) The clinical work that (good) psychiatrists do gives them practical experience that philosophers don’t typically have (fair enough), but it’s very narrow and doesn’t equip them with the resources to think about bread-and-butter philosophical issues. In any case, for many psychiatrists, “clinical work” nowadays means “medication management,” not therapy. I don’t see how expertise at managing a dosing schedule gives a person insight into the foundations of ethics. I’m willing to hear the argument, but off hand, I don’t see it.

That’s not to say that there aren’t brilliant philosopher-psychiatrists out there (e.g., Jonathan Lear, Richard Chessick…Sigmund Freud), i.e., people with excellent philosophical skills who have capitalized on their clinical work. I’d also be willing to say that they have insight and understanding that most philosophers in the field lack. But that’s a far cry from the claims you’re making.

One look at Brennan’s derisive comment below* should tell you that if you were looking for intelligent engagement with your arguments, you’ve come to the wrong place. If you’re interested in discussing the issues, feel free to come by my blog or contact me privately (contact info at the blog). I sometimes blog on issues at the intersection of philosophy and psychology in the broad sense (that includes psychiatry), and wouldn’t mind batting this one around. We’re mostly philosophers, but there are some psychologists and psychiatrists lurking in the “audience.” You might find it fruitful to have a conversation with us. And rest assured, we won’t ask you about your MCAT score or reduce your arguments to a diagnosis.

Val saw what I wrote and had this to say:

Irfan – I agree with a good deal of what you have said. An enormous amount of psychology and psychiatry research is indeed methodologically weak. As the saying goes, nearly of all of psychology research is trivial if true, and if attempting to show something non-trivial, is impossible to convincingly demonstrate. My experience as well has been that most psychologists and psychiatrists are grossly ignorant of the surrounding philosophical issues.  However, there are plenty of psychiatrists that I work with who are keenly aware of the epistemic problems of the assumptions inherent in modern psychiatry and are well read in the psychiatrist-philosophers, (Jung, Jaspers, Freud…Popper is also popular. Human Action was recently under discussion in the geriatrics department). …

I agree with that, of course. I also think it goes the other way. Most philosophers are grossly ignorant of psychology and psychiatry, but it’s unclear to me (one year into a psychology program) how much of a debility that turns out to be. If so much psychology research is trivial, what leverage does one get out of relying on it to do moral or political philosophy? Some, I think, but it’s difficult to articulate what it is.

Same issue from a different direction: as a journal editor and conference organizer, I read dozens of manuscripts in ethics and political philosophy from authors who are trying (sometimes trying too hard) to showcase their familiarity with cutting edge work and cutting edge ways of doing philosophy. A large proportion of this work showcases the latest work in psychology. Decades ago, Robert Nozick told us that either we work within Rawls’s system, or explain why not. Now the same is implicitly being said of Jonathan Haidt. It is, one might say, a haidtful state of affairs.

Much of this psycho-philosophical experiment-mongering strikes me, frankly, as trivial, and if you dig hard enough, you find in many cases that philosophers tend, subtly (or not so subtly) to overstate, distort, and cherry pick research findings from psychology to make them less trivial than they are.

The truth is, by comparison with the intuition-mongering philosophy literature, the psychological literature tends to be very, very equivocal. Here’s a random example that I just happened to read yesterday, Daniel Wegner and Sophia Zanakos, “Chronic Thought SuppressionJournal of Personality, 62:4 (December 1994). The abstract says:

We conducted several tests of the idea that an inclination toward thought suppression is associated with obsessive thinking and emotional reactivity….[Our measure of thought suppression] was found to correlate with measures of obsessional thinking and depressive and anxious affect, to predict signs of clinical obsession among individuals prone toward obsessional thinking, to predict failure of electrodermal responses to habituate among people having emotional thoughts.

Then you read the article and the qualifications start coming: “Throughout this article, we have tried to caution that our intepretations of these results are not the only possible interpretations at this time” (p. 636).

It’s one of dozens of examples I could have used, from cognitive to clinical to political psychology. I’m not faulting the authors. My point is: psychology findings do not easily lend themselves for use as “inductive backing” for some controversial claim in ethics or political philosophy. They just aren’t written that way, or with that purpose in mind. But that’s the way philosophers often use them, at least in my experience. The psychology research of the philosophers is a lot like the God of the philosophers: not the original article. Philosophers seem wedded to the psychology of journal abstracts, not journal text–to unqualified thesis statements, not to the thesis-death-by-a-thousand-qualifications-followed-by-recommendations-for-more-grant-funding-and-research that one typically finds in the text. The jury is still out for me, but I often find myself wondering how useful all this psychology-mongering really is for philosophy.

Of course, then I read hand-waving, flat-footed philosophy that resolutely ignores the empirical literature, and I swing the other way. It also helps to read classic texts–Aristotle, Aquinas, Hobbes, Locke, Freud–and see how much they got wrong, empirically speaking. (Just think of what passes for biology or cultural anthropology in any one of these writers.) I just got finished reading Calvin Hall’s Primer of Freudian Psychology, published in 1954. One doesn’t think of 1954 as being that long ago–the Eisenhower Administration wasn’t ancient history–but the author has the nerve (so to speak) to assert that asthma, arthritis, and ulcers are psycho-somatic effects of ego defense mechanisms (pp. 85-87). Primal repressions, we’re told, arise in Lamarckian fashion via the “racial history of mankind” (p. 85). I guess sometimes pseudo-science is just pseudo-science. So I’d be the last to trash appeals to hard fact as a constraint on normative theorizing.

Val again:

I’ve often thought that psychiatry rewards the philosophically minded more than any other specialty. General medicine, for instance, largely reduces to this model: is the blood sugar >6%? If yes, implement algorithm given to you by the Joint Commission. Pattern recognition and memorization required, but not a lot of analysis.

In psychiatry, if a patient complains of depression, you have to say, what does depression mean to this patient? Is depression even real? How can I judge this patient as having depression when there are no absolute standards? How will I know if his depression is responding to treatment? Why is the treatment even working? What caused the depression? Why do some develop depression in similar circumstances but not others? Good clinicians conceptualize patients in such a manner, and this is how they are discussed at conferences. Poor psychiatrists uncritically push pills.

MIT press released a very good collection last year, Classifying Psychopathology, for sale on the shelves in the medical school book shop. I doubt very much a well read psychiatrist wouldn’t be “as good” (to use Brennan’s silly words) at discussing the contents as a Ph.D philosopher who specialized in ethics.

I agree with most (or a lot) of that, but notice that the context of Val’s comment is psychopathology. Yes, within that context, psychiatrists have a lot of challenging, important philosophical work to do. But the context is itself very narrow. You can master all that there is to know about psychopathology, whether psychiatrically or philosophically (or both), and still be light-years away from dealing with issues that are central to ethics.

Anyway, there’s a lot to think about and respond to there. To keep this post within reasonable length, I’ll post any further thoughts I have in the combox. But I figure that some of PoT’s lurking readers may have things to say–there are some psychologists and at least one psychiatrist out there, along with a few non-psychiatrist MDs–so I’ll just leave this open for comment.

*Brennan’s comment was below mine when I first wrote. As of March 9, 2015, Brennan’s response to Val no longer bears his name, and is attributed instead to an anonymous “Guest.” The same is true of a few other comments of his in that discussion.

Conference Announcements

Just a reminder: the due date for submissions for the Ninth Annual Felician Institute Conference on Ethics and Public Affairs is this coming Sunday, March 1. We’ve got some great submissions already, but there’s still room for more. For more information, here’s a link to the Institute’s website. The conference itself is to take place Saturday, April 25, 2015 at Felician’s Rutherford campus. The plenary speaker is James Stacey Taylor of The College of New Jersey, defending the idea of markets in political votes.

My friend Graham Parsons is organizing what promises to be a great conference on the Ethics of War at West Point Military Academy (WPMA), to take place at WPMA on Friday, March 27, and Saturday, March 28, 2015.  Nigel Biggar, Richard Miller, Fiona Robinson, and Jeremy Waldron will each address plenary sessions; Michael Walzer will provide the keynote address. I’ll be there for Walzer’s address as well as the Saturday sessions, so if there are any PoT readers at the conference, let’s meet up.

An afterthought: I’ll be giving a paper (really, a mini-paper) at the 21st annual meeting of the Association for Core Texts and Courses at the Radisson Hotel in Plymouth, Massachusetts (April 9-12, 2015), so if there are any PoT readers at that conference, let’s make sure to meet up there.  My paper is called “From Nicomachean Ethics to the Grant Study: Virtue Ethics Meets Behavioral Science” (slightly modified from what I submitted). Here’s my four-sentence abstract:

George Vaillant’s Adaptation to Life (1977) is a classic of contemporary behavioral science; meanwhile, Aristotle’s Nicomachean Ethics is one of the founding texts of ancient Greek moral philosophy. Both texts implicitly address the same topic, but each does so in ways that fundamentally contradict the claims of the other. Given this, it’s a useful (and entirely Aristotelian) exercise to read the two books in tandem, using the one to challenge and correct the claims of its rival. The resulting inquiry leaves us with a better sense of the strengths and weaknesses of both behavioral science and moral philosophy, and leaves us with some difficult questions as well.

I’ll post parts of the paper here, as well as the exact date/time I’m giving it, in a few weeks. A recent article on the Grant Study (ht: Kate Herrick).

Addictions, Cravings, and Compulsions: Challenging the Frankfurtian Model (with two postscripts)

Readers of this blog know, or may remember, that yours truly was, briefly, a drug addict. It was actually a rather interesting experience to undergo, philosophically speaking, and one of the things I did while going through it was to read up on the philosophical and psychological literature on addiction, and to compare what I read there with my own six-month experience of addiction. I have a folder full of journal entries on the subject–at least a hundred pages or so–and some day I’d like to get some of that material out there into “the literature.”

A basic problem with the literature, as I see it, is that very few of the people writing in it either are, or have ever been addicts, and their lack of first-hand experience distorts much of what they write on the subject.* Their definitions of “addiction” are far too narrow to cover the varieties of addiction (even to cover the varieties of specifically pharmacological addiction, setting aside the supposed behavioral varieties, e.g. sex addiction, shopping addiction, etc.). And by my lights, they’re far too timid about considering the possibility that addicts are responsible for having becoming addicts, and are capable of choice as addicts.

But one particularly problematic assumption, ubiquitous in both the philosophical and psychological literature, is the claim that addiction necessarily involves a craving for the addictive substance. The paradigm example of this assumption is the celebrated discussion of addiction in Harry Frankfurt’s famous paper, “Freedom of Will and the Concept of a Person” (originally published in the Journal of Philosophy, 68:1 [Jan. 1971], reprinted in The Importance of What We Care About [1988]). It’s in many ways a very insightful paper, and like a lot of people, I’ve been heavily influenced by it. Reading Frankfurt while I was an addict, however, I couldn’t help thinking that he’d generated a conception of “addiction” designed specifically to clarify the thought-experiments in the essay, regardless of whether any of it bore any relation to the real-world phenomenon of addiction.

Whether it’s explicitly cited or not, the Frankfurtian conception of addiction plays an outsize role in the literature on addiction. And it’s not hard to see why. Suppose that you’ve never been an addict, but are interested in the topic. Suppose that you don’t know any addicts, either. How do you know what it’s like to be one? As it happens, you can’t really get a visualizable “picture” of addiction by reading social scientific or psychiatric studies of addiction in peer reviewed journals, by reading the “substance abuse” chapter of a textbook of abnormal psychology, by consulting the newest version of DSM, or by reading either the philosophical or psychological literature on “addiction science.” Nor will it help to attend lectures of this sort. The preceding sources will give you important facts about addiction, and teach you how to logic-chop some important distinctions. They’ll give you some important vocabulary, as well, and introduce you to the various “models” of addiction. But they won’t tell you what it’s like to be an addict, and like it or not (so to speak), the first-person perspective is crucial for understanding what it is to be one.

Enter Frankfurt: Frankfurt gives his readers a vivid “picture” of what it’s like to be an addict. Though it’s a third-personal account, it’s vivid and detailed enough to enable a non-addict to imagine what it would be like to be a (Frankfurtian) addict from the first-person perspective. And clearly, it would suck: a Frankfurtian addict is someone with an irresistible first-order craving for a pharmacologically-addictive substance. Either he resists this first-order craving at the second-order level, or not, and different implications follow in each case. Frankfurt never mentions by name what addictive substance he has in mind, but I get the impression that he’s discussing a stereotypical case of either heroin or cocaine addiction (or perhaps alcoholism).

As I say, it’s an interesting discussion, but I find the picture it paints of the addict very misleading. In particular, I don’t think there’s good reason to think that cravings are either necessary or sufficient for addiction.

To see this, consider a somewhat stylized, thought-experimental version of my own case of addiction. Imagine a very strict Kantian who goes to the doctor with some medical complaint. Our Kantian takes his doctor to be a reliable authority on medical matters, and regards following his doctor’s orders as a matter of duty to self. Further, our Kantian discharges his duties to self from the motive of duty. In other words, if the doctor tells him to do something, he does it because it’s his duty (to self), whether or not he wants to.

So our Kantian goes to the doctor with some medical complaint, and the doctor gives him strict orders to take a certain medication, X. As it happens, X is an addictive, psychotropic medication. Suppose that our patient has a temperamental hostility to the idea of taking any drug for any reason. So he really doesn’t want to take X. But he feels duty-bound to do so, under the doctor’s orders. So he grudgingly fills out the prescription and grudgingly takes X. Within a few weeks, he becomes addicted to it, but doesn’t know that he is. He might in principle continue like this for years, never grasping that every dose he takes pushes him further and further into addiction.

So here is the situation:

  • Our Kantian is ex hypothesi addicted to X;
  • He keeps taking X, thereby reinforcing his addiction to X;
  • He would suffer intense withdrawal if he stopped taking X;
  • Despite not wanting to take X, he continues to take X, but only from the motive of duty.

I take it to be obvious that you cannot have a craving for a substance that you do not want to take, and you cannot have a craving for a substance that you only take from the motive of duty. And yet you can clearly be addicted to such a substance, at least in the pharmacological sense of being physically dependent on it. If that’s right, craving for X is not a necessary condition of addiction to X. You can be addicted to X and not know it, hence not crave it. You can be addicted to X and not want to take it, but take it from the motive of duty–hence not crave it.

Reflecting a bit on my own experience, I’m willing to admit that there’s a slight complication here. (The phenomenology of addiction defies neat philosophical claims.) Even in the case of the Kantian addict, I think it’s possible that though our Kantian doesn’t want to take X, and takes it from the motive of duty, the pharmacological/physiological effects of addiction can alter one’s personality so that he’s in some sense psychologically compelled to take X without craving it.

This is an odd thought (and phenomenon), and I would have dismissed the possibility out of hand had I not experienced it myself. Think of it like this. Suppose that our Kantian takes X from the motive of duty and only for that reason. He doesn’t like taking X, wishes he didn’t have to, doesn’t want to. But dutiful Kantian that he is, he takes it. Suppose he takes it every night at precisely 10 pm. As 10 pm approaches, he might find himself in the grips of some very odd internal states. He might, for instance, develop an anxious compulsion to take X, or an uneasily anxious feeling about the idea of not taking X. He would thus find himself in the odd state of taking X from the motive of duty, not wanting to take it, but anxiously feeling compelled to take it, and averse to the idea of not taking it–all at the same time. I actually felt like that fairly often.

Related is the possibility that if our addict fails to take X promptly at 10 (and is sufficiently addicted to it), he either senses or subconsciously anticipates the onset of withdrawal symptoms, and develops a vague (but powerful) psychological compulsion to hurry up and take it. (“Hurry up, please, it’s time….”) Remember, ex hypothesi  that our Kantian neither knows that he’s addicted nor knows that withdrawal is an issue. My point is that the physiology of withdrawal can to make its presence felt in his appetitive states despite his ignorance.

Some might be tempted to call this physiologically-induced appetitive presence a “craving,” but it doesn’t feel, phenomenologically, like anything I would call a craving. In retrospect, I think of it as a classic case of chronic, pharmacologically-induced anxiety.  I’m inclined to think that in a Kantian, this anxiety would manifest itself as a specifically deontic compulsion: the compulsion to take the drug would not be experienced, phenomenologically, as a “craving” for it, but as a very urgent, anxious imperative to the effect that X must be taken. (“Hurry up, please, it’s time….”) But an imperative or an anxiety is not a craving in the ordinary understanding of that term, even if it produces a compulsion to do something. (I’m not a Kantian, but the picture of the Kantian agent I’ve painted here approximates my own experience of addiction. One feature of addiction is that it alters your personality so that you find yourself doing things that would otherwise be “out of character,” and yet weren’t produced ex nihilo, either.)

I suppose you could reintroduce the idea of craving here by claiming that our Kantian has a craving for the substance under the guise of a “craving” for doing his duty from the motive of duty, but even if that is a coherent thought (I’m not sure it is), it’s so distant either from Frankfurt or from what the literature describes as a “craving” that we’d have to revise our understanding of “craving” to be able to use it this way.

So while I want to insist that cravings are not a necessary condition for addiction, I’m willing to accommodate some version of the phenomenon that the Frankfurtian picture ascribes to addiction: addictions involve compulsive or anxious behavior, but compulsions are not accurately described as “cravings.” (It’s essential to my account that in large part, the compulsion or anxiety has a pharmacological etiology. Of course the pharmacological etiology could itself have a psychological one.)

I think it’s obvious that cravings are not sufficient for addictions. We crave many things, but it’s an abuse of language to say that we’re addicted to them. I crave knowledge, but I can’t be said to be addicted to it in the way that I was addicted to Ambien. I once had a three-year-long craving to listen to a single album (AC/DC’s Black Ice): I listened to it several times a week for three solid years. But that wasn’t an addiction in the relevant sense, either. I’m very skeptical of the extension of the concept of “addiction” to behavioral contexts without a pharmacological component, e.g., sex addiction, porn addiction, shopping addiction, etc. In my view, “addiction” is a specifically pharmacological concept involving the ingestion of a physical substance and a neurobiological mechanism that produces physical dependence on the substance.

A final observation: I get the sense that the addiction literature has not fully taken on board the possibility that prescription drugs are, like “illicit” drugs, highly addictive, psychotropic substances.** The literature, then, seems fixated on addictions to alcohol, heroin, cocaine, cigarettes, and the like, and has much less to say about FDA-approved drugs–neuroleptics, anti-depressants, stimulants (including caffeine), benzodiazepines, SSRIs, and so on. That seems to me a massive omission. If anything, it’s the latter category that needs more sustained philosophical attention than the former. I hope to give it some more attention in future posts here.

*A notable exception to this rule is Owen Flanagan of Duke University. See Flanagan’s “What Is It Like to be an Addict?” in Jeffrey Poland and George Graham, Addiction and Responsibility.

**Flanagan is, once again, an exception to the general rule. See the preceding note.

Postscript, March 2, 2015: A simpler and more obvious counter-example to the “craving conception” of addiction just hit me. Suppose that X is addicted to a psychotropic medication, and simply forgets to take it at the appointed time. Surely forgetting to take X is incompatible with craving X. QED.

Anyone who doubts the supposition (that psychotropic medications are addictive) can either check the Physicians’ Desk Reference or Peter Breggin’s Psychiatric Drug Withdrawal for clinical information, or Robert Whitaker’s Anatomy of an Epidemic for narrative/anecdotal accounts.

Obviously, an even simpler counter-example to the craving conception of addiction is the (to me, obvious) phenomenological fact that people can be addicted to psychotropic drugs, experience no craving for the drug whatsoever, and willfully “go off their meds” when they decide for whatever reason to do so. The example in the post is, after all, just an elaborate way of saying that.

According to Jon Elster, “All addictive behaviors seem to go together with some form of craving. The idea of craving–the most important explanatory concept in the study of addiction–is complex” (Jon Elster, Strong Feelings: Emotion, Addiction, and Human Behavior, p. 62). I agree that the concept of craving is complex, but the rest of Elster’s claim–an axiom of the literature on addiction–seems hopelessly wrong to me. It either ignores the possibility (and reality) of iatrogenically-induced addiction to psychotropic medication, or else consigns it to a different, and ultimately marginal conception of addiction that plays almost no role in the sexiest, most prestigious books and journals. The literature doesn’t yet seem to have taken seriously the possibility that doctors can impose addictions on unwilling and unwitting patients.  The very definition of “addiction” manages to get doctors off the hook, so to speak, and manages to blame the victims.

For another couple of examples of the craving assumption, check out Merle Spriggs’s “Autonomy and Addiction,” (PDF) especially pp. 6-7, along with the reference to Morse (n.42).

Postscript, September 28, 2015: I’ve been in the market for a therapist lately. To find the right one, I made an initial list of seven who seemed suitable, drawn mostly from the overlap between the Psychology Today “Find a Therapist” listing and the one for my insurance carrier. One turned out not to be available, one never responded (not the first time), and the conduct and demeanor of a third struck me as off-putting and unprofessional.

So I made appointments with the remaining four, three of whom turned out to be excellent, but one of whom, a PsyD (for whatever that’s worth), struck me, frankly, as a hack. Within short order, Dr. Hack had driven the intake session down (what seemed to me) an irrelevant byroad, and had decided to conduct an aggressive interrogation designed to uncover my flaws as a person. The “flaws” tumbled out, one after another, all based on inferences that no human being could legitimately have made about a stranger within twenty or thirty minutes of meeting him.

It didn’t take Dr. Hack long to conclude that I was clinically depressed and needed to go on an anti-depressant. My affect, Dr. Hack informed me, was “flat,” and that flatness was an infallible indication of depression. It hadn’t occurred to Dr. Hack that perhaps the “flatness” of my affect was a response to the flatness of his personality. When I protested that I didn’t think I was depressed (at all)–didn’t feel depressed, didn’t meet the clinical criteria of depression–I was abruptly told that that was precisely how depression manifested itself in men (as opposed to women): men denied their depression in bouts of irritation and rage; women “stayed in bed all day.” The latter had become the societal stereotype of depression, Dr. Hack informed me, but since atypical depression is still depression, I’d have to accept a diagnosis of depression, whether I liked it or not. And that meant going on an anti-depressant as a condition of working with Dr. Hack, too. Dr. Hack magnanimously allowed that he wasn’t qualified to tell me precisely which anti-depressant at which dose; that was a job for a psychiatrist. But the bottom line was: no anti-depressant, no therapy.

That made things easy, since I had no intention either of going on an anti-depressant or of working with Dr. Hack. Bottom line: I unloaded my co-pay and got the hell out of there.

I tell the story because I think it tells us something about the therapy profession today as well as about its relationship to psychotropic medications.

For one thing, I think therapists suffer from a real problem of professionalism. Even when they get PsyD’s, a supposedly practical doctorate, some of them don’t seem to learn the basics of professional etiquette. Going back to one of the therapists I called before I met Dr. Hack: it’s not kosher to ignore a legitimate query regarding professional services you’ve advertised. You may not want a certain client, even based on the message they leave on your voice mail, but it’s not legitimate to ignore them as though they’d never called you at all.

Therapists like to think of themselves as “health care practitioners,” but don’t seem to have grasped that behavior like that is flatly unacceptable in a health care profession. Incidentally, for a profession so eager to regulate the rest of the world, it’s amazing how proprietary they can be about their supposed right to refuse service (or refuse to contact potential clients) on the basis of whims and hunches about X’s “sounding like” the proverbial “problem client.” In conversation outside of clinical contexts, I’ve heard therapists tell me, sotto voce, “Oh, I stay the hell away from clients like those.” Fine: you have the right to stay away from a certain kind of client. You don’t have the moral right to delete a legitimate query from an unwanted client without further ado.

A second aspect of the same problem: the rush to clinical judgment. As a rule, no therapist can (legitimately) give a DSM-5 diagnosis within thirty minutes of the first intake session. Maybe there are clinical geniuses out there–and/or sufficiently simple cases–that are exceptions to that rule, but otherwise, it seems to me a pretty clear rule.

A corollary of the rule is that you shouldn’t be reaching for the prescription pad half-way before the first session is done. Yes, there are some obvious exceptions to that rule, but the exceptions don’t find their way that often to the average therapy office.

Further implication: prescription is a medical judgment. That means that if you’re going to prescribe a psychotropic medication, you’d better have done a history and physical on your client/patient in the medical sense. If you don’t know how to do a history/physical–and most therapists don’t–then you have no business talking about prescriptions. By “talking about prescriptions,” I mean: saying anything that asserts or implies that the client needs a prescription for some psychotropic medication. At best, a non-MD has the professional right to refer the client out to an MD, but that’s it. Otherwise, my view is that they should keep their mouths shut on the subject.

One more implication: Given the way graduate programs in psychology are currently structured, no PsyD (qua PsyD) ever has any business talking about prescriptions.  Maybe some day, PsyD’s and Ph.D’s will be educated so as to know what they’re doing when it comes to psycho-pharmacology–my friend Ray Raad has made some interesting arguments for that–but that day hasn’t arrived yet, and won’t arrive anytime soon. Until then, I’d prescribe silence.

The mental health professions have expanded the concepts of “mental illness” and “addiction” far beyond what those terms mean in ordinary discourse. Maybe we ought to consider medicalizing the overprescription of psychotropic medications by mental health care practitioners. I’d be interested to see the profession’s reaction to the proposal that overprescription is itself a mental illness or an addiction. At that point, it seems to me, the old adage “physician heal thyself” would come to have new and revolutionary meaning. A thought for DSM 6.