On Fresh Air a few days ago:
We’re going to talk about new ways of understanding and treating addiction. My guest, Maia Szalavitz, is the author of a book that examines scientific, behavioral and medical research about addiction. She says the methods of treatment and punishment haven’t caught up with the research.
Szalavitz is a journalist who’s been covering addiction and drug-related issues for nearly 30 years. She writes a column for VICE and has been a health reporter and columnist for Time magazine. She was addicted to cocaine and heroin from the age of 17 to 23. She stopped using in 1988, about two years after she was arrested and charged with cocaine possession. She faced a mandatory minimum sentence of 15 years to life. A little later, she’ll explain why she never served time. Her new book about addiction is called “Unbroken Brain.”
GROSS: OK. So you were 17 when you started using hard drugs. And what do we know now about the brain development of teenagers and why teenagers are more vulnerable to becoming addicted?
SZALAVITZ: Well, there are three critical periods of brain development in the human. The first one is obviously prenatally. The second one is 0 to 5. And the third one is adolescence into young adulthood.
And what’s going on in the brain at that time is that the areas that give you drive and motivation and that get you out of the house and that get you seeking boyfriends and seeking friends and, you know, seeking to interact with your peers more than your parents – those areas are growing really strong.
And you are learning, you know, how to seek thrills and pleasure and how to maneuver amongst your peers and how to have relationships. Unfortunately, the stuff that develops later are the regions that are involved in self-control and in reining in that motivation and reining in that desire. So when you’re a teenager, you have sort of a very strong engine with weak brakes.
And the brakes don’t really develop until your 20s or so. And that means that if you are engaging in a highly pleasurable or highly comforting experience as a teenager, you’re going to be more likely to get addicted because your brakes aren’t developed that much yet.
Ah yes. I remember that teenage engine – that surge. I remember the way it used to rev itself sometimes with no road to run on. You know? Wild feelings with no very clear referent? “I want to…something…run away…somewhere…what do I want?” The link to addiction seems to make a lot of sense.
GROSS: So you quote a couple of things. You say 90 percent of all addictions begin during adolescence. And addiction is less common in people who use drugs for the first time after they’re 25. And addiction often remits with or without treatment among people in their 20s just as the brain becomes fully adult. What do you extrapolate from those statistics?
SZALAVITZ: Well – that this is a developmental disorder. And that there is a period of extreme risk. And this is not to say, of course, that you cannot become an addict later in life. But the most common time and the most likely time for you to develop an addiction is your teens and early 20s.
The teenage person isn’t the real person yet. Or, you could argue, the teenage person is the real person, before the fakery and caution and hypocrisy of the developed prefrontal cortex have tamed and limited her. I don’t buy the romantic view, myself: I prefer people with judgement and self-control over people with strong but self-centered feeeeeeeelings. I do think people are more their real selves as they gain judgement and experience.
And another thing that’s going on at that time is – if you aren’t using drugs or escaping into something else excessively at that time, you are developing social skills and self-soothing skills and other skills that allow you to live comfortably in your body. And if you spend that time escaping with drugs, you aren’t learning those other things – so that when you try to stop, you won’t have those ways of dealing available to you.
They go on to talk about “tough love,” and Szalavitz says it’s a crock of shit.
This notion of tough love and hitting bottom. It was two years after I got arrested that I got into treatment. After I got arrested, I got worse and worse. I didn’t hit bottom when I had the insight that allowed me to seek help. What I got at that point was some kind of hope that I could change.
And we have this idea that if we just are cruel enough and mean enough and tough enough to people with addiction that they will suddenly wake up and stop. And that is not the case. Addiction is actually defined by the DSM and by the National Institute on Drug Abuse as compulsive behavior that continues despite negative consequences. That’s the definition of addiction. So therefore, if punishment, which is just another word for negative consequences, worked to fight addiction, addiction actually wouldn’t exist.
And so we just have this thing so wrong. Addiction is a problem with learning from punishment, and we expect punishment to fix it. There’s something deeply wrong with that.
The harm reduction approach is much better, she says. Needle exchanges and respect; those work much better than “tough love.” Interventions can backfire – Kirt Cobain killed himself after an intervention. I did not know that, even though I drive past his house when I take Cooper for walks along Lake Washington. (You’d think I’d have picked it up as local knowledge, I mean.)
Then there’s a part where they talk about 12 step programs, and Gross keeps saying they’re very successful, which annoyed me because the stats for 12 step are terrible. It’s a huge myth that they succeed – they rarely do.
GROSS: So, you know, a lot of people have been able to give up their addiction, whether it’s drugs or alcohol, with the help of 12-step programs. And I think it’s fair to say a 12-step program helped you, although there are things that you found were not helpful within the program.
But you say, like, just relying on 12-step programs is the equivalent of saying to somebody who has cancer, we’re not going to give you any drugs. But here’s a self-help group. It’s really going to help you.
SZALAVITZ: I think the 12-step programs are fabulous self-help. I think they can be absolutely wonderful as support groups. My issue with 12-step programs is that 80 percent of addiction treatment in this country consists primarily of indoctrinating people into 12-step programs. And no other medical care in the United States is like that. We don’t tell people with cancer that you must learn to surrender to a higher power, to pray, to confess to your sins, to make restitution.
If you went to a doctor for cancer and you were told that, you would think that you had found a quack. But in addiction, if you go to a treatment center, you will be told this is the only way. And the alternative is jails, institutions or death. So what I think is that we need to have within professional treatment no 12-step content.
That too is a problem, but I don’t think they should be called fabulous self-help when they seldom work. I think I blogged about a long article on the subject in The Atlantic last year, including this stark passage:
In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.
Szalavitz explains why 12 step programs shouldn’t be pushed on people some more, and Gross just repeats the myth about their success.
That doesn’t mean that professional treatment can’t refer people to AA as a support group. But professional treatment should consist of things that you cannot get for free elsewhere. So it should consist of cognitive behavioral therapy or motivational enhancement therapy or any of a number of different talk therapies that help people with addiction. I am not saying if 12-step programs work for you, you should quit them and do something else.
I am saying that your oncologist is not your breast cancer support group.
GROSS: But, I mean, 12-step programs do help so many people.
No. They don’t. That’s a myth. (What’s the source of the myth? Why, 12-step programs!)
SZALAVITZ: The data shows that cognitive behavioral and motivational enhancement therapy are equally effective. And they have none of the issues around surrendering to a higher power or prayer or confession. I think that one of the problems with the primary 12-step approach that we’ve seen in addiction treatment is that because the 12 steps involve moral issues, it makes people think that addiction is a sin and not a disease.
The only treatment in medicine that involves prayer, restitution and confession is for addiction. That fact makes people think that addiction is a sin rather than a medical problem. I think that if we want to de-stigmatize addiction, we need to get the 12 steps out of professional treatment and put them where they belong as self-help.
And not very effective self-help at that. I think they should be seen as support groups and nothing more.