The main reason that people support prohibition is because they support public health. People believe that prohibition prevents drug abuse. In the real world, though, prohibition enables drug abuse.
Consider the forbidden-fruit élan. Under prohibition, drug consumption becomes a badge of independence. Substance abusers are not just drawn to drugs; they are drawn to illegal drugs. Prohibition also creates incentives to overindulge. Efforts to avoid detection drive production toward more concentrated drugs and forces consumption into smaller time slots. Consumption is necessarily done on the sly with more dangerous substances. Nothing about prohibition fosters moderation. Even Marxists, who were never loath to remove rights and freedoms, understood this basic concept. Writing in the British socialist magazine in 1908, labor leader Harry Quelch noted that “experience has proved that any form of prohibition has but stimulated that worst form of the drunkard’s vice, secret drinking.”[i]
Prohibition also comes with expectations that lead to irresponsible consumption. These laws are based on the notion that drugs are dangerous and can take over the human will to resist them. Expectations like the “fried brain” and “loss of control” all contribute to the likelihood of self-fulfilling prophesies.
The power of expectations was demonstrated years ago in research[ii] where drinkers were given unlimited access to alcohol in a “tasting” test. They were served drinks that contained vodka but were told that they contained only tonic water, or they were served drinks that contained only tonic water but were told that they contained vodka. The results showed that for both alcoholics and social drinkers, subjects who expected to drink vodka (but received none) drank almost twice as much and acted more inebriated than those who expected to receive only tonic water (but actually received vodka).
Another problem is that prohibition professionalizes control of consumption: law enforcement professionals strive to stop people from selling drugs, and treatment professionals attempt to keep people from wanting drugs. This ensures that drug use occurs outside cultural norms and sends those with unruly habits to “addiction experts” who coddle and enable them.
In my upcoming book, Blowing Smoke: Rethinking the War on Drugs without Prohibition and Rehab (Rowman & Littlefield, 2012), I argue that the only effective way to control substance abuse is to de-professionalize its control. Let’s remove the forbidden fruit, change the expectations, and get the medical profession out of the rehab business. Let’s then subject substance abusers to common-sense embedded cultural controls.
Laypeople have the power to control drug habits because they own—or should own—the most valuable social assets of any society. It is the hardworking, taxpaying, and child-rearing among us who control the homes, the warm beds, the meals, and the social contacts that connect people to jobs and opportunities. Responsible people are found at every level of society. They control the goods.
When this group bestows these goods on those who act responsibly and withholds them from those who do not, it wields tremendous leverage over society’s general level of civility. Responsible people can and should expect others around them to act similarly, just as they have had to do to get where they are. When faced with irresponsible behavior, responsible people naturally cut off the goods. In this way, they create incentives for everyone to do the right thing.
The medical profession is not capable of moderating this kind of tension. It is not within its nature to administer sanctions, and it tends to pathologize irresponsible behavior. The lay culture, on the other hand, deals with these tensions on a daily basis. From the time that children are taught to pick up their toys, laypeople have been shaping responsible habits. They know how to do it by instinct. Laypeople also understand that the consumption of anything (food or alcohol, for instance) is best enjoyed when linked to cultural or religious traditions, which tends to frame acceptable levels of consumption.
Prohibition laws perpetuate the temperance mindset of the 19th century: the masses are ignorant and need smart people to tell them how to live. While appeals to health are now used instead of appeals to morality, the outcome is the same: violence, lawlessness, irresponsible consumption….and the decay of public health.
[i]. Harry Quelch, “Socialism and Temperance Reform” Social Democrat 12, no. 1 (January 15, 1908): 1–8.
[ii]. Alan G. Marlatt, Barbara Demming, and John B. Reid, “An Experimental Analogue,” Journal of Abnormal Psychology 81, no. 3 (June 1973): 233–41.
Saturday, December 17, 2011
Monday, December 12, 2011
The DSM and scientism
The American Psychiatric Association (APA) is planning a 2013 release of the next edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM). First printed in 1952, the manual has been a boon to the profession because it got all clinicians on the same sheet of music, and it provided diagnostic codes so that providers could bill insurance companies.
Technically, the manual is only a classification manual. It provides labels for all of the emotional and behavioral struggles that people experience. Currently there are over 400 different entries.
The problem with labels, though, is that they explain nothing. The DSM does little more than classify the symptoms that people experience and the signs that others observe. A diagnosis, on the other hand, infers that there is an underlying disease state that produces the symptoms and signs at hand. In psychiatry, there are no objective tests or biomarkers for mental disorders, a point recently admitted by a past-president of the APA, Dr. Carol A. Bernstein. In the same article, she complained that practitioners who use the DSM tend to “reify” the various classification labels; that is, they turn labels into real-world diagnoses. You won’t hear that kind of admission very often from within the field. Instead, you’ll hear that the new DSM represents a big step forward in science and then you can watch both practitioners and patients routinely reify those labels.
An example of how this works in the real world is as follows: a restless and fearless child who begins violating classroom rules (getting up out of his seat, talking out-of-turn, bullying others) will be sent to a mental health clinic where he’ll be labeled with Attention-Deficit Hyperactivity Disorder. When he begins fighting and setting fires, he’ll receive the label of Conduct Disorder. When he starts using drugs, he’ll be labeled with Substance Abuse Disorder, and when he begins to have volatile adolescent emotions, he’ll be labeled with Bipolar Affective Disorder. Along the way he’ll receive medications and talk therapies. Parents begin to see that their main job is to get their kids to therapy sessions and to make sure kids take their medications.
It shouldn’t be a stretch to imagine how children raised in this kind of label-driven, pharmaco-therapeutic climate might develop emotional and behavioral habits that keep them from becoming self-controlled, responsible adults. Indeed, they often become narcissistic, labile and entitled adults. It used to be that children who misbehaved were met with discipline and punishment, all of which was designed to make them self-controlled, responsible individuals. Fortunately, one can still find pockets where this kind of child-rearing takes place.
The rise of the DSM has correlated with a popular belief in scientism, which maintains that science is the only way to solve problems of the human condition. This faith is misplaced. Scientists are human beings, and human nature is nothing if not opportunistic. Common sense dictates that science has bounds, and when it oversteps, society can be harmed.
Technically, the manual is only a classification manual. It provides labels for all of the emotional and behavioral struggles that people experience. Currently there are over 400 different entries.
The problem with labels, though, is that they explain nothing. The DSM does little more than classify the symptoms that people experience and the signs that others observe. A diagnosis, on the other hand, infers that there is an underlying disease state that produces the symptoms and signs at hand. In psychiatry, there are no objective tests or biomarkers for mental disorders, a point recently admitted by a past-president of the APA, Dr. Carol A. Bernstein. In the same article, she complained that practitioners who use the DSM tend to “reify” the various classification labels; that is, they turn labels into real-world diagnoses. You won’t hear that kind of admission very often from within the field. Instead, you’ll hear that the new DSM represents a big step forward in science and then you can watch both practitioners and patients routinely reify those labels.
An example of how this works in the real world is as follows: a restless and fearless child who begins violating classroom rules (getting up out of his seat, talking out-of-turn, bullying others) will be sent to a mental health clinic where he’ll be labeled with Attention-Deficit Hyperactivity Disorder. When he begins fighting and setting fires, he’ll receive the label of Conduct Disorder. When he starts using drugs, he’ll be labeled with Substance Abuse Disorder, and when he begins to have volatile adolescent emotions, he’ll be labeled with Bipolar Affective Disorder. Along the way he’ll receive medications and talk therapies. Parents begin to see that their main job is to get their kids to therapy sessions and to make sure kids take their medications.
It shouldn’t be a stretch to imagine how children raised in this kind of label-driven, pharmaco-therapeutic climate might develop emotional and behavioral habits that keep them from becoming self-controlled, responsible adults. Indeed, they often become narcissistic, labile and entitled adults. It used to be that children who misbehaved were met with discipline and punishment, all of which was designed to make them self-controlled, responsible individuals. Fortunately, one can still find pockets where this kind of child-rearing takes place.
The rise of the DSM has correlated with a popular belief in scientism, which maintains that science is the only way to solve problems of the human condition. This faith is misplaced. Scientists are human beings, and human nature is nothing if not opportunistic. Common sense dictates that science has bounds, and when it oversteps, society can be harmed.
Why people can't wrap their brains around drug legalization
As a clinical psychiatrist I have worked with hundreds of substance abusers and their families, and I’m convinced now, more than ever, that we need to legalize drugs. Sound like a contradiction? It isn't. The main reason people fear drug legalization is because they're devoted to the disease model of substance abuse. Simply put, most people believe that if we legalize drugs—including the “gateway” drug marijuana—we’ll experience an epidemic of out-of-control drug addiction that will shake the foundations of civilization.
My soon to be released book, Blowing Smoke: Rethinking the War on Drugs without Prohibition and Rehab (Rowman & Littlefield, February 2012), traces the history of the disease model and argues that its roots are political not scientific, and that the model paradoxically enables substance abuse. Current neuroscientific knowledge does not support the disease model; it only shows why quitting can be hard. Human nature is more resourceful than the disease model allows, which is why prohibition laws won't stop the flow of drugs, and multiple trips through rehab won't stop consumption.
While early drug control laws, like the Harrison Narcotics Tax Act (1914) and the Marihuana Tax Act (1937), were aimed at immigrants and minorities, modern prohibition laws are based on the disease model. Prohibition is believed to be a public health initiative. The disease model informs the United Nations’ Single Convention on Narcotic Drugs (1961), which is the legal basis for the war on drugs throughout the world. The thinking behind the treaty is straightforward: if drug abuse is a disease, then drugs are pathogens that need to be banned. The U.S. implemented this treaty through the Controlled Substance Act (1970).
The disease model was part of a larger cultural trend in the mid twentieth century that began to view the masses as weak and in need of enlightened protection from the political and scientific elite. This view didn't arise from the massess, it was passed down from the elites, who were certain that they knew what was best for everyone else. During this time Americans also lost the right to self-medicate. Most medicines today are “by prescription only." Prior to 1951, you could walk into any pharmacy and buy almost anything you wanted, with the exception of those drugs controlled by the tax acts.
So what is it about the disease model that enables substance abuse? Drug rehab teaches addicts that they have a genetic brain disease and that they aren’t responsible for their behavior; the sick-role entitles addicts to a wide range of welfare and disability benefits; disease model-inspired prohibition laws create a forbidden-fruit élan; and the model creates a set of expectations that does nothing to foster moderation: drugs will fry your brain, you’ll lose the ability to control yourself and you’ll likely commit crimes to support your habit. That many drug users behave like this is true enough, but the reason has less to do with the chemical properties of drugs than with the expectations and enabling that society delivers courtesy of the disease model.
Blowing Smoke argues that the only way to effectively manage the drug problem is to meet human nature head-on: embrace drug use as a cultural norm and let informal cultural controls reinforce responsible use. Quitting isn't necessary, only moderation. Doctors can't change addicts, but addicts can change themselves, and they're more likely do so when family members and friends help them experience uncomfortable consequences for irresponsible consumption. Want to help drug addicts? Then help them face painful consequences for irresponsible use.
While repealing prohibition laws would eliminate the violence associated with the drug trade, harm reduction efforts that seek to shift control to the medical profession would be misguided. If we legalize drugs and continue to treat drug abuse like a disease, irresponsible use will continue to grow and many reasonable people would start calling for a return to prohibition.
My soon to be released book, Blowing Smoke: Rethinking the War on Drugs without Prohibition and Rehab (Rowman & Littlefield, February 2012), traces the history of the disease model and argues that its roots are political not scientific, and that the model paradoxically enables substance abuse. Current neuroscientific knowledge does not support the disease model; it only shows why quitting can be hard. Human nature is more resourceful than the disease model allows, which is why prohibition laws won't stop the flow of drugs, and multiple trips through rehab won't stop consumption.
While early drug control laws, like the Harrison Narcotics Tax Act (1914) and the Marihuana Tax Act (1937), were aimed at immigrants and minorities, modern prohibition laws are based on the disease model. Prohibition is believed to be a public health initiative. The disease model informs the United Nations’ Single Convention on Narcotic Drugs (1961), which is the legal basis for the war on drugs throughout the world. The thinking behind the treaty is straightforward: if drug abuse is a disease, then drugs are pathogens that need to be banned. The U.S. implemented this treaty through the Controlled Substance Act (1970).
The disease model was part of a larger cultural trend in the mid twentieth century that began to view the masses as weak and in need of enlightened protection from the political and scientific elite. This view didn't arise from the massess, it was passed down from the elites, who were certain that they knew what was best for everyone else. During this time Americans also lost the right to self-medicate. Most medicines today are “by prescription only." Prior to 1951, you could walk into any pharmacy and buy almost anything you wanted, with the exception of those drugs controlled by the tax acts.
So what is it about the disease model that enables substance abuse? Drug rehab teaches addicts that they have a genetic brain disease and that they aren’t responsible for their behavior; the sick-role entitles addicts to a wide range of welfare and disability benefits; disease model-inspired prohibition laws create a forbidden-fruit élan; and the model creates a set of expectations that does nothing to foster moderation: drugs will fry your brain, you’ll lose the ability to control yourself and you’ll likely commit crimes to support your habit. That many drug users behave like this is true enough, but the reason has less to do with the chemical properties of drugs than with the expectations and enabling that society delivers courtesy of the disease model.
Blowing Smoke argues that the only way to effectively manage the drug problem is to meet human nature head-on: embrace drug use as a cultural norm and let informal cultural controls reinforce responsible use. Quitting isn't necessary, only moderation. Doctors can't change addicts, but addicts can change themselves, and they're more likely do so when family members and friends help them experience uncomfortable consequences for irresponsible consumption. Want to help drug addicts? Then help them face painful consequences for irresponsible use.
While repealing prohibition laws would eliminate the violence associated with the drug trade, harm reduction efforts that seek to shift control to the medical profession would be misguided. If we legalize drugs and continue to treat drug abuse like a disease, irresponsible use will continue to grow and many reasonable people would start calling for a return to prohibition.
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