Journal of Drug Abuse Open Access

Maya Szalavitz was on stage. The venue: The New York Sunday Times, Sunday Review section on June 26, 2016, page 9.

She gets philosophical. We hear that there are two schools of thinking about addiction. One school says that the brain had been hijacked, making one powerless over a drug (including alcohol). The other school sees the addict as a criminal. And she suggests a third school, based on learning, her answer. But there also may be a viable fourth school including some elements of the first two schools. And there may be a fifth school or even more.

She tells us that a new perspective is needed. After all, neuroscience has changed and many existing treatments simply do not work; we know more about learning pathways. That neuroscience has changed is no surprise. What science has not changed? And who thought traditional rehabilitation-based, AAoriented addiction treatment worked all the time for everyone? But what does “work” really “mean”? Is it number of days sober per year, a lessening of problems, longer times between relapse and shorter relapse? And longitudinally, what is the story? How many years does the recovering person have as “clean and dry” before recovery? Lots of mysteries here; that she glosses over.

It’s important that editorials are responsible, not simply a dive into one’s own reflection, Narcissus - like, thinking one’s image magically superior, important in all circumstances. Personal reflection is hardly universal law. In private, many think there is one royal road for solving a personal problem. If she solved something; fine. But to make it a law-like pronouncement for us all, that’s another matter. It should give us pause.

She holds onto an idea the neuro-developmental sequence, her own reactive nervous system and the magic of heroin was the basis of her addiction, giving her comfort, safety and love. Then her answer to addiction is to create new pathways of learning.

She does not buy into the idea of a hijacking of brain. Instead, we learn that new neural pathways are constructed, which may be deconstructed. But there is an uncomfortable fact: we know, alcoholics can have badly damaged brains. Surely addiction can also approached with tools to learn new ways, to call this revolutionary and “revolutionary” is her word and to intimate that this is the only way is a bit of a stretch. For a long time we have known cognitive-behavioral approaches are great but often supplementary. But tell us that that cognitive behavioral therapy is necessarily superior to “traditional” rehab approaches:

confronting denial and accepting powerlessness over addiction is simply overstatement. Despite the fact she relies on metaanalysis of outcome studies showing the superiority of cognitive behavioral approaches, other meta-analyses show that traditional rehabilitation approaches buttressed by AA are also a good answer to the problem of addiction.

So much of outcome of treatment has to do with the reasons for a person is job-related, family-related, due to the criminal justice system which forced one into treatment or a consequence of the environment to which the addict must return. To simply associate the traditional rehabilitation with a painful and unproductive mode of treatment is senseless and simplistic. Often this breaking down of denial, getting people to “hit bottom” is just a first phase in the process. After these harsh methods there may be expressions of love, support, dignity and empathy. Accepting powerlessness may be just a first step, opening the way to more kindly responses from others.

It is hubris for Ms. Szalavitz to suggest insights into her own recovery ought to be followed by others. We need ask if these insights about herself pertain to the sexually abused children who fill our treatment centers, the well-to-do patient prescribed too much valium or does addiction come easily marginal citizen by virtue of ethnicity and poverty who winds up dumpster diving? Cognitive behavioral therapy may fit; likely in recovery. However, there as so many pathways, even unusual strategies like acupuncture. Those who trumpet their own experiences as the best way, even “revolutionary, should find a good mute for the end of their instrument.