Week 3 Discussion
salel.rgpl3
Week3TheExperienceofAddiction.pdf
O R I G I N A L P A P E R
The Experience of Addiction as Told by the Addicted: Incorporating Biological Understandings into Self-Story
Rachel R. Hammer • Molly J. Dingel •
Jenny E. Ostergren • Katherine E. Nowakowski •
Barbara A. Koenig
Published online: 19 October 2012
� Springer Science+Business Media New York 2012
Abstract How do the addicted view addiction against the framework of formal theories that attempt to explain the condition? In this empirical paper, we report on
the lived experience of addiction based on 63 semi-structured, open-ended inter-
views with individuals in treatment for alcohol and nicotine abuse at five sites in
Minnesota. Using qualitative analysis, we identified four themes that provide
insights into understanding how people who are addicted view their addiction, with
particular emphasis on the biological model. More than half of our sample articu-
lated a biological understanding of addiction as a disease. Themes did not cluster by
addictive substance used; however, biological understandings of addiction did
cluster by treatment center. Biological understandings have the potential to become
dominant narratives of addiction in the current era. Though the desire for a ‘‘unified
theory’’ of addiction seems curiously seductive to scholars, it lacks utility. Con-
ceptual ‘‘disarray’’ may actually reflect a more accurate representation of the illness
R. R. Hammer (&) Mayo Medical School, 200 First Street SW, Rochester, MN 55905, USA
e-mail: [email protected]
R. R. Hammer
Seattle Pacific University, Seattle, WA, USA
M. J. Dingel
University of Minnesota, Rochester, MN, USA
J. E. Ostergren � K. E. Nowakowski Mayo Clinic Biomedical Ethics Research Unit, Rochester, MN, USA
J. E. Ostergren
School of Public Health, University of Michigan, Ann Arbor, USA
B. A. Koenig
Department of Social and Behavioral Sciences, Institute for Health and Aging, University of
California, San Francisco, CA, USA
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Cult Med Psychiatry (2012) 36:712-734
DOI 10.1007/s11013-012-9283-x
as told by those who live with it. For practitioners in the field of addiction, we
suggest the practice of narrative medicine with its ethic of negative capability as a
useful approach for interpreting and relating to diverse experiences of disease and
illness.
Keywords Addiction � Substance use disorders � Narrative therapy � Biological etiology
Introduction
The National Institute of Drug Abuse’s active endorsement of addiction as a ‘‘brain
disease’’ has been described as an attempt to create ‘‘a unified framework for a
problem-based field in conceptual disarray’’ (Campbell 2007). This increasingly
popular biological model—addiction as a ‘‘disease of the brain’’—reduces the
problem to a system of spent neurotransmitter-soaked reward circuits, for which an
individual may be genetically susceptible (Dingel et al. 2011; Volkow and Fowler
2000), and seeks the development of pharmacological treatments to achieve a cure
(Kalivas et al. 2005).
Another dominant model—the adaptive/constructionist model—is popular with
addiction treatment counselors and psychologists as it puts more emphasis on the
effect of a person’s environment, relationships, and identity when examining the
etiology of addiction (Gergen 2005; Peale 1998). Proponents of the adaptive/
constructionist model more readily espouse talk treatments aimed to facilitate self-
realization and self-managed change (Prochaska et al. 1992), a process in which
success is gauged by a patient’s ability to talk themselves back to health (Carr
2011).
Addiction as a socially constructed illness has been pitted against addiction as a
physiological disease. Some scholars, fed up with the addiction model turf war,
have suggested mounting ‘‘a collective refusal against the domination of narratives
around addiction as a disease that requires cure through formal [medical] treatment’’
(Gergen 2005; Pryce 2006). Alcoholics Anonymous (AA) and Narcotics Anony-
mous (NA), on the other hand, encourage something of a treatment middle ground.
AA/NA provides some of the earliest studies on narrative therapy (Thune 1977), but
has also moved to espouse the concept of addiction as a ‘‘disease’’ insofar as it is of
utility to convince addicts 1
of the severity of their situation and the importance of
abstinence.
Historically, addiction has been understood in various ways—a sin, a disease, a
bad habit—each a reflection of a variety of social, cultural, and scientific
conceptions (Kushner 2006; Levine 1978). Today, there are a myriad of lingering
theories addressing the problem of addiction, and yet, in spite of the diversity of
theories and strategies, the problem persists. Addiction today remains as formidable
1 We use the term ‘‘addict’’ as a stand in for other terms like substance user, alcoholic, or smoker.
Throughout our paper, we have chosen to refer to participants as they have chosen to describe themselves.
Many of our participants self-identified as ‘‘addicts.’’ However, in our discussion of interview data should
the participant self-identify as an alcoholic, we have referred to them as an alcoholic.
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a reality as it ever was, with 23 million Americans in substance abuse treatment and
over $180 billion a year consumed in addiction-related expenditure in the United
States (Executive Office of the President, and Office of National Drug Control
Policy 2004).
The primary aim of this paper is to explore how people who are addicted view
their addiction against the framework of formal theories intended to explain their
condition. In doing so, we will add to the ‘‘cultural stock of stories’’ (Hanninen and
Koski-Jannes 1999) that narrate the problem of addiction and discuss the curious
desire for moving toward a more ‘‘unified theory’’ of addiction when the narratives
from those who are addicted seem to reveal that no such ‘‘unified theory’’ need
apply. Regardless of which addiction paradigms patients profess, clinicians must
attend to individual accounts of illness—a practice which the rising field of
‘‘narrative medicine’’ promises to deepen.
Adding to the Cultural Stock of Stories
Hanninen and Koski-Jannes, in 1999, applied narrative analysis techniques to 51
written testimonies of recovered alcoholics, bulimics, smokers, and sex and
gambling addicts in Finland. They ascertained five dominant narratives from the
accounts: the AA story, the personal growth story, the co-dependence story, the love
story, and the mastery story.
They analyzed each narrative paradigm for ‘‘emotional, explanatory, moral, and
ethical meaning,’’ for ‘‘connections of each narrative type with the story types,
belief and value systems’’ prevalent in the larger culture, and for significant trends
in each story type by gender or substance used (Hanninen and Koski-Jannes 1999).
Elements of these addiction narratives reverberate in the findings of other
qualitative researchers: certainly in Erica Prussing’s fieldwork on alcoholism
narratives of Native American women (Prussing 2007); also in Deborah Pryce’s
work in South Africa in which she found narrative solutions for what had previously
been pharmacologic problems (Pryce 2006); and in Wiklund’s examination of
narrative hermeneutics of addiction (Wiklund 2008). What we add to their work is
an account of how patients narrate themselves using the new biological accounts of
addiction, an increasingly prevalent cultural story, and one widely represented in
popular media.
Sample and Methods
Participant Sampling and Data Collection Sites
We interviewed 63 people from five sites in Minnesota: 14 from a methadone
treatment program (22 %), 29 from nicotine or alcohol inpatient and outpatient
treatment programs (46 %), 6 from an alcohol treatment program at a veteran’s
hospital (10 %), and 14 from smoking cessation free clinics (22 %). These sites
were selected in order to obtain a socio-economically and ethno-culturally diverse
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sample. The five treatment sites were located in a large metropolitan area and a mid-
size city. Participants ranged in age from 25 to 73 with the majority falling between
the ages of 30 and 59. The sample included men (45 %) and women (55 %); 19 %
self-identified as African American, Asian, Native American, or Bi-racial with the
remainder self-identifying as of European ancestry. Of the full sample, 28 % were
in alcohol treatment only, 35 % were in nicotine treatment only, and 37 % were in
polysubstance treatment.
The treatment sites varied in their approach to substance use. Most offered a
combination of group or individual therapy sessions and pharmacological
treatments, including methadone and drugs such as acamprosate and nicotine
replacement therapy. Several programs used audiovisual aids or treatment strategies
that emphasized the biological components of addiction. One used a brief
educational film that highlighted the disease model of addiction; a second treatment
site included a large display of living zebra fish used to study the genetic basis of
nicotine addiction.
Procedures and Analysis
At each site, we distributed information about the study by either affixing a flyer to
waiting room bulletin boards or distributing a handout with the interviewers’ phone
number. Interested patients called to schedule an interview at their convenience.
Upon obtaining participants’ informed consent, we conducted semi-structured
interviews of 30–45 min. Participants were compensated for their time. We used a
semi-structured interview guide that probed respondents’ knowledge of and beliefs
about six main topics: (1) understanding of the patient’s own addiction; (2)
conception of free will; (3) knowledge of addiction genomics; (4) benefits, risks,
hopes, and fears of new genetic treatments and tests; (5) willingness to participate in
genomics research on addiction; and (6) effect of media and direct-to-consumer
tests. The interview guide was crafted to answer the main questions of a large study
funded by the National Institute on Drug Abuse. That ongoing work examines the
social impact of an emerging genetic understanding of addiction. At the beginning
of the interview, we asked participants to share the ‘‘story’’ of their addiction.
Subsequently, while answering specific questions, participants were encouraged to
draw from their personal experience to explain their responses.
The interviews were audio-recorded, fully transcribed, and uploaded into N’Vivo
8 software. We used qualitative content analysis to analyze the interview transcripts.
Each transcript was carefully read by at least two members of the team. We initially
assigned codes to segments of text based on themes delimited in the interview
guide, but over time, refined and revised codes to incorporate themes that emerged
from the data. Discrepancies between members’ coding choices were discussed until
a common code was agreed upon or a new code written. Summaries of each code
were then constructed based on analysis and discussion of each category; key
quotations describing common themes were noted.
This paper is based primarily on one code: ‘‘patient experience of addiction’’ and
its subthemes. Participants were classified by self-reported age, gender, and
occupation. These contextual variables were analyzed after themes were distilled
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from the transcripts themselves. All names used in the analysis that follows are
pseudonyms. 2
The Experience of Addiction, in Their Own Words
‘‘People have different experiences with [addiction]’’ Julia said, and each person has
a ‘‘completely different process.’’ On the contrary, Mike claimed that ‘‘people are
cut out of the same cloth,’’ to say that he believed the struggle with addiction is
more or less the same for everyone.
We examine, hence, both the commonalities and idiosyncratic reflections on the
experience of addiction expressed by interviewees. Other narrative analyses in the
literature, such as the work of Hanninen and Koski-Jannes, have described a story’s
purported ‘‘cure’’ or key to recovery. As we did not obtain full life-histories from
our participants, our results describe mainly participants’ experience of addiction,
their understanding of addiction as a disease or otherwise, and their perspectives on
the biological underpinnings of addiction. Also, since our participants were
recruited in treatment centers, these accounts lack the voices of those who have
sought recovery on their own (Cunningham 1999), who have foregone treatment
(Cunningham and Breslin 2004; Sobell et al. 2000) or who have been denied access
to care.
We have organized participants’ responses by the major themes that emerged
from our qualitative analysis of the interviews, rather than by the demographics of
respondents or the particular substance used. The four major themes are (1) What’s Normal?, in which addiction is perceived as something a person grows up with, something ‘‘inherited,’’ whether by nature or nurture; (2) Punctuated Equilibrium, in which addiction follows a pattern, oscillating along a static equilibrium, flaring
with specific triggers; (3) Pedal to the Metal, in which addiction rapidly causes a person to ‘‘lose everything’’ often before the person is aware they have been
‘‘sabotaged’’; and last, (4) The Snowball Effect, in which addiction slowly arises in social substance users over a prolonged period of time, quantity and frequency
gradually increasing until the accrued momentum makes it too difficult to stop.
Trends in gender, age, and substance are mentioned within the discussion of each
theme. We note where participants’ views reflect a biological understanding of
addiction, and how they hypothesized whether these conceptions were or were not
useful to them in their quest for recovery.
What’s Normal?
A 50-something homemaker, Jill, described her alcoholism as a longstanding
problem: ‘‘I was raised in a family that at five o’clock it was cocktail hour—every
day…So I didn’t know it was weird to drink everyday. I thought everyone did that, and all their friends, everybody.’’
2 Interview guide available upon request.
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Jill’s story was similar to 11 others (19 % of the sample) who understood
addiction as something they grew up with, something ‘‘inherited’’ whether by nature
or nurture. Ten of the twelve comprising the What’s Normal? theme were women, most of these mothers, who were in treatment for alcohol or nicotine addiction.
The interviewer asked if she thought her alcoholism was genetically predisposed:
‘‘Mm-hmm, it was just normal.’’ The interviewer probed further asking, ‘‘Why do
you think it was a predisposition?’’
Jill said that her biological relatives, grandmother, her grandmother’s sister, her
mother, and her aunt were all heavy-drinkers, never treated. ‘‘Also, I have low self
esteem. And not a lot of confidence or anything, so it would loosen me up.’’ She
recalled how she started:
Everyone else did it…The first time I got drunk I was 15 and I was living at my parents’ house and they were gone and I opened a bottle of gin and drank
almost the whole thing and got violently ill. Had to be taken up to my bedroom by some friends, threw up all over my bedroom.
The interviewer surmised, ‘‘So, a lot of social influence to start drinking then?’’
Mm-hmm. And that it was just normal…I really thought everyone had a cocktail at five. And when I think back, I think, well, [so and so]’s parents
never did that…but all of my parents’ friends did.
Another mother, Latoya, in treatment for heroin and nicotine addiction, believed
that addiction was a part of human nature: ‘‘I feel like everybody got addiction, you
know what I mean, ‘cause they have addiction to smoking, addiction to going to
work, you know, so somebody has an addiction somewhere in them.’’ Connecting
her experience to a trend she perceived in others, Latoya had developed a sense that
her addiction, though problematic and disabling, was not unique to her, but in fact, a
common experience along the spectrum of ‘‘normal’’ human behavior.
Seven of the twelve with the What’s Normal? theme felt that a genetic understanding of addiction was useful to them. Jill stated that because she thinks she
has a genetic predisposition to alcoholism, an ‘‘addictive personality,’’ she is ‘‘very
careful about pills because I figure I could become addicted to anything because I
have an addictive personality. When they say have a drink, a drink, well, I’ll have more than a drink.’’ She felt that if she had been told she was genetically susceptible to addiction before she took her first drink, it may have had a preventative effect.
Perhaps owing to the majority of mothers comprising the theme, as well as a
tendency to embrace the idea that addiction was heritable and environmentally
pressured, many 3
in the What’s Normal? theme mentioned the hope to author a ‘‘new normal’’ for their children. Some highlighted the biological understanding
they were taught as part of treatment. In this way, the biological component of their
story was a useful fuel for vigilance in parenting children who may have a genetic
vulnerability to addiction. Even if they did not find the genetic understanding useful
3 In general, if we say that ‘‘the majority of participants expressed’’ or ‘‘many’’ we are referring to a
proportion greater than two-thirds of the cohort.
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for themselves, they thought it might be useful information for their children.
Tanya, a mother in treatment for nicotine addiction, said:
I seen my mom smoke; I was like, oh, that’s cool! I should smoke. And I have
been smoking since I was 15. Now I’m 37 and I kind of want to make a good
influence on my daughter – so she sees how hard it is for me to stop smoking.
Hopefully, she will never pick up that first cigarette and get addicted to it.
Routine and ritual, a large component of the addiction experience described by
nearly all of the participants, tended to be discussed more often among those who
‘‘grew up’’ with addiction. Participants described their smoking habits with the
warm nostalgia that some might use to talk about how their mother had chocolate
chip cookies on the table every day after school. Jill admitted that she ‘‘never
thought of abstaining’’ because drinking was such a normal, ritualized part of her
day:
I was drinking after I got up in the morning. I would have a Coke, and then I’d
make a drink and drank all day long…I didn’t drink until the bottle was gone, I’d drink until it was half gone and then I would go upstairs and go to bed and
get up the next morning, have a Coke, make a drink.
From the accounts of participants who used substances because it was ‘‘normal’’
at home to do so, once the context of ‘‘normal’’ changed, the stigma they felt being
suddenly ‘‘abnormal’’ was a commonly reported motivator for starting treatment.
Abby, a late-forties smoking mom, decided to quit when she started working for a
firm that did cigarette litigation. ‘‘It was really frowned upon [at the firm], it was
like a taboo to be a smoker.’’ Irene, a smoker in her fifties, blamed her 30-year habit
on Hollywood’s glamorization and ‘‘the Marlboro man, he was just too sexy for
life.’’ She also attributed her smoking to ‘‘watching my parents all my life smoke
cigarettes. [I thought] that it was just a general part of life. I mean, I really thought
everybody did this.’’ When asked what led her to seek treatment, she described a
cultural shift in stigma against cigarette smokers.
People started making me feel like I was a convicted felon…Now all of a sudden it’s a filthy, dirty disease that everybody is shying away from…We used to walk into a loaded elevator with a cigarette and not one person would
ever say ‘[cough] Excuse me, I don’t want you to smoke!’ It was socially
accepted and everyone kept their mouths shut… I mean, before I quit smoking, I told my husband, I said, ‘I wanna move to Missouri where smoking
is still legal because they make me feel so terrible here.’
Irene’s comments bear the flavor of oppression and victimization that charac-
terize aspects of Hanninen and Koski-Jannes’ personal growth stories where the
recovery comes only after the ‘‘butterfly breaks out of a cocoon.’’ It follows that if
addiction stemmed from oppressive relations or even oppressive traditions within a
rigid family structure, then the solution was to be found in the agency and
authenticity gained when the storyteller breaks loose from co-dependency and
listens to their own needs and desires.
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The What’s Normal? perspective also echoes elements of Hanninen and Koski- Jannes’ co-dependence story in which addiction is a familial pattern or curse that
extends across generations, caused by secrecy and repression of truth, and results in
an external locus of self. In the co-dependence narrative, addicts were not morally
guilty but victims of victims. Hanninen and Koski-Jannes observed that the cure for
this group was achieved through an individual’s courage to stop repressing negative
feelings or secrets and embrace openness and awareness about themselves and their
family. Awareness could ‘‘break the curse.’’
The sense of normalcy with substance abuse inherited from and triggered by their
family environment, or in mimicry of family behaviors, easily fit with the biological
narrative, and the idea that one’s susceptibility to addictive behaviors could be
transmitted through genes. For some, an awareness of their genetic status seemed
like it could offer a similar awareness of ‘‘the curse.’’
However, for five respondents in What’s Normal? the biological understanding had its rub. ‘‘It’s scares me for my children,’’ Elise said. She said that nobody wants
this for themselves or their family, but she felt powerless and susceptible, and
imagining that it was biologically linked made it worse. Irene described feeling
biologically ostracized in response to the news of recent addiction genetics research
and felt that scientists were ‘‘delving too deep’’ with DNA studies:
You know what I mean by the lesser in society?..People with the weak genes.
We only want to keep the bright, intelligent, normal, non-addictive. I think
we’re getting into some danger zones when we start getting too deep in this
stuff. I really do…. All of a sudden I’m a leper. … It makes me feel bad and it makes me feel like my parents were little lepers of society. And if given the
choice, the powers that be would get rid of the leper.
Suffering societal stigma was mentioned by nearly all participants, across all
themes. For Irene, oppression and judgment for her morally charged behavior
seemed to be just one more problem she had accepted as ‘‘normal’’ behavior of
others.
Punctuated Equilibrium
Joe, a self-described blue-collar worker in his late-forties, shared what he believed
to be a strong connection among his mental health, employment, and alcoholism
cycles:
It is anxiety and stress that I was dealing with. [Alcohol] just calmed me down
so that I used it as a tool, like a self-medication for me…I have depression and anxiety and overwhelming problems with employment, it was very stress-
ful…but it has nothing to do with family or anything…I would quit for a month here and there; I have quit for a couple of weeks here and there. But I
always went back when the anxiety and depression set in when I’m dealing
with work.
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Overall, Punctuated Equilibrium was the most common theme among all of the interviews, representing 22 of respondents (35 %). Titled to make a loose analogy
with evolutionary genetics, this theme describes addiction as a problem that
oscillates along a static equilibrium, flaring only with specific triggers. Most
respondents with this theme reported being employed and many described work as
one of the significant stressors, or punctuations, contributing to their addiction. The
Punctuated Equilibrium theme was more common among middle-aged males, mainly alcoholics and smokers.
Joe placed his alcoholism in the flux of cyclic depression and anxiety. He
relapsed and remitted upon the tides of his mental health and employment status. A
common factor that influenced his drive to drink or empowered his abstinence was
the amount of stress in his life:
I resigned one job due to the stress and then I would start another one and that
is the one I’m at now and I enjoy the job, but the increase in work duties just
kept piling up where the stress was built up again for me. You know, in this
day and age, they try to put as much responsibility as they can on people …I mean management does, basically to cut costs and that hurts the blue-collar
people. I mean, and the stress just got worse and that is why I started again. It
just kept back and forth, back and forth.
Joe described some of the limiting factors that have kept him from straying too
far from his equilibrium. One of the most significant influences to curb his drinking
and restore balance was his wife:
My support has always been my wife. She pointed out that if I didn’t quit, she
would leave…. There were divorce threats; that is basically it. I just quit, and, you know, just go for awhile and then the tension would build up, the stress
would build up again and I would go back to it.
The Punctuated Equilibrium theme has much in common with the stress-based theory of addiction. This model assumes that people spend a significant portion of
life in ‘‘equilibrium’’ with euthymia, solid relationships, and reliable employment.
This steady state is disrupted when their threshold for stress is surpassed, an adverse
event takes place, or some other anomaly occurs to punctuate that even ground with
a change in slope, causing their addictive habits to return.
Many of these individuals did not describe physiological withdrawal when they
remitted from their substance abuse. Nor did they commonly describe severe
cravings when in equilibrium and in the absence of a trigger. But most could
identify and predict the context or stressor that would trigger them into relapse.
Most often, the trigger was emotional stress or mental illness. Depression and
anxiety were mentioned most frequently as cyclic patterns of instability that trended
with substance abuse, as well as self-reported diagnoses of bipolar disorder and
post-traumatic stress disorder (PTSD). Dave, who had a shaved bald head and
carried an army camouflage backpack, remarked that his ‘‘crazy anxiety’’ was a
significant trigger for his abuse. Rick, who suffers from PTSD, said, ‘‘I was never
relaxed, which resulted in chronic muscle strain, nerve impingement, and those
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physiological results of fight and flight reactivity, that was constant for me. And the
cigarettes really did help me relax.’’
Several mentioned that they thought their treatment was more effective if it
involved relieving symptoms of mental illness or resolving the emotional stress.
Otherwise, the temptation to self-medicate with an addictive substance was too
great. Dawn concurred with Rick and Dave: ‘‘[My addictive substance] calms down
the anxiety…it takes the depression away, makes me feel like superwoman.’’ She described how her relapses were connected to her anxiety attacks and relationship
problems:
[Treatment] helped to a point; I mean every time I went to treatment I had
some good clean time behind me, but I don’t know, I always went back to
using again. And…where I get in trouble is with my anxiety. So, I mean if something happens, something…say, for instance, right now, my significant other has been AWOL since Tuesday, so the only time he does stuff like that is
when he relapses and he is out there walkin’ the streets. So, you know,
somethin’ like this usually, I’d be out there lookin’ for him and I’d be goin’
out there getting’ high, too.
Many participants who described Punctuated Equilibrium spoke of making deals with themselves, vows to quit that crumbled when mental illness or another
comorbidity flared. Paige, a housewife in her fifties, spoke about her pattern of
abuse and the bargaining process:
I had a blackout, don’t remember, ended up in the hospital…then I got out of the hospital after three days and swore I would never drink again. And within
two weeks I was having wine again. I told myself it was just wine, it couldn’t
do any damage. So, yeah. And it just spiraled down and I was very, very
depressed and constantly hopeless…I have emotional triggers that are problematic.
Paige also described her addiction as a disease. For her, understanding alcoholism as
a disease in need of treatment, just like her depression needed treatment, stripped
away the moral judgment. She used the biological understanding of addiction as a
helpful construct that ‘‘takes away guilt and shame processes that we go through and
[that are] hard to carry that around and get into recovery.’’ Thinking of addiction as
a natural condition to balance around a normal value, just like diabetics learn to
monitor and adjust their blood glucose within normal limits, helped reduce for her
the stigma of seeking treatment for addiction.
Chip, a mid-forties janitor, said, ‘‘I kinda think that mental illness is a part of my
genes, you know. I didn’t just pick that up randomly, and I sometimes smoke like
right now, I’m a little depressed so I smoked to kind of balance it.’’ He did not
consider his substance use to be a genetic trait, but he did think he had a biological
problem, depression, that he could treat with cigarettes.
When speaking of ‘‘emotional triggers,’’ the transitions in and out of addictive
behaviors were sometimes subtle. Natasha Dow Schüll describes the challenge of
discerning successful addiction treatment for gambling addicts because the
treatment programs available so much resembled the repetitive habits they sought
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to treat. How different was ‘‘the zone’’ of playing video poker, from the zone of
going several times a week to small group therapy meetings, from the zone of filling
out self-assessment forms in treatment? The rituals of gambling treatment were
eerily similar to the rituals of video-gaming. To illustrate her theory of a
‘‘modulating self,’’ Schüll uses a reflection upon addiction from one of her
interviewees, Rocky, ‘‘The idea I’ve been fiddling with—that certain behaviors
balance out other behaviors in some complicated way—is an equilibrium concept.
Being a chemist and a nuclear scientist, I have a feel for different kinds of
equilibria’’ (Schüll 2006).
Similarly, the demanding work of scrutinizing self-management processes among
those who described the Punctuated Equilibrium theme, such as the administration of a salving substance, a drug to fight cravings, the pursuit of meetings, counseling
appointments, vigilance to avoid environments where the substance is offered, or
intensive treatment to control the substance use, could provoke enough anxiety itself
to trigger a relapse. To what extent did treatment provoke anxiety or emotional
stress that could only be relieved by substance use, and then to what extent did
substance use cause anxiety and stress that could only be relieved by going to
treatment? For this subset of participants, in particular smokers, this dilemma was
termed ‘‘the vicious cycle.’’ Jack, a 50-something salesman, said
I thought after treatment I could control my drinking, but as soon as I got out
and I started drinking and I just was back in the same cycle again… I fought with that, the first time I went to treatment because I thought I didn’t believe
the whole thing that with alcoholism you can’t control it. I didn’t really buy
into that. I thought a lot of people were using that as a crutch.
Triggers that were more easily discerned were negative circumstances, specific
events in time that offset equilibrium. Whereas the plot and time narrative
components of emotional states are not so easily discerned or recalled, these
triggers, as concrete events, could be literally placed in one’s history, allowing the
addict to ‘‘move on’’ past that place. Jerry, an aircraft mechanic, described his
unprecedented abuse of alcohol within the last year as a result of an unfortunate
series of events:
This whole past [year] was nothing but a joke in my life ‘cause I lost my
brother, two weeks after that, I worked for [company], they fired me…And then we lost the house to bankruptcy. My dad has health problems… I wanna be able to drink with my friends in a bar…use it as a recreational tool, not like it’s been overpowering my life like it has been.
Jerry believed that there was a place, a context, for healthy use of the substance, and
had confidence that he would be able to return to that state. Alcoholism, he thought,
was an episodic anomaly created by circumstances, like a rude and unexpected
episode of unbridled speciation to a stable ecosystem. Equilibrium would reestablish
itself with time. Alcohol use was not a part of his innate character, nor would it be
something he had to constantly manage in the future. Jerry did not consider himself
an alcoholic but someone who had experienced a bout of alcoholism as one might
experience a bout of the flu.
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Like a car coasting out of its lane, these participants described an awareness of
addiction similar to drifting onto the warning track. After bumps and jostles, as Joe
described in the encounter with his wife, he eventually straightened out and
achieved equilibrium. The drifting and realigning, as Rocky might predict, would all
balance out in the end following the law of conservation. What seemed most
harrowing about this narrative type was the struggle to maintain self-awareness of
where one was on the continuum of illness and treatment. Self-evaluation could be
as difficult as driving in fog.
Julia, a student in her twenties, described herself as a ‘‘chronic relapser’’ for
whom social stress was the trigger for alcohol use.
I always felt out of place. I always felt like I didn’t fit into my skin. I was so
afraid of people and of the world and I had horrible social anxiety and all I
ever really wanted was to like, be a part of something, to have friends and to
be comfortable with people, and I couldn’t do it sober. And when I had my
first drink it was like, Wow, this is what I’ve been looking for all of my life!
In the context of Julia’s ‘‘social anxiety,’’ (in which the very use of a pharmaceutical
industry advertisement-constructed term bespeaks the influence the media has to
deliver diagnoses that individuals can choose on their own to adopt and regulate
(Dumit 2006)) the use of alcohol seemed to level the playing field with her peers.
She used alcohol as self-medication to regulate what seemed a more distressing
disorder, social anxiety. She felt more equal terms with others when intoxicated.
This might be considered for some not pathological but cultural, and positive at that,
but Julia goes on to discuss why, for her, it was a problem:
I remember that there was a line that I crossed where I suddenly realized that I
had to keep drinking even when everybody else was done until I blacked out
or passed out. But, I remember thinking to myself, I am only happy if I have a
drink in my hand.
For Julia, the warning track on the road was the line between being satisfied by the
company of friends with whom she felt comfortable (a feeling enabled by the
substance) and being satisfied by the comfort of the drink itself, with no regard for
those in company.
The narrative of disequilibrium caused by a deficiency, whether it be comfort,
interest, or love, has some overlap with Hanninen and Koski-Jannes’ Love Story,
where addiction was a compensation or a substitute for a sense of emptiness,
unfulfilled desire, or lack of love. Dawn mentioned that she felt like she had ‘‘no self
control, no self worth, you know, and then so, when the drug is there and you go use
the drug, it fulfils those empty, that emptiness.’’ The substance, then, is
compensation for what is lacking. Its use is merely an attempt to realign or
reestablish what is perceived to be better ‘‘balance’’ or fullness. As Joy deftly noted:
‘‘If I’m bored or lonely, or hungry, or tired, I found is when I smoke a lot. Then, I
don’t feel so lonely, I don’t feel so sad, I don’t feel so bored, and I don’t feel as
hungry.’’
Punctuated Equilibrium narrators were keenly aware of their ‘‘fullness’’ status, and yet, they also had insight about when they were pushing the limits of healthy.
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The existence of guardrails like insight, self-awareness and concern, are evidence
against the claim that addicts have ‘‘no control’’ over their substance use—that they
are void of agency and powerless to addiction.
Pedal to the Metal
For some addicted, there are no guardrails. Those with the Pedal to the Metal theme shared the perspective that their addiction caused them to ‘‘lose everything’’—their
lives careened quickly toward total wreckage. Powerfully addicted from the first
exposure, this was the least common of all the themes, shared by 10 interviews
(16 %). This theme was typical of younger (the 20- and 30-somethings)
polysubstance abusing men like Bill, a mid-thirties day laborer and smoker, whose
story goes like this:
I was just standing at the refrigerator and me and my friend were at this girl’s
house and they were in the other room doing whatever the hell you think, and
well, anyway, there was a carton of cigarettes on top of the refrigerator and I
decided to try it and the next thing you knew, I was stealing all of her parents’
cigarettes…I heard that you can’t smoke like a pack the first time you smoke a cigarette, you know. But I smoked three packs the first night! That is how
much I loved it. And I never even coughed the first time I tried it.
Bill went from nonchalance and naı̈veté to near obsession almost instanta-
neously. His use remained excessive thereafter, rarely if at all limited by his setting
or circumstances. After his first use, addiction, for Bill, was at full acceleration and
an insatiable appetite for the cigarette. ‘‘These days I smoke three or four packs a
day! And if I stay up all night I could smoke six or eight.’’
Nora, a nursing assistant in her late fifties, discussed her view that she was
predisposed to addiction from birth, perhaps genetically, and her pattern of
indulging to excess was a personality characteristic.
I was an addict before I ever even had that first drink. And that first drink just
sucked me in. I don’t feel like I would have had the same unmanageability if I
had never drank[sic], but I believe that I was an addict and an alcoholic
waiting to happen…I always wanted more of everything. Anything if it was like a food that I liked or whatever I want more than one…I think it is part of my personality, but there was not a lot of progression for me. It was like once I
discovered that I felt different when I drank or used drugs I wanted to feel that
way all of the time…. But I was hooked on alcohol the minute I drank. It was always there.
Users with this narrative described how, for them, quitting one substance could
only be managed by starting another addictive substance. Nora, who wanted ‘‘more
of everything,’’ described this phenomenon, ‘‘Different substances would quit
working for me and then I’d switch to another substance.’’
Physiologic withdrawal was a nearly universal experience for those describing
this theme. Nora related the first time she had withdrawal from alcohol as being
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‘‘just past the point of having a choice.’’ She needed alcohol, now, not just for
emotional or social satisfaction, but for biologic wellbeing, and no exertion of nerve
or willpower could undo her physiologic dependence. These individuals reported
that abstinence policies espoused by AA/NA had much utility. They desired an
external source of control while they regained trust in their own autonomy. It would
be difficult to imagine people from this cohort would ever agree with Jerry, that
addiction would resolve itself like a case of the flu. These folks did not trust
themselves anymore, and many desired to check into an inpatient treatment facility
to receive the intensive care they felt they needed.
The seemingly irreversible sabotage of the mind was a common theme in the
Pedal to the Metal stories. Eddy said that even though he knew he was an alcoholic, and that he would have this consuming obsession his entire life, that people like him
with ‘‘the disease’’ deny what they know, or they inconveniently forget. It is as if
they are being tricked by their own biology to get one more taste.
We forget…we forget even a month ago how bad alcohol had affected us, how we get sick, how we become homeless, how we lose all the money…we forget all that stuff because there are promises that if we stay sober…we gain all of these things back but the obsession is so powerful from day to day that
we live with it that all the hard times go out of our mind and we think we can
drink like a normal person when in fact we can’t…We take one drink and that’s all we want is more. It’s a terrible disease, it really is.
Matt, a custodian in his twenties in treatment for alcohol abuse, was having a
hard time calling himself an alcoholic. That stated, he observed that he could not
seem to get himself to slow down when out at the bars with friends. Every time he
drank, he drank to the point of black out, and yet he said:
I have more of a problem with it than I do an addiction…I’m probably an alcoholic, but just as much a denier. So, my head is still having a very tough
time talking myself into believing I’m an alcoholic…I just don’t think I was built to drink. But yet, I would. You know, I would wake up and I would be
hung over and miserable and puking and I would drink again. Then there are
other people out there who get a little tipsy and they are like whoops, this is
my drinking experience and stop right there!… I don’t know, that is just crazy to me that somebody can do that. It is amazing! My hat is off to them.
Matt seemed to think the problem was just in his body’s response to alcohol, that
he was biologically less fit to tolerate the use. He acknowledged remorse after each
binge, asking himself why he drank in the first place. Yet, as though detached from
conscious control, struggling for insight into the pattern and its consequences, Matt
would find himself hung over and miserable morning after morning.
Lily described the withdrawal aspect of addiction as ‘‘the vicious cycle,’’ using
language she learned from people in NA:
If you have never tried [heroin] then don’t because it is a very loving,
encompassing drug that makes you feel that everything is okay for as long as it
lasts. And then, of course, you are going to have the battle of getting more and
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then I had to work the job, to the get the money, to get more [drug], and then
that cycle…and suddenly you are a hamster on a wheel and you want to kick yourself again because you are the retard in this, nobody else is! … but everyone is so scared of withdrawal…we all know that the fix, the cure is the same thing that hurt us. The cause is the cure and the cure is the cause.
In Lily’s case, and for others in Pedal to the Metal, their equilibrium seemed irreversibly reset, perhaps even obliterated, the moment they first tried the
substance. Their new equilibrium was not so much the oscillating dance to level a
plateau, but the full throttle acceleration on an exponential curve to get more and
more of the drug, chasing a failing high, never wanting to come down. Those with
addiction more typical of Punctuated Equilibrium acknowledged a difference between themselves with and without the substance, and how the transition between
states was reversible. Those with the Pedal to the Metal kind of addiction, on the other hand, could not re-identify with the person they were before the addiction.
Grady aptly described this transition. A child selling heroin on the streets, he
tried his own product out of curiosity, and everything changed:
For me, I got addicted to it because I was selling it, you know… like people would come and get their drugs everyday because they needed it… I thought they was just partying, right, I didn’t know that they was just coming sick
everyday – coming to get it – I didn’t know that. You know…so I tried it one day, you know…I just kept usin’ and usin’ and usin’ and then … I tried to go without and I asked this older dude, I said, man, what is wrong with me? You
know I was sick and didn’t even know it. Yeah, and he said you need to do
some of that stuff you are sellin’ me, and you will be all right. You know and
it was just like I couldn’t believe how I went from [snaps fingers] just like this
and feelin’ all sick.’’
The rapid transition into a new biologic identity, a rewired brain, a new physiology
dependent upon the merciful administration of a substance, was often a huge
surprise, as Grady described. Mike proclaimed himself addicted after the first use,
‘‘When I started, I was Hell on wheels…it’s tripped in your head, it is on, and it is a lifetime thing.’’ He spoke of his upheaval as ‘‘masked insanity.’’ He elaborates:
…it just changes totally to where it becomes all-consuming, you don’t even care about all of that now, just to get high or get going, two things that you
know either I’m sick or I’m high. Everything comes down to those two things.
And everything is secondary—way secondary, so…and it happens so quickly…just pfft, you are there.
For those with this tragic distillation of self, the language they used to describe
their solitary obsession, their relationship with the substance and the powers it
holds, shared vocabulary with genres of the divine, fantasy, and romance. Mike
spoke of his drug use as one would talk of romantic love:
It is your up, it is your down, I mean it is your happiness, it is your comforter,
it is your sidekick, you know, it is…I have always said that my three wives and other women I lived with for long periods of time and I didn’t marry, but
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that they were really more my lovers and my using was what I was really
married to.
Similarly, John had a difficult time describing his love for alcohol and cigarettes,
a love for which he felt he was predisposed. During the interview, it was as if words
were not powerful or poignant enough to convince the sober, presumably non-
addicted interviewer of the character of his obsession:
It affects me differently than people who don’t have that predisposition, who
just smoke socially, if you will, or drink socially. Related to drinking: The first
time I took a drink it was like the black and white world became
Technicolor… The first time I smoked a cigarette, I can act it out for you, but then you can’t record that. It felt like this. (Demonstrates – sighs) And I’m
taking a deep breath and sinking into my chair like it was extremely relaxing. It relaxed my mind, my body, my breathing, everything. And that is what I
was continuing to search for every time I smoked a cigarette after that.
When addicts are broadly misconstrued as individuals devoid of control or
agency, it is because of testimonies such as these. Pedal to the Metal type responses
were a slim minority of our participant sample, so it is unfortunate that this theme
has become something of a stereotype laid over all people who struggle with
addiction.
The Snowball Effect
The Snowball Effect theme described addiction as a problem that gradually accrues over a prolonged period of time, often 20 years or more, until eventually the
behavior gains momentum such that it is too difficult to stop. A third of our
respondents conveyed this theme, a cohort notably older than the other themes
(most aged mid-forties to seventies), and it was slightly more common in alcoholics,
but not specific to gender or employment. In a way, this theme is something of a
confluence of What’s Normal? with Punctuated Equilibrium, distinguished mainly by the prolonged time course of the addiction story and the change in the self-
perception of one’s relationship to a substance. Isaac, a 47-year-old business owner,
described the slow progression of his alcoholism.
It took me a long time to become an alcoholic. I had to work really, really hard
at it… I have been around people who drink, like all of my working life, and I can drink and not drink. It was never a…there was never any kind of associative, addictive behavior. I mean I could drink on weekends and then not
drink all week. I know where there would be consequences to drinking and not
do it. I would never plan or necessarily look forward to it. And, I mean that
was 25 years. I mean, and then all of a sudden it just run tough. At that point,
you are making conscious choices to drink rather than do something else. Or,
plan to drink, start planning your activity around drinking, start planning your
work day around drinking, start planning…and then at that point you kind of realize that what you are doing is exhibiting addictive behavior rather than
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normal behavior. So, what I’m really saying is it is not like someone who takes
their first crack and becomes instantly addicted. I mean there was obviously
a…I mean, there obviously becomes a psychological thing because you have been drunk over a period of time. You just regard it as an acceptable thing.
You go to a ballgame, you have a few beers, you go to a barbecue, whatever;
you have a few there. It is not like it is taboo thing. And it was never, actually,
really a problem until I started working for myself.
‘‘It was no longer a choice?’’ asked the interviewer. Isaac said, ‘‘No, it was a choice,
but it was a choice that was made in one direction. I mean it was like, shall I go to
the liquor store now, or…the arguments took less and less time, really.’’ Suddenly, after years in the making, Isaac’s story contains aspects of the Pedal to Metal theme. The Snowball Effect theme, hence the title, often included many different narratives of addiction experience. Multiple constructs of self, various histories of use in
different contexts, all rolled upon one another, generated something like momen-
tum. The weight of all these stories and experiences over the years seemed to pull
the person toward more and more substance use.
The hallmark of the Snowball Effect was the misassumption that after so many years of using without problems, addiction would never be an issue. The person was
blind-sided by addiction. A mid-forties news manager, Mary, while working her
‘‘24/7 job,’’ started using nighttime dosages of Xanax and alcohol to sleep. Over
time, she started drinking earlier, and earlier. Then she was laid off:
I was so shocked that I ended up the way I ended up and I went downhill so
quickly. That is what kind of surprised me because I was the person in college
who was pulling my friends out of bars or the designated driver… I mean, yes, we had a wine cellar, but was I drinking every day? By no means! No! Was I
binge drinking? No!… I guess my assumption was that since it was never a problem before it wouldn’t become one. And then once I started drinking with
regularity it became a problem pretty quickly. I mean very quickly within a
two-year span. And the last six months being really bad, meaning, I fell into an
oven and those kinds of things.’’
Those in the Snowball Effect theme tended to be highly cerebral and evaluative regarding their addiction. Their conversation yielded abundant debate on what
addiction really is, with much questioning. When does one know if they are
addicted? For example, Janet was inquisitive regarding the addiction status of her
peers. She admitted that she drank alone, almost every day, and that was a problem.
But when she was out with friends, she eyed others’ drinking habits with resentment
and concern asking:
You know, I look at these people who have been drinking for 30-40 years and
I go, okay, now what are they? I mean, they cannot be not an alcoholic, I wouldn’t think. But I don’t know. It is different for everybody….I never really got totally drunk where I staggered and did all of this and blacked out. But I
would be drinking all day—the slow drinking. You know, and not getting
anything done. So I am an alcoholic.
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The Snowball Effect theme of addiction was laden with rationalization as to why a substance was needed. If it could be explained and justified, or if it had never been
‘‘an issue’’ before, it must not be a compulsion, it must not be ‘‘addiction.’’ Kay, a
self-described alcoholic in her late-thirties and a custodian, shared some of her
excuses:
You know, if you are at work and you are having a bad day, you can’t wait to
get home and have a beer…you proceed to drink and if you have someone come over you have more drinks…It starts out so simple and innocent and it gets into a great big mess!
Narrative and Negative Capability
Of what use are accounts of illness such as these to those who care for the addicted?
Narrative therapy explores how people give sense and meaning to their experiences
by forming narratives (Bruner 1990; Polkinghorne 1988). In this process of self-
storytelling, ‘‘individuals are constantly engaged in the process of creating
themselves’’ (Crossley 2000). The goal of narrative therapy is to imagine, create,
and promote the most positive, empowering conception of self (Charon and
Montello 2002; Ritchie, et al. 2007).
Alternative to the objective knowledge of addiction as a neurobiological disease
(Jellinek 2010; Volkow and Fowler 2000) or a rational product of the self-
determining will (Elster 1999), narrative theories of illness offer a more subjective
knowing. As described by Jamesian nurse-philosopher Mary Tod Gray, ‘‘Subjective
knowing expresses the view from within: how the experience of the drug addiction
feels to the individual…the addict’s interior experience’’ (Gray 2004). Through this practice, therapists observe how addicts construct narrative identities (McIntosh and
McKeganey 2000; Taı̈eb et al. 2008) that draw upon discursive repertoires of
established cultural stories and metaphors, often overlaying their own experiences
upon an existing template. A myriad of factors influence this template, also known
as a dominant narrative (Payne 2006; White and Epston 1990).
Treatment centers employ their own dominant narratives in explaining addiction,
and clients’ frameworks for understanding addiction are shaped by the language and
ideology of their treatment milieu. Our participants who spoke of addiction with a
genetic/biological understanding were primarily, but not exclusively, under
treatment in two treatment centers that explicitly teach a biological model of
addiction as part of treatment. This finding supports other researchers’ claims that
addicts’ views of themselves are in part shaped by the language of their treatment
centers. Summerson Carr’s work, Scripting Addiction, explains this phenomenon in detail.
Patients may or may not find useful the particular dominant model of their
treatment center. For example, when reliant upon the biological story of addiction, a
treatment center may focus on a drug prescription for treatment, and underestimate
the environmental and social circumstances involved. Or to the contrary, if focused
inordinately on the psychosocial narrative, a treatment center may overwork to
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re-author a personal narrative or improve the quality of family dynamics as the
solution for addictive behaviors, and possibly underestimate the extent to which the
substance use has re-authored the physiology of the patient.
Notably, some participants made use of biological understandings of self in their
personal narratives, such as the easy assimilation of a genetic understanding of
addiction in the What’s Normal? theme, the unanimous surprise at the perceived physiological hijacking and sudden switch of self in Pedal to the Metal, and, in less than half of respondents, how understanding addiction as a disease removed guilt
and shame. These biological understandings—delivered through treatment centers,
media representations, pharmaceutical advertisements, and family histories—have
the potential to become ‘‘dominant narratives’’ of addiction for the current era.
One might expect to find themes clustering by the substance used or by the legal
status of the drug. We expected the interview accounts to reflect those differences.
That cigarette smokers would relate one experience, narcotic addicts another story,
alcoholics yet a different narrative. What was surprising was how the themes were
not necessarily determined by substance. Some of our cigarette smokers had Pedal to the Metal themes to their addiction, and some heroin addicts had a Snowball Effect reaction to their drug. Because the participants’ experiences did not seem to cluster neatly by substance, this finding seems to highlight the complexity of the
experience of addiction. The experience of addiction is layered with individual
biological/genomic landscapes, cultural contexts for the behavior, and psycholog-
ical determinants, all of which shape the experience. Julia said it best; everyone has
‘‘their own process.’’
Furthermore, there was little evidence of or use for a ‘‘unified theory’’ of
addiction among patients themselves. A unified theory of addiction may be just as
dubious as a ‘‘unified theory’’ of people. We are more unique than our DNA, more
imprinted than the intaglio of our family crest, and more fickle than the times. The
dynamism and fluidity of each person’s self-narrative is not unlike the complexity of
each person’s genome. An earlier era’s view of the genome as fixed, unchanging,
and immutable (Keller 2002) is giving way to a more liquid understanding
incorporating epigenetic phenomena. Our biology, psychology, society, environ-
ment, and circumstances are in a state of constant correction, in which, almost
imperceptibly, addiction is simultaneously a cause and a result.
People bear templates of DNA and experiences alike whereupon the epiphe-
nomena of their unique biochemistries, cultures, and willful souls are entangled. Just
as geneticists and molecular biologists labor to witness the patterns and anomalies
written in the libraries of genomic testimony to being, so clinicians and therapists
witness the motif and novelty in their patients’ accounts of illness—accounts told,
imaged, and assayed. What might be of use for those working directly with
addiction patients, in light of the mysterious and often unpredictable nature of
nature, is adopting a perspective of negative capability as offered by the practice of
narrative medicine.
Negative capability is a state of mind in which an individual transcends the
constraints of a closed intellectual system, such as a theory. Narrative medicine is an
emerging practice in the United States that uses literature and illness narratives as a
touchstone upon which to build a moral imagination. Physicians and health care
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practitioners meet together to perform close readings of texts, to write, and through
these exercises, hone their skills of ‘‘attention, representation, and affiliation.’’ The
intent is that this sensibility will carry over into professional work with patients.
Through bearing witness to the stories of patients, told in their own words,
physicians are realizing that the power of ‘‘recognition allows [them as]
protagonists, despite moral ambiguity and interpretive tension, to act’’ (Charon
et al. 1996, p. 244; Nussbaum 1990, pp. 3–53).
Narrative medicine is a means to foster empathy as remedy for the counter-
productive stigma that can burden the patient–provider relationship when together
they face the challenges and frustrations of disease and illness. Acknowledging the
universal aspects of experiences like shame, anger, and grief narrows the gaps
between self and other, patient and physician, patient and counselor, patient and
family member in a relationship where both are able to empower one another in the
process of recovery.
Looking to our interviews for an example, grief was a common sentiment that
emerged from the transcripts. In the practice of narrative medicine, attuning to
patient language is critical. For example, after listening to Nora’s account of grief
over quitting alcohol: ‘‘I felt like I should hang a black wreath on the door…oh, I was depressed and angry and it was like giving up my constant companion,’’ the
practice of narrative medicine would explore the weight of Nora’s analogy. Her
image of the ‘‘black wreath on the door’’ is a powerful symbol of the attachment she
feels toward alcohol and it should call the listener to reflect upon his or her own
black wreaths, literal and figurative. If the listener is able to imagine and ascribe
personal significance to the idea of a ‘‘black wreath,’’ in the shadow of this totem,
Nora and her listener can experience the healing power of an intersubjective bond.
The black wreath, a representation and externalization of the addiction suffered by
the patient, can be examined as an object that both patient and clinician recognize at
the same time, as equals, as co-experiencers of grief. A scene such as this—in which
two people puzzle together over one of life’s more mysterious experiences—seems
preferable to the imbalanced relationship where a broken victim seeks the help of a
‘‘provider,’’ offering only a prescription, who is assumed to be whole and healthy by
contrast. Nora’s image of the black wreath also evokes the loss of a friend, which
should cause the listener to wonder (in a state of negative capability) about whom or
what else Nora has loved and lost, and how other sources of grief may be entangled
with Nora’s emotional response to quitting alcohol.
Michael Stein, an internist, recently authored a literary account of his clinical
work with addicted patients, in which he weaves together representations of himself
and his patients, melding his voice and theirs into one story with one common goal:
empowering recovery (Stein 2010). In The Addict, Stein reflects on the unique stories of each of his patients, interspersing poignant self-reflection about his own
biases and how, with humility, his struggle to attune to the needs of his patients
continually challenges his understanding of the nature of addiction, as well as his
understanding of his own role in offering care. In Stein’s account, and through our
research group’s conversations with people in treatment for addiction, we recognize
in the stories aspects of ourselves. They teach us to suspend disbelief, to hold off the
irritable reaching after fact; they discipline the listener, the reader, the witness, to
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honor the state of negative capability. In this place of uncertainty and possibility, the
distance between us and addicted ‘‘others’’ disappears.
Experiences are the human conduit for affiliation, and though in this paper the
experiences as told by the addicted may seem disorderly or in disagreement with
one another, perhaps this is an important aspect of addiction that should not be
glossed over in favor of a unified framework. Addiction is protean, such that if we
try to reduce its character to one nameable form, with one ‘‘unified theory,’’ we will
have failed to address it in its entirety. Keeping close the wisdom of William James,
we suggest that ‘‘the sanest and the best of us are one clay with the lunatics and
prison-inmates’’ (James 1911). Addiction is not just the disease of one particular
organ, not just the result of an unfortunate upbringing, or an unfortunate choice;
addiction is not the affliction of, or, what is ‘‘the matter’’ with the ill other, addiction
is a matter with us. When deliberating about policy, we recommend that patients’ voices not be
disenfranchised from the research done for their supposed benefit, that the
experience of the addict not be reduced or considered universal, ‘‘unified,’’ or
‘‘typical.’’ The data we have presented in this paper show how narratives of people
addicted are a combined product of individual agency and socialization from
treatment program ideologies. The diversity, then, of addiction narratives is now
and always will be myriad and infinite, and the effort to understand them a noble
foray into an ever deepening pool with the bottom always beyond reach—a problem
that we believe is more awe-inspiringly Kantian than hopelessly Sisphyean.
While continuing to probe the intersubjective depths, attention to narratives can
reduce stigma and promote affiliation between the provider and the patient while not
delimiting the illness to a reductive explanation informed by a single scientific
theory. Without patient voices directly represented in research (Meisel and
Karlawish 2011), we may miss a relationship between the biological and social
narratives of addiction that would better unite the efforts of all those who seek to
care for those suffering the throes of substance abuse.
Acknowledgments The project described was supported by Grant Number R01 DA014577 from the National Institute on Drug Abuse and the Mayo Clinic SC Johnson Genomics of Addiction Program. The authors wish to thank the following for assistance with recruiting and interaction with participants, interviewing, coding, and analysis: [alphabetical] Kathleen Heaney, Jennifer McCormick, Bradley Partridge, Marguerite Robinson, and Marion Warwick.
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