The Thirteenth Step: Addiction in the Age of Brain Science

IN AN ENCOUNTER with a patient, every clinician is faced with a fundamental dilemma. Although present in all areas of medicine, this issue becomes most acute in psychiatry and behavioral health. In these fields, feelings, intentions, and decisions are at the core of the clinical disorders that bring patients to treatment. So the question cannot be avoided: should what happens in the patient’s mind be viewed as yet another set of physiological processes, possible to register from the outside in an objective manner and to predictably manipulate with interventions such as drugs, similar to what we expect of blood pressure or serum glucose? Or are these inner processes inherently different from physiology, requiring that we view them as uniquely subjective, volitional processes of the mind? In other words, is the patient an agent expressing a unique free will or an object that follows deterministic¹ laws of nature? An inability to resolve this dilemma, or at least to find pragmatic ways of handling it, has been behind much of the tensions and feuds that have preoccupied psychiatry and related disciplines for more than a century. It has also diverted time and energy from developing, implementing, and providing better treatments for patients who need them. We cannot move on without addressing this issue.

In a way, every patient encounter is a mystery. After years of sobriety, the patient suddenly decides to drink again. Afterward, across the exam room, a fellow human is sharing that uniquely personal experience and the feelings, intentions, and decisions that went into it. I have no way of directly accessing the patient’s mind. If I were required to provide scientific proof, I don’t think I could even prove that the patient has a mind. But as I tune in, listen, and watch the expressions that accompany the account, I experience feelings of my own: sadness, anger, perhaps joy. Thoughts come to me about what may have happened. As is so often the case, something important about what is going on is embedded in the language used to describe it. I say that the patient’s account strikes a chord or resonates with me. The image that comes to mind is that of two strings, on two separate instruments. One plays a tone, and the other, if properly tuned, is put in motion to play the same note, albeit with different overtones. In a clinical setting, this subtle process is critical. Developing an ability to tune in to uniquely subjective feelings of patients constitutes half the job skills required of any psychiatrist. Without this skill, it is hard to imagine how a clinician could ever connect with a patient suffering the intense sadness of a major depression, the irrational fears of an anxiety disorder, or the seemingly irresistible urges of addiction. Before patients will trust a doctor with what torments them and build the alliance necessary for the hard work of treatment to succeed, they want to know that the doctor has a sense of what they are experiencing and cares about it. Somehow, a process needs to take place that will ultimately enable one person to say “I feel your pain” and the other to trust that to be the case.

Stated differently, when experienced from the inside, the desires, fears, or intentions to act in a particular way have a peculiar subjective quality that is hard, if not impossible, for others to access. My desires and fears are mine. In fact, my desires and fears are me. The notion that other people, whom we can only observe from the outside, also have minds, feelings, and intentions is by no means self-evident. Who knows—maybe, unbeknown to me, I have been given Jim Carrey’s role in a sequel to the 1998 movie The Truman Show. Maybe people around me are just playing roles scripted for them by a demonic movie director. Or maybe they are animated by a new technology from Pixar. It is surprisingly difficult to refute these obviously ridiculous notions, yet I take for granted that they are ridiculous. Instead I assume that people around me who speak, laugh, cry, or act do so because of feelings, intentions, and decisions similar to mine. That is because, like most healthy adult humans, I have developed what has come to be called a theory of mind.

This important concept, introduced by University of Pennsylvania primatologist David Premack and his colleague Guy Woodruff in 1978,² has been extensively studied since then. Human children begin to develop a theory of mind before the age of two, most likely by noticing similarities between themselves and others. The child feels happy and smiles. Mother is smiling too; perhaps she feels the same way? This way we grow up instinctively attributing to others feelings and intentions much like our own. But our own feelings, intentions, and decisions appear to us as primary, irreducible phenomena that ultimately cause our behavior. This appearance is unreflected, for the most part not explicitly articulated, and fully developed long before rationality or scientific training could allow us to probe its basis or limitations. Because this is the way we come to view ourselves, and because the theory of mind we apply to other people is based on attributing to them inner experiences similar to our own, we come to view other people in much the same way—as irreducible agents of their actions, actions carried out as a result of decisions that ultimately represent nothing less than the exercise of a free will. From that perspective maybe it is reasonable to hold that to stop using drugs, it is enough to “just say no.”

And yet, at the same time, we know that patient histories are also quite predictable, in the best and clinically most useful sense of the word. If you tell me that you have been struggling with alcoholism for the past ten years and then take a drink, I can predict that on most occasions you will not stop at that one drink, even though you planned to. If you tell me that your father was an alcoholic, that you took your first drinks when you were fifteen, and that the friends with whom you were drinking fell asleep while you did not at all become impaired, I can predict that you run a high risk of developing alcohol problems in coming years. These are the kinds of predictions that medicine relies on for successful treatment, as well as successful prevention. Based on these kinds of predictions, we can intervene and say things such as “Let’s practice behaviors that will help you avoid taking that first drink, and if you do practice enough to master them, we can predict that the probability of relapse will decrease.” Or “Let’s make sure you take a nalmefene tablet before going to a cocktail party, and we can predict a reduction in relapse risk.” Perhaps more provocatively, “Stay on this antidepressant for four weeks, and we can predict that your existential despair will likely give way to an interest in repainting the garage or going to the movies with your wife.” Viewed from this perspective, feelings, intentions, decisions, and actions certainly appear to be predictable, determined by factors that we can identify and sometimes influence—thus both objective entities and largely deterministic.

“Astonishing,” as used here, is a nice British understatement. Unsettling, provocative, or infuriating are probably closer to the real meaning. In the abstract, people perhaps find this perspective on the mind somewhat less astonishing today than they did in 1994 when Crick put it forward. In everyday life the notion remains as foreign as ever. It brings with it the dilemma we are discussing, which paradoxically becomes worse as we become better at figuring out the laws of nature that govern brain function, improving our ability to make predictions and to influence outcomes in the domain of the mind. The crude and incorrect prediction that bloodletting would cure a mysterious fever probably did not offend many sensibilities, in part simply because it didn’t work. But as science and medicine become capable of making powerful predictions about feelings, thoughts, and decisions, phenomena we have come to view as our innermost self for as long as we can remember, the challenge becomes unavoidable. The prediction that taking a medication will change one’s outlook on whether life is worth living, or change one’s willingness to stay sober, is just so much more provocative. It seems to reduce a human being, with all the woes and joys that flesh is heir to, to an object not much different from a complicated machine. From this perspective phenomena we view as our innermost self seem merely to be byproducts of sophisticated biological machinery.

It is not all that hard. Stripped of ideological overtones, the simple fact is that both perspectives on the human mind outlined above are essential for a successful therapeutic relationship, and both are justified. What is critical is to realize when each of them is appropriate, and to develop an ability to shift between them. Every encounter with a patient must start with conveying a willingness to listen to and take in the subjective feelings of the patient. Some clinicians are easily moved and have a natural talent for establishing this connection. That is a true gift, but it also poses a distinct risk. We all like to do the things we are good at. If listening and using a well-developed ability for empathy is what a clinician is good at, that can end up being all that happens during a visit, and the next one, and the one after that. Although clearly valuable, being a good listener does not reach beyond what a sympathetic friend might be able to offer. A good working relationship starts by walking alongside the patient until a thread of trust has been woven. After that, however, a clinician needs to step back and apply the other perspective—objectively assessing behavior, brain function, and interventions that might predictably change mind contents and actions in the direction in which the patient has expressed a wish to walk. Or maybe the patient has not expressed any such wish; in such a case, as we will see in a subsequent chapter, there are psychological techniques to help him or her become more ready for the change that is necessary for improved health or perhaps even survival. Challenging though these perspective shifts are, they are one of the reasons I love clinical medicine, and psychiatry in particular. This marriage of science and humanism is hard to find in any other profession.

Although I find it impossible to apply the two perspectives to a person at the same time, I do not think that they are contradictory. At the core of every human mind are infinitely complex and subtle processes that we cannot access directly. Networks of neurons distributed through the brain come together in ensembles that fire in ever-changing patterns, but we can only infer their existence indirectly. The consequences of their workings can, however, obviously be viewed in many different ways. Each of these is as incomplete as it is indirect and can be likened to a window that allows only a limited view, from a certain restricted angle. Depending on which window we look through, things will look different. If the processes of the brain-mind are viewed through the window of a functional magnetic resonance imaging (fMRI) camera, they may look like colorful maps of activity.³ Viewed through an electroencephalogram (EEG), they will appear as waveforms on paper. Viewed from the inside, they feel like—well, like me. But these perceptions and many others are simply different reflections of the same underlying processes that occur as infinitely complex neuronal ensembles fire in patterns that change on a millisecond to millisecond basis. None of the reflections is identical to the processes themselves; all are generated by those processes.⁴ From this it follows that none of the perspectives on the mind outlined here is inherently right or wrong. Some are useful for some purposes, others for other purposes. This is not much different from saying that using a microscope would not be very helpful to perceive the beauty of a painting by my favorite painter, de Chirico. But the instrument would certainly be useful if I were charged with restoring the paint. So the antagonisms between different schools of thought in psychiatry strikes me as less an issue of being right than of choosing the right tool at the right time.

But before we choose that tool, we cannot escape one final philosophical issue. If subjective feelings, intentions, and decisions are indeed reflections of neuronal processes that can be objectively described and predicted, is there any room left for a free will? Or is it, against that background, not at all meaningful to have a dialogue with the patient about choices and their consequences? Maybe the only approach left to us once the neural processes are sufficiently well understood will be that of the police in Philip K. Dick’s short story “The Minority Report” (1956): to predict undesirable behavior, and stop it before it happens?

This is one of the great unresolved questions of philosophy, and I clearly do not aspire to answer it. But I subscribe to a pragmatic approach to this problem that seems logically unassailable, which was proposed by the cognitive scientist and linguist Steven Pinker.⁵ Pinker first notes that even if science were in principle able to fully describe and predict the human mind, it is unclear whether this would ever translate into an actual ability to predict behavior with a certainty sufficient to eliminate the perception of a free will. The brain may simply be too complex. But be that as it may, says Pinker, whether people have a free will or not, we all benefit from treating them—and being treated ourselves—as if they do. Pinker uses a drastic example. Let’s say that person X is inclined to kill person Y. If X knows that he is viewed as being devoid of free will, he also knows that once he commits the murder, it will hardly be possible to hold him accountable. His behavior was deterministic—determined by his genes, the environment, or both. He had no choice. But if he knows that we believe all people have a freedom to choose and therefore intend to hold him accountable no matter what, the input to the calculations of his mind becomes different, and the crime is less likely to happen. Thus no matter what we think about the existence of free will and determinism, we all benefit from maintaining the notion that people can choose and take responsibility. Maybe this is an illusion. But, as it turns out, it is one that is both heartwarming and useful—a combination that is hard to argue with.