Instant Genius - How thinking about addiction differently can help us find better treatments

Episode Date: June 9, 2024

Addiction can be devastating not only for the addict themselves, but also for their loved ones and anyone around them. But what causes it, and how should we treat it? According to Dr Elias Dakwar, a psychologist based at Colombia University, New York, we should be looking beyond the commonly held brain disease model of addiction and deeper into its philosophical or existential underpinnings. In this episode, we speak to Dr Dakwar about the years of clinical research he outlines in his latest book The Captive Imagination: Addiction, reality and our search for meaning. He tells us about his thinking on how addiction stems from our desire for happiness and feelings of meaningless, how it fits in with the notion of personal freedom, and details some of his work with clinical patients in treating addiction in new ways. Warning: Recreational drug use can be dangerous to your health and possession of certain controlled substances in the UK can result in an unlimited fine, prison sentence or both. For more information visit talktofrank.com Learn more about your ad choices. Visit podcastchoices.com/adchoices

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Each week, you'll hear world-leading scientists and experts talking about the most fascinating ideas in science and technology today. I'm Jason Goodyear, commissioning editor at BBC Science Focus. Addiction can be devastating, not only for the addict themselves, but also for their loved ones and anyone around them. But what causes it, and how should we be treating it? According to Dr. Elias Dachwa, a psychologist based at Columbia University in New York, we should be looking beyond the commonly held brain disease model of addiction and deeper into its philosophical or existential underpinnings.

In this episode, I speak to Dr. Dacroix about the years of clinical research he outlines in his latest book, The Captive Imagination, Addiction, Reality and Our Search for Meaning. He tells us about his thinking on how addiction stems from our desire for happiness and feelings of meaninglessness, how it fits in with the notion of personal freedom, and goes on to detail some of his work with clinical patients, eating addiction in new and innovative ways. First off, this podcast comes with a warning. Recreational drug use can be dangerous to your health,

and possession of certain controlled substances in the UK can result in an unlimited fine, prison sentence or both. For more information, visit talktofrank.com. So first off, welcome to the podcast. Thank you. It's good to be here. Thanks very much for joining us. So first off, can you tell us a bit about yourself, you know, what you do and how you came to do it.

Sure. So I'm currently a researcher and a practicing psychiatrist. I'm based in New York City. I work at Columbia University where my research is based. And my interest is addictions. I'm interested in understanding how people develop addictions, how to help them disrupt addiction. And also the ways that addiction touch on aspects of our common humanity, the way that addiction can give us a glimpse into what it means to be a suffering, meaning-making, confused human being. So that's the topic of today's discussion based on your new book, The Captive Imagination. So let's get into that now then. So addiction. First off, I mean, is it difficult to pin down? What exactly are we talking about? Well, it covers a pretty broad

swath of the human experience. But I think we have both in a philosophical and clinical sense some understanding of what addiction is. So from a clinical perspective, addiction is pretty clearly defined as reward-seeking behavior that is destructive and that importantly persists even in the face of that destructiveness, increased anguish, increased suffering. And it can really relate to a variety of reward-driven behaviors, primarily drug-related behaviors, pursuing alcohol or cocaine, but it's also understood to pertain to non-drug behaviors like gambling. And the field is getting clear on other types of behavioral addictions, including social media, video games, etc. From a philosophical perspective, there's an understanding that something about a person's capacity for freedom is compromised, that our capacity to make decisions that are best for us and that stem from clear appraisal of the options available to us.

Something happens that's quite clearly compromised in addiction. And that's really where my interest is. the existential philosophical roots of addiction. Now addiction etymologically means speaking towards, and that emerged from devotional language in the church, actually, the way that we would devotedly turn to God or to the sacred more generally. And addiction was seen as a way of speaking towards things of the world in a similar spirit with the same level of devotional intensity, to the point of great confusion and entrenchment and destructive behavior. I find that a very interesting foundation on which to understand addiction. There's clearly this passion associated with it,

but also this way that a whole world is constructed around whatever it is we're pursuing. And we all have a way of occupying worlds that are tailor-made to our occupations, our inclinations, our ways of understanding things. An addiction can represent a manner in which that representational world building goes haywire. It becomes inflamed. The manner in which it's divorced from what's really before us. The manner in which our speaking towards becomes uprooted from what we're speaking towards. I think it becomes very highlighted in the disorder.

So I'm very interested in that. And that's where the book really takes off. It looks at that aspect of addiction and what that has to say about us as human beings, but also how we might enter into understanding and treating it more effectively. So having said that, there's a certain amount of self-deception at play. Am I right in saying that? Yes, yeah, there is. Inasmuch as we come to some fixed sense of what we are in the first place. So self-deception in as much as we're deceiving ourselves, but also self-deception in that we create a self-deceived. And the worlds that we create aren't only about what's outside of us, they're also about what's within us and what we are as beings in the world. And that deception, that deception of myself as someone who needs this or that, or someone who's suffering from this particular thing, or someone who needs this solution. fundamentally, I am aggrieved, I am an abandoned child, I am God's gift, I am the damned of the earth.

Many modes of self-construction can underpin addiction, and the deception often begins there in the ways that we construct ourselves. So in the book you mention a phrase destructive self-creation. Is that what you're talking about there? Yes, exactly. So much of addiction literature is rife with self-destruction and perceiving addiction in these absolutist terms of the person deliberately engaging in self-destructive activity. And I'm encouraging us to recognize that people with addiction are really trying to make a way like the rest of us and trying to find a mode of understanding and a mode of being that resonates with them, that is meaningful. And that begins with how they see themselves, how they construct themselves.

The self-creation, in the case of addiction, can be clearly quite destructive and agonizing, but it's creative nonetheless. And I think by inhabiting that creative core at the heart of addiction, we can better understand how it emerges, but also steward that imaginal energy towards something more fruitful. And as I mentioned before, there's an understanding in philosophical frameworks of addiction that the person's capacity for freedom is compromised in some way. A tenet of the book is that, well, actually, freedom remains. It's just being steered towards this destructive self-creation. How can we help the person reclaim that freedom and corral it towards a way of being that's more expansive, and that isn't as constrained about.

this imagined world that grows more constricting by the day. Yeah, so having said that, can we say where does this sort of behavior emerge from then? Are there certain characteristics that people are more prone to this sort of behavior, for example? Well, there's, I think, a confluence of things. There may be certain vulnerabilities in the person predisposing to imagination and fantasy. There may be aspects of the person's circumstances. is that make a flight into that fantasy more compelling. Coupled with a sense of real desperate

meaning-making may be a feeling of there being a dearth of meaning in one's world and finding an addiction consolation and solace. There may be ways of being affected by the drug that are quite intense and nearly exalting that diminish the salience of other things in the world, independent of the person's vulnerabilities beyond the drug, there may be a certain relationship with the drug or with the reward, whatever it might be, gambling, video games, etc. That exalt the person to a way of being that feels deeply true, deeply real. And that's where I think the vulnerabilities are very illustrative of our relationship, whether we're addicted or not as human beings, to this world before us.

The way we engage with the world often involves finding very compelling things, compelling people, pursuits that grab our attention and around which we orient ourselves. The reason that might be the case can be very difficult to discern. It's perhaps difficult to discern why some people prefer coffee instead of tea or why we choose to listen to certain music or choose certain career paths. Yet we found ourselves in this position. And now that that's the case, instead of kind of wrangling with ourselves what makes us uniquely vulnerable here, kind of acknowledging that there's a common human yearning to inhabit this world in a way that's meaningful to us, independent of what that meaning might look like, and inhabiting that position from a place of greater clarity and possibility so that whatever path we found ourselves on because of this confluence of vulnerabilities

or more subtle factors, we can recognize that there may be a different way possible to us. And that's the way addiction treatment often proceeds, where either through very dramatic measures or more gradually, there's a disentanglement from this particular path that for whatever reason the person has found himself on, and a recognition that other possibility, are available, along with a commitment to walk a new path, a path that is more deliberate and mindful of the allure of that old reality the person was inhabiting. I say this because I really want to be careful about attributing to addiction a kind of set of vulnerabilities that distinguishes the person from the rest of us. I really have found in my clinical practice and in

my research, that the most fruitful way to engage with addiction is as a parallel to what we're all engaging with as these meaning-making half-deluded beings, making our way through this dark landscape. Some people never stop being part of what's happening around them. They stay curious, engaged, connected to ideas and to others. That's what defines life at Villa Gardens in Pasadena. It's a community shaped by conversation, culture, and a shared sense of curiosity. So when the conversation turns to what's next, it doesn't feel like stepping away. It feels like staying exactly where you belong. Explore your options at villa gardens.org, a non-profit life plan senior community within the Front Porch family.

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deliver exceptional sound and unforgettable listening experiences at home. Try it for yourself at a focal powered by name boutique. Visit focal powered by name.com for more information. So in the book, you talk about addiction as being more than its apparent determinants. So what exactly do you mean by that? So the addiction science field is largely composed of three modes of determinism. One is behaviorism, which is that we come to act the way we do because of this reinforced process of learning certain behaviors and becoming habituated to them. The other is a variant of that called cognitive science, which interprets our behavior as determined by the workings of the mind. But mind here should be taken in a somewhat bracketed way, not mind in its kind of boundless, kind of mysterious immensity, but as a kind of apparatus that involves memories and cues and conditioned response.

and attentional biases and retrieval mechanisms, etc. So a kind of computer that processes and decides. And the final one is kind of neuromaterialist conception of behavior, which is that our brains encode cognitive and behavioral inputs in a manner that entrenches us in certain behaviors for better or for worse. A central claim of the book is that these determinisms, while fruitful in some respects, don't encompass the entirety of what it is to be a human being. They don't get into our subjective experience, the fluidity of our experience,

the manner in which our ability to reimagine the world in quite profoundly different ways every single day. That capacity is not given the kind of attention. needs, especially given its role, as I argued in the book, in addiction. Our ability to also maintain a freedom from what we construct so that even as we do have these apparent worlds that we inhabit, there's not only the capacity to maintain a creative engagement with them and refashion them, but also to not be in them. And, you know, that is reflected in an interest I outlined in the book in meditative practices in some of the non-ordinary experiences occasioned by contemplative traditions

and some of the substances that I explored as potentially helpful for disrupting addiction. But most importantly, from an existential perspective, I think constraining ourselves to a comprehensible roadmap of what's possible for us and resigning ourselves to a deterministic narrative. We must act in this way because these things proceeded where we are now. I think that really vitiates the essence of what it means to be a human being, that there is this plasticity to human existence that is crucial to not only emerging from addiction, but from making our way through suffering more generally, whether it's more private, as in the case of an addiction, say,

or more collective, as in the case of totalitarian politics, or there's a very rigid notion of who we are as beings and what this world should be. I find in many of the frameworks of neuroscience helpful anchors for understanding the correlates of addiction and better intervening, but I strongly caution against limiting ourselves to them and seeing the human being only through that lens. So coming off the back of that, you talk about something known as the brain disease model of addiction and its associated flaws. Can we explore that a little bit, please? Sure. So very succinctly, the brain disease model posits that in addiction specifically,

that addiction is the result of a vulnerable brain being impacted by drugs repeatedly to the extent that the person becomes driven to pursue the drug at the cost of everything else. So it's a variant of what in psychiatry more generally is called the stress diathesis model. So there's a genetic vulnerability of some sort and then some kind of insult to the brain. In this case, it would be a drug that over time regular drug use leads to addictive behavior. Now, that is the kind of deterministic model of addiction. and it was initially proposed as a kind of humanistic solution to the punitive, moralistic attitudes towards addiction that had existed previously, that addiction is a flaw in character

or some kind of spiritual problem and needs to be addressed through criminalizing drugs, through criminalizing people who use them, and other punitive measures. So in some respects, the brain disease model helped remove the stigma from addiction by placing it firmly in a medical model of approaching the condition. I think there are some major challenges here. The first, as I've said before, is that we're more than our brains. We are relational. We are dealing with all kinds of existential questions that can't be reduced to neural correlates. we are cultural. We inhabit all kinds of imaginal worlds, both private and shared. And reducing addiction to a condition of the brain is to disregard all of those things.

Another problem with it is that it creates a scheme whereby the person with addiction has an impaired brain. and a brain impaired in a manner that is compromising fundamental aspects of our humanity. We lose the capacity for freedom. We lose the capacity for choice. That we have become, in a popular metaphor, hijacked by the drug. And one should always be careful about the metaphors that we use to describe human beings, and especially in psychiatry, given its carceral history of institutionalization and dehumanization. This danger, I think, is underscored by the war on drugs and the ways that people who use drugs are already being peripheralized and delegitimized.

I'm also concerned about the way that this brain disease model, while at the same time, de-stigmatizing to some extent, can also reinforce certain stereotypes about the person with addiction is less than human and challenged by issues that don't plague the rest of humanity. But finally, I think in terms of treatment, a brain disease model suggests that treatment needs to target the brain in some way or somehow interfere at that interface between the drug and the brain. And that creates a very myopic framework by which to understand the possibilities of addiction treatment, especially as we know already that there are many potentially helpful treatments that have nothing to do with targeting the brain. for example, Alcoholics Anonymous, AA, you know, while, you know, it's not a blockbuster treatment, it does help people. Psychotherapy of various sorts, behavioral treatments.

The ways that people with addiction, as survey data have shown, can all at once and without any medical treatment emerge from addiction on their own. So something is happening with addiction that I think is far more complex than can be reduced to a brain disease. Again, I'm not discounting the utility of the brain disease model artfully applied, but approaching it as the final word, I think, creates a lot of problems. So throughout the book, there are several different case studies of various different patients that you've seen.

And I thought it's quite interesting to have a look at how the different patients view their relationships with their addiction differently. you know, what can we say about that? What can we learn from that? So the thread running through the book is the importance of the individual in treatment, the interiority of the individual, the world that the individual inhabits, how that pertains to the addictive process. And that's revealed, as you suggested, in how each of these individuals is very different and has a very different relationship to the reward, to the addiction,

in a very different way of relating to me and to others in their lives. Addiction is portrayed as a person's unique journey to make sense of the world, to make sense of their suffering, and ultimately to liberate themselves from that meaning-making process that can go wrong. So our ways of making a home in this world can be as different as all of us are. We're all quite unique, and we have our own ways of being in this world. People with addiction are no different. So we have people who are turning to heroin because it gives them a sense of solace and companionship.

Other people turn to heroin because it allows them a complete negation of the world. entering into total oblivion. So one person is looking for a sense of connection, another person is looking for a sense of the void of complete disconnection. Some people turn to alcohol because it provides them a reprieve from the oppressive conformity that their day-to-day life involves, a sense of quiet rebellion at the end of the day, feeling liberated. And all of these things, I should say, aren't problematic in themselves. It's when this relationship with the substance or the reward or the reprieve becomes calcified.

And the person's conception of the thing, the way the person speaks towards the thing, becomes a replacement for the relationship in all of its fullness itself. And when we're only focusing on how we hope to utilize a relationship, and whether that's with a drug or with a person, all kinds of tricky things start happening. Suffering that gets obscured in the process starts to break through the cracks. Other aspects of the substance or the person that we don't want to see start to reveal themselves. And the problem with addiction is that even as these other things start to show themselves, we narrow in even more deeply on how we hope the thing will be utilized, how we hope the thing

will exist in our imagination. So we take flight further and further into our imaginations as reality grows more and more horrendous. And that's the schism that we often see in addiction. A schism, by the way, that often resolves itself. Again, I mentioned earlier that people with addiction often end up emerging from it on their own. You know, the system. You know, the a schism becomes so dissonant that the person has no choice but to relinquish this artificial world that they've created and that is suffocating them. But in some cases, that's not the case. And other people need to get involved. And these are the cases that I discuss where each in his or her own way comes to a place of feeling suffocated, but unable to relinquish what's

suffocating them, unable to heed the reality that is forcing a collapse of what they find meaningful and what they find beautiful about their lives. So let's shift gears a little bit there then and have a look at some of the treatments that you mentioned in the book. I mean, specifically some of the newer ideas. So I'm thinking specifically about the use of ketamine. So this is a drug that's used recreationally, but we can use it. to help us to treat addictions. Now, that's fascinating. Yeah, and it gets to the heart of pharmacon.

A pharmacon in ancient Greek means poison. It means medicine. It means scapegoat. And all substances can occupy any of those roles in our lives, depending on the relationship that we bring to them. And as I've suggested so far, addiction represents a very very important. particular kind of relationship to a substance or really to anything, one that isn't as heedful of the expansive complexity of what's before us. It really tries to impose a fixed perspective on things. Where ketamine is interesting to me is in its capacity to destabilize that world we've constructed around this unity. iridirectional, problematic relationship to alcohol or cocaine or anything else.

Ketamine emerged as an anesthetic in the 60s and very quickly came to be recognized as powerfully psychoactive when it's given at doses below the anesthetic range. And its psychoactive profile is comparable to that of, you know, what are called psychedelic substances in as much as it can cause dreamlike states, states resembling profound meditation, states that resemble conversion experiences or transpersonal, mystical experiences. I was interested when I was starting my research career in how meditation might be leveraged to help people with addiction. I was interested in the ways that meditation can provide this expansive, spacious foundation on which to appraise what's happening to us and then make

decisions with greater suppleness and poise. But of course, people who are struggling with addiction who are really in the thick of it may not have the access to that. The very same vulnerabilities that we're trying to ameliorate with meditation or also militating against the practice. So I reasoned that medicine like ketamine might be helpful at providing the spaciousness given its psychoactive profile. That's really where a lot of my research has focused, how we might within a contemplative psychotherapy framework, harness the psychoactive powers of ketamine to create opportunities for entering into a destabilized space where the usual reality no longer has us in its grip, and we're able to occupy more enduringly a vantage point that isn't as

determined by what seems to be reality. At the same time that we also gain more capacity to fashion a new way of being in the world, to appraise what's happening to us in a manner that gives us greater equanimity, so that we're not feeling as agitated and craving driven when making decisions. And in a series of trials, I found that approach to be quite effective. So that's interesting, and as much as it provides some insight into other ways that we might address addiction, but it also, to bring it back to who we are as human beings more generally, it also offers us opportunity to really think about what the nature of reality is and how all of us might stand to live more deliberately, more gracefully, less encumbered by suffering. And we all have,

you know, realities that we regard in absolutist terms as what is the case. And it doesn't have to be the case. There are many ways that other possibilities might be obscured. Other necessities might be compromised by virtue of a very fixed understanding of who we are and what this world is. And the trials with ketamine and meditation provide, I think, an example of how we all might destabilize things a bit in a fruitful manner and recognize the participatory role we have in this world we live in. Thank you for listening to this episode of Instant Genius, brought to you from the team behind BBC Science Focus. That was Dr. Elias Dachwa, a psychologist and addiction researcher based at Columbia University, New York.

To find out more about the topics we've just discussed, check out his latest book, The Captive Imagination, Addiction, Reality, and Our Search for Meaning. If you liked what you just heard, please do consider subscribing to Instant Genius on your app store of choice. The current issue of BBC Science Focus magazine is out now. Pick up a copy wherever you buy your favourite magazines, or download us on your preferred app store.

You can also find us online, and Science Focused Magazine. This podcast is sponsored by Name, Audio and Focal. The texture and emotional depth of music can be lost through digital sources or poor signal. Name Audio believes you can have digital precision with analogue warmth. Alongside French acoustic specialist focal, name creates high-end audio systems combining innovation with craftsmanship, so you can listen to music, just as the artist intended. Discover more at Name Audio.com.

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