The Brief Addiction Science Information Source (BASIS)

Addiction & the Humanities Vol 6(6) – I Wish I Said That

The Oxford English Dictionary (OED) defines “aphorism” (second definition) as “Any principle or precept expressed in few words; a short pithy sentence containing a truth of general import; a maxim.” Arguably, much of peoples’ attitudes and knowledge are reflected in and derive from such aphorisms. However, such sayings might gain broad recognition and acceptance without containing a truth. This week, Addiction and Humanities reviews several selections from The Quotable Gambler (Paul Lyons, 1999) to determine how they map onto current knowledge and practices related to gambling.  

The more it changes…

Gambling promises the poor what property performs for the rich: something for nothing.- George Bernard Shaw

Mr. Shaw would not be surprised by the number of states that earmark some casino fees and revenues for reducing property taxes.

Something for nothing

A dollar picked up in the road is more satisfaction to us than the 99 which we had to work for, and the money won at Faro or in the stock market snuggles into our hearts in the same way. ~ Mark Twain

In contrast, Aronson & Mills (1959) found that people tend to attribute a greater value to things they put effort into acquiring or achieving. They labeled the effect “effort justification.” Perhaps gamblers cognitively distort winning as a result of their efforts.

Controlling chance

You cannot beat a roulette table unless you steal money from it. ~ Albert Einstein

A gambler is nothing but a man who makes his living out of hope. ~William Bolitho

Despite Einstein’s admonition, some research demonstrates that people diagnosed with an a gambling disorder have higher than usual belief in their ability to control chance (de Stadelhofen, Aufrère, Besson, & Rossier, 2009).

Maybe it’s not about the money

There are two great pleasures in gambling: that of winning and that of losing.  ~ Old French Saying

The subject of gambling is all encompassing.  It combines man's natural play instinct with his desire to know about his fate and his future. ~ Franz Rosenthal

Gambling satisfies the need for stimulation and the discharge of impulses. It also distracts from stress (Clarke et al, 2007). Research has demonstrated that gambling provoked by excitement-seeking is associated with other psychological problems (Pantalon, Maciejewski, Desai, & Potenza, 2008).

But it is a slippery slope

They start gambling for fun, continue for greed, and finally the game becomes a passion.  ~ Francois-Paul Brueys D'Aigalliers

The first steps on the slope

One of the worst things that can happen to you in life is to win a bet on a horse at an early age. ~ Danny Mcgoorty

Clinicians identify early wins as a risk factor for developing gambling-related addiction problems. More work needs to be done to determine whether there is much truth to Mcgoorty’s claim.

With untoward consequences

All the world loves the game, and most sensible people willingly resign themselves to it until they see violence, deception, confusion, loss of money and time paired with it; until they understand that they can spend all their life for it. ~ Montesquieu.

Words of advice

If you must play, decide upon three things at the start: the rules of the game, the stakes, and the quitting time.  Chinese Proverb

It would appear that suggestions for responsible gambling have been around for many years.  

Conclusion

Perhaps you have employed quotes from others or constructed your own aphorisms about the recognition and remediation of addiction. Please forward those sayings with a description of their utility to the BASIS so that we can compile them into an issue for the benefit of our readers. 

-Julia Braverman

Please use the comment link below to provide feedback on this article.

References

Aronson, E., & Mills, J. (1959) The effect of severity of initiation on liking for a group. Journal of Abnormal and Social Psychology, 59, 177-181

Clarke, D., Tse, S., Abbott, M., Townsend, S., Kingi, P., & Manaia, W. (2007). Reasons for starting and continuing gambling in a mixed ethnic community sample of pathological and non-problem gamblers. International Gambling Studies, 7(3), 299-313.

de Stadelhofen, F., Aufrère, L., Besson, J., & Rossier, J. (2009). Somewhere between illusion of control and powerlessness: Trying to situate the pathological gambler's locus of control. International Journal of Clinical and Health Psychology, 9(1), 117-126.

Lyons, P. (1999). The Quotable Gambler. New York, New York, The Lyons Press.

Pantalon, M., Maciejewski, P., Desai, R., & Potenza, M. (2008). Excitement-seeking gambling in a nationally representative sample of recreational gamblers. Journal of Gambling Studies, 24(1), 63-78.

Addiction & the Humanities, Vol. 6(5) - Exposure to Drug-related Music Lyrics

Many researchers suspect that exposure to public health toxins, such as gambling, alcohol, and tobacco, can lead to changes in engagement with those toxins (LaPlante & Shaffer, 2007; Shaffer, LaBrie, & LaPlante, 2004). Consistent with this perspective, many studies have examined the health effects of toxin-related imagery in movies, music, literature, and the like (Addiction and the Humanities, Vol. 6(3); 3(2); and 1(11). This week, for Addiction and the Humanities we review a study that examined the association between adolescents’ exposure to cannabis in popular music, and their cannabis use (Primack et al., 2009).

Methods

• The researchers examined the baseline survey data of an anti-smoking clinical trial involving all students (N=959; 80% of those eligible) enrolled in 9th grade health classes at three large Pittsburgh, PA high schools.
• The baseline survey included socio-demographic, parenting style, sensation seeking, rebelliousness, and alcohol-use scales and variables.  
• The study estimated students’ cannabis lyric exposure in two ways:
• First, by asking students the number of hours per day they listen to music and their favorite musician. The researchers used this information, in combination with the results of a separate content analysis of musicians’ songs (Primack, et al., 2008), to determine each student’s unique exposure to cannabis lyrics (i.e., the product of students’ hours per week listening to music by the number of cannabis references per hour in their favorite artist’s songs).  
• The researchers categorized students’ exposure scores into tertiles: low, medium, and high.   
• Second, by determining students’ favorite artist’s number of songs that contained cannabis lyrics (i.e., 0 songs, 1-2 songs, or 3 or more songs with cannabis lyrics).  
• The primary outcome variables of interest were: (1) ever cannabis use, even a puff (yes or no) and (2) past 30 day cannabis use, even a puff (yes or no).

Table 1: Odds Ratios (95% Confidence Intervals) for Cannabis Use/Exposure Relationship

**p<.05; multivariate regression analyses controlling for all covariates (i.e., socio-demographic, parenting style, sensation seeking, and rebelliousness scales and variables)

Results

• As displayed in Table 1, multivariate logistic regressions, controlling for all covariates (i.e., socio-demographic, parenting style, sensation seeking, and rebelliousness scales and variables), showed that compared to those with the lowest exposure to cannabis lyrics, those with the highest exposure had higher odds of past 30 day cannabis use.
• Regression analyses also showed that compared to those with the lowest song exposure, those with the highest exposure had higher odds of past 30 day cannabis use and ever cannabis use.

Limitations

• The study relied on self-reported data without corroboration; therefore, this study is subject to the problems commonly associated with self-report.
• The study does not consider the role of individual resiliency factors (e.g., positive social networks), which might influence exposure processes.
• The measures of exposure assume that students’ favorite artist also is their most played artist, which might not be the case.
• The study design is cross-sectional; therefore, it cannot establish whether the cannabis exposure and engagement relationship is causal.

Discussion

The study supports research that suggests that exposure to specific public health toxins is associated with increased engagement with those toxins. It is the first study to illustrate this phenomenon with cannabis, using exposure estimation calculations. Future research in the area might consider the role of resiliency factors, which might change the nature and shape of the relationship between exposure and engagement. Also, research on exposure effects for other public health toxins suggests that exposure effects often are attenuated over time, through adaptation processes (LaPlante & Shaffer, 2007; Shaffer et al., 2004). Researchers and others should consider whether such processes might apply here, and/or how to facilitate such processes and minimize prototypical exposure effects.

-Debi LaPlante

What do you think? Please use the comment link below to provide feedback on this article.

References

LaPlante, DA & Shaffer, H. J. (2007). Understanding the influence of gambling opportunities: Expanding exposure models to include adaptation. American Journal of Orthopsychiatry, 77, 616-623.

Primack, B. A., Dalton, M.A., Carroll, M. V. Agarwal., A. A. Fine, M. J. Content analysis of tobacco, alcohol and other drugs in popular music. Archives of Pediatric Adolescent Medicine, 162, 169-175.

Primack, B. A., Douglas, E. L., & Kraemer, K. L. (2009). Exposure to cannabis in popular music and cannabis use among adolescents. Addiction, 105, 515-523.

Shaffer, H.J., LaBrie, R.A., LaPlante, D.A. (2004). Laying the foundation for quantifying regional exposure to social phenomena: Considering the case of legalized gambling as a public health toxin. Psychology of Addictive Behaviors, 18(1), 40–48.

Addiction & the Humanities, Vol. 6(4) - A diary of morphine-addiction

Although evidence suggests that that natural history of addiction is similar across people and expressions of addiction (Shaffer et al., 2004), personal stories about the development of addiction remain compelling and informative. This week’s Addiction and the Humanities presents annotated excerpts from an intensely gripping story about the gradual metamorphosis of the psychological state, thoughts, and emotions of a physician who became addicted to morphine. The fictional story,Morphine, is based on the real experiences of the author, a famous Russian writer Michael Bulgakov*, who became morphine addicted early in his life.

 Background: The story is set in Russia, during January 1917. This is a period involving the Russian Revolution and the First World War. The protagonist, a young doctor Polyakov, not being eligible for active military service after graduation from a medical school in St Petersburg, is beginning an assignment to practice medicine in a remote country village. Below we present annotated excerpts from his diary, as described in, Morphine. The excerpts are unmodified quotes from the book; we give the annotations in italic. 

Jan. 20. 1917. Perpetual blizzards… I’m sick of it. Alone every evening. <…>

Social isolation could have protective or risk-related implications for addiction. Here, social isolation does not appear to provide protection from exposure to potential objects of addiction and leaves the person with no social support. The diary portraits a lonely and distressed person.

Feb. 15.  Last night an interesting thing happened. I was just going to bed, when I suddenly felt pain in the region of my stomach. And what pain! Groaning, I reached the kitchen, and called Anna K., the nurse. She came to my room and had to give me a morphine injection. <…> I must give due praise to the man who first extracted morphine from poppyheads. The pain stopped seven minutes after the injection. It would be a good thing if a doctor were able to test many more drugs on himself. He would then have a completely different understanding of their effect. After the injection I slept soundly and well for the first time in months – and I forgot completely about the woman who deceived me.

The first experience of morphine injection is extremely rewarding. It relieves not only physical pain, but also emotional distress.

Feb 16. I am alone in my quarters. Fearing a recurrence of yesterday’s pain attack, I injected myself in the thigh with .01 gram. The pain cease almost instantaneously. A good thing Anna K. left the phial behind.

Being alone, previous rewarding experience and availability of drug - all become factors in the addiction progress.

Feb 18. Four injections. No harm in that.

Tolerance is evident as he increases the dose to reach the same effect previously obtained at a lower dose.  

Feb 21. Anna K. is behaving very oddly – just as though I weren’t a doctor at all! 1.5 syringes = .0.015 grammas morph.? Yes. It is two weeks now since I last thought about the woman who deceived me. I am very proud of that. I am a man.

Morphine injection “protects” against condemnation of other people. The character feels pride rather than shame.

            For the first minute there is a sensation of being touched on my neck. The touch grows warmer and spreads. In the second minute there is a sudden surge of cold in the pit of my stomach, after which I start to think with unusual clarity and experience a burst of mental energy. If I had not been spoiled by my medical training, I would say that a man can only work normally after an injection of morphine. <…> Anna K. is frightened. Calmed her, saying that since childhood I have been remarkable for having tremendous will power.

Exposure to morphine can produce extremely rewarding psychological states that are accompanied by misleading feelings of self-confidence. Medical training and knowledge about consequences are not enough to protect the person from continuing morphine use.

March 2 I shall go to bed very early <…> And my sleep will be sweet.

Morphine is a central nervous system depressant, often leading to deep relaxation and sleep.

March 19. Last night I had a quarrel with Anna K. “I’m not going to make up the solution any more. ‘ It was then that I first discovered in myself a nasty tendency to lose my temper and, worse, to shout at people when I am in the wrong. <…> And I snatched the keys out of her hand.

Personality change and episodes of violent mood swings can be symptoms of addiction. This often leads to deterioration of interpersonal relationship with other people (e.g., his nurse, who also became Dr. Polyakov’s mistress at that time).

April 9. The devil is in this phial! This is its effect: on injecting one syringe of a 2% solution, you feel almost immediately a state of calm, which quickly grows into a delightful euphoria. This lasts for only a minute or two, and then it vanishes without a trace as though it had never been. Then comes pain, horror, darkness.

This is a common description of euphoria and withdrawal effects. Increasingly shorter periods of euphoria are followed by longer periods of physical suffering. 

May 6. Two syringes of a 3% solution. My previous notes must sound somewhat hysterical. In fact there is nothing particularly unusual or alarming about my condition. It does not in the least affect my capacity to work. On the contrary….

People with addiction often deceive themselves by suggesting that the drug injection may even improve their work ability.

May 18. A book is open in front of me… “.. morbid anxiety, a nervous depressed condition” <...> “Depressed condition” indeed! The body which moves, agonises and suffers is a corpse. It wants nothing, can think of nothing but morphine. The feeling must be something like that of a man buried alive, groaning and writhing as the first tongues of flame lick at his feet. Death. That is what lurks behind that clinical, academic phrase “a depressed condition’. I can’t hold out. I have just had injected myself. Three syringes of a 3% solution. That will last me until midnight.  .. Nonsense. That last entry was nonsense. It’s not as bad as that. Sooner or later I’ll give it up…but now I need sleep, sleep.

Dr. Polyakov experiences mood swing episodes. The dysphoria and physical discomfort associated with withdrawal are accompanied by denial; Another symptom of addiction is irregular sleeping patterns that encourage tiredness and physical distress.

 <…The pages in between describe Dr. Polyakov’ attempts to be treated in a clinic in Moscow that ended by his running away and stealing morphine from the hospital, his coming back to the country, the relationship with the nurse, gradual increase of the injection dose, and his descent into madness…>

Nov 18. <…> I may be in a state of moral decay, but I am nevertheless making an effort to arrest it. This morning, for instance, I did not have an injection.

Attempts of self-cure are difficult and made even more difficult in almost complete social isolation.

Jan. 17. 1918. During abstinence I am terrified by the slightest sound and I find people detestable. I am afraid of them. In the euphoric phase I love everyone, although I prefer solitude.

People with opioid addiction often experience fear and tension during the withdrawal periods. To reduce the discomfort of sounds, lights, and people, one sign of addiction is seeking isolation or trips to an isolated place like the bathroom or bedroom.

Feb. 13. 1918 <…> I have decided against treatment. It’s hopeless. And I don’t want to torment myself any longer. NO ONE IS TO BE BLAMED FOR MY DEATH.

Dr. Polyakov commits suicide and leaves his notebook as a “pathological history” to “warn others.”

Discussion

In 1927, Medical Worker (Medicinsky rabotnik) journal first published this story as an impressive and sincere description of addiction. As described in the annotations, the story contains the initial rewarding experience associated with morphine use, the progression of increasing doses, later self-excuses for using, additional need to increase the dose (tolerance), a switch between self-confidence and disparity, and finally, the agonizing suffering and complete destruction of life. This story raises questions about the role of personality and social settting in addiction. Which is the “devil” here: The person, the environment, or morphine itself? The tale is based on the real experience of the author, who was a physician in a rural area, who developed an addiction to morphine despite his medical training and knowledge. This is a bright illustration of how knowledge itself does not prevent or limit addiction. Unlike his character, Bulgakov managed to overcome his addiction after coming back to Kiev (a big city) from the province and getting support from his family and friends.

-- Julia Braverman

What do you think?  Please use the comment link below to provide feedback on this article.

References cited

M. Bulgakov (1975). A country doctor’s notebook. Morphine. pp.114 – 144. London : Collins, 1975.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367-374.

The tale is a part of a book of stories that is available on Amazon, ebay, and LibraryThing

The pictures are taken from the story-based movie Morphia (2008) presented at Cannes fest, 2009.

---

^* M.Bulgakov is the author of  a novel “Master and Margarita” that critiques often name among the 100 best books of 20^th century..

Addiction & the Humanities, Vol. 6(3) - Movies, Urges, and Smoking Cues

The Motion Picture Association of America (MPAA) administers a well-known movie ratings system based, in part, on movie characters’ smoking behavior. Specifically, the MPAA’s rating system currently considers three primary questions for movies that contain smoking: (1) Is the smoking pervasive; (2) Does the film glamorize smoking; and (3) Is there an historic or other mitigating context? Movies with affirmative answers to the first two questions, but not the third, receive a higher warning rating than other movies. Do smoking cues in movies warrant higher warnings? This week, Addiction and the Humanities reviews recent research examining how static and dynamic smoking images from movies relate to smokers’ urges to smoke and actual smoking behavior (Lochbuehler, Engels, & Scholte, 2009).

Methods

• The authors conducted two convenience sample studies:

1. a counterbalanced within-subjects (i.e., all participants received both conditions) comparison of 31 adult smokers’ (12 male; 19 female) cravings following exposure to photographs (i.e., static cues) in which smoking is depicted and photographs in which smoking is not depicted;
2. a randomized between-subjects (i.e., participants were randomly assigned to receive one condition or the other) comparison of 65 adult smokers’ (22 male; 43 female) cravings and smoking behavior following exposure to movie clips (i.e., dynamic cues) in which smoking was either depicted or not.

• For both studies, the authors assessed urges using a visual analogue scale (VAS).ⁱ
• For the static study, the authors also assessed urges using a 4-item Questionnaire of Smoking Urges (QSU; e.g., “I crave a cigarette.”).
• For the dynamic study, the authors also called participants one hour after the experiment and asked how many cigarettes they smoked during the previous hour.

Results

• Table 1 shows that the static cue results indicated an effect of smoking cues on two measures of smoking urges, the QSU and the VAS: (1) QSU (t(30)=3.61, p<.01); and (2) VAS (t(30)=3.24 p<.01).
• The dynamic cue results indicated that, movie clip cues had no effect on cravings (F(1,61)=0.25, p>.05) or in the number of cigarettes smoked during the hour following the experiment (F(1,55)=0.12, p>.05), after adjusting for baseline smoking cravings.

Table 1. Mean (standard deviations) Craving Scores by Study Condition
  Note. *=p<.01

Limitations

• Some aspects of the experimental design, including the small sample sizes and the university-based convenience samples, limit the generalizability of the study findings.
• The authors created the study cue materials from a single media source: the movie Atonement. The use of alternative and/or additional media sources could provoke different findings.

Discussion
The results of this study were mixed (i.e., smoking cue effects influenced craving for static, but not dynamic cues). Other research suggests that smoking cues in movies have a variety of predictable effects on individuals’ smoking related behaviors and cognitions (see, A&H Vol. 3(2) for a discussion). Randomized experiments that utilize more representative and larger samples of participants will help elucidate the conditions under which smoking cues in movies affect viewers. Additional research also should pursue a direct comparison of the effects of static versus dynamic smoking cues. More generally, smoking in movies is an ongoing hot topic for public health advocates, movie viewers, and those in the movie industry, and remains worthy of additional research attention.

References
Lochbuehler, K. Engels, R. C. M. E., Scholte, R. H. J. (2009). Influence of smoking cues in movies on craving among smokers. Addiction, 104, 2102-2109.

ⁱParticipants mark a line anchored by two descriptive words at the point that they feel represents their current state.

Addiction & The Humanities, Vol. 6(2) – Can Movement Speak Louder Than Words? Understanding Addiction through Contemporary Dance

Dance is a powerful expression of the human condition. People often find a dance piece particularly poignant and thought-provoking when it successfully casts a light upon hidden parts of us: our hopes, fears, joys, and afflictions. Because dance can reveal the concealed, it holds the potential to change the way people think about problems that people often attempt to hide, such as mental health disorders.

Previous issues of Addiction and the Humanities have mentioned the recent surge in portrayals of addiction on popular television reality shows. To reflect on this trend, this week’s issue of Addiction and the Humanities discusses a contemporary dance piece which Mia Michaels choreographed for the wildly popular TV show So You Think You Can Dance (SYTYCD). The piece, entitled “Gravity”, portrays the emotional aspect of an addict’s desperate struggle to escape her situation.

Watch Lyrical Dance videos and dance lessons at DanceJam.com

The Show
SYTYCD choreographers often pick creative or symbolic themes for their dances; this often is evident most vividly in the contemporary genre. Mia Michaels, who recently left the show after five seasons of choreography, specializes in contemporary dance. Her style favors raw, physical movements that convey strong emotions and often centers on themes such as relationships, sickness, and loss. She created “Gravity”, which premiered on July 8, 2009, for those who have suffered from or have been otherwise affected by addiction.

“Gravity” both reflects and challenges society’s popular understanding of what addiction looks like, what it involves, and whom it affects. Dancers Kupono Aweau and Kayla Radomski stand in as the addiction and the addicted, respectively. Radomski’s ripped clothing and messy hair lend a stereotypically negative and “junkie” quality to her character. Aweau, on the other hand, is perfectly poised and immaculately dressed. Dark and predatory, he stalks his quarry relentlessly as she alternates between clinging to him and struggling to escape his grasp. Michaels’ decision to cast a human being as an addiction challenges the folk notion of addiction as a problem of weak willpower, and reinforces instead the idea of addiction as an outside force that can act upon the individual and simultaneously be a powerfully attractive force, reducing her agency and ability to break the habit, despite adverse consequences (Buchman & Reiner, 2009).

In dance performances, there often is a troublesome sense of distance between the performer and the viewer when the quality of movement is too abstract or refined. Not so with this piece.
Michaels’ raw and largely unstylized choreography blurs the line between beauty and brutality. Rough physical movements like covering the addict’s mouth, twisting her limbs and even throwing her, make the dance disturbingly real. At a particularly powerful moment, Radomski struggles to reach up, only to be restrained by Aweau’s vise-like grip on her arm. The desperate and terrified expression on her face, set against his cold, knowing smile, pierces through any notion that a person with an addiction is in control at that point.

Discussion
The facial expressions and movements that dancers rely upon for communication also are key factors in generating empathic response from the audience. Research provides support for this assertion and some potential mechanisms for this phenomenon. In a study investigating the relationship between action and emotional perception, Winters (2008) found that embodying a specific posture and watching somebody else embody the same posture generated similar emotional states in both the viewer and the dancer. Recent neurobiological research shows that watching a person’s movement activates the same regions of the brain that correspond to performing that movement oneself. Also, the evolution of empathy has its basis in mirror neurons that respond to action and expression (Parr, Miller & Fugate, 2005; Rizzolatti et al., 2001; Calvo-Merino et al., 2005). For example, witnessing pain in others activates the brain in a similar way to feeling pain oneself (Jackson, Meltzoff & Decety, 2005; De Vignemont & Singer, 2006). It follows that the expression of pain, uncertainty and fear worn by Radomski throughout “Gravity” might have stimulated empathic responses from the audience, and drawn them into the nightmare of addiction. 

Using dance as a medium to help people gain understanding can battle negative attitudes on a grand scale. For example, SYTYCD has succeeded in making contemporary dance an accessible art form for the public, as its huge viewer base evidences. During the final week of SYTYCD’s sixth season, Fox Network ranked first for viewership among teens and adults aged 18-34 (“Fox Dances to Victory”). Further, part of the reason for the show’s success is Michaels’ choreography, which brings dance down to earth and makes it both understandable and enjoyable for the common viewer. Through her choreography, she brings similar clarity to important social topics. For a reality show like SYTYCD, the typical audience is not familiar with all the vocabulary and technique of contemporary dance. Similarly, most people are unaware of the complexities of addiction. A piece like “Gravity” makes both contemporary dance and addiction, which are not instantly understandable to most, accessible to the common audience. Specifically, Michaels shows the addict’s inability to free herself from her condition despite its adverse consequences. The resulting pain is something that almost anybody who has experienced helplessness will understand. This is important because ignorance-based misunderstanding breeds stigma (Buchman & Reiner, 2009), which is an ongoing problem for individuals suffering from addiction.

Although these findings have positive implications for both dance and addiction awareness, we must be careful to remember the limitations of this research. Just as one cannot seek to address all of the issues connected with addiction in one study, one cannot even begin to try to represent all the aspects of such a complex syndrome within a ninety-second dance. It is risky to assume that one dance can represent addiction. Furthermore, it is dangerous to assume that all people with addictions experience the same feelings and emotions. However, research indicates that people who engage in different kinds of addictive behaviors share similar psychosocial experiences (Shaffer et al., 2004).This evidence suggests that addiction sufferers are alike in many aspects, and that individuals who are addicted to different substances can relate to shared emotions such as shame, fear and hopelessness.

Conclusion
The power of contemporary dance to evoke emotions in its audience, combined with theories about the associations among perception, movement, and emotional response, indicates a potential to promote recognition and empathy among viewers. Although it is naïve to think that a simple emotional portrayal will sway the public attitude away from stigmatization and towards acceptance of addiction, dance can be a step in the right direction.  In this respect, SYTYCD has the potential to do for addiction what it has done for dance: bring awareness to the general population about its different forms and manifestations. What choreographers like Mia Michaels do is valuable because it brings attention to addiction, allows the public to sympathize and identify with people suffering with addictions, and provides a cathartic moment for those involved—audience, dancer and sufferer alike.

-Katerina Belkin

What do you think? Please use the comment link below to provide feedback on this article.

References

Buchman, D., Reiner, P.B. (2009). Stigma and Addiction: Being and Becoming, The American Journal of Bioethics, 9 (9) 18-19.
 
Calvo-Merino, B., Glaser, D. E., Grezes, J., Passingham, R. E., & Haggard, P. (2005). Action observation and acquired motor skills: An FMRI study with expert dancers. Cerebral Cortex, 15, 1243–1249.

De Vignemont, F., Singer, T. (2006). The empathic brain: how, when and why? Trends in Cognitive Sciences, 10(10), 435-441

“Fox Dances to Victory Among Adults 18-34, as So You Think You Can Dance Crowns A Winner.” Date published: 22 December 2009. Date viewed: 14 January 2010. Stable URL: http://tvbythenumbers.com/2009/12/22/fox-dances-to-victory-among-adults-18-34-as-so-you-think-you-can-dance-crowns-a-winner/37013

Jackson P.L., Meltzoff A.N., Decety J.(2005) How do we perceive the pain of others? A window into the neural processes involved in empathy. Neuroimage, 24(3), 771-9.

Parr, L.A., Waller, B.M., Fugate, J. (2005). Emotional communication in primates: implications for neurobiology. Current Opinion in Neurobiology, 15, 716-720.

Rizzolatti, G., Fogassi, L., Gallese, V. (2001). Neurophysiological mechanisms underlying the understanding and imitation of action. Natural Review, Neuroscience. 2 (9), 661–670.

Shaffer, H.J., LaPlante, D.A., LaBrie, R.A., Kidman, R.C., Donato, A.N., Stanton, M.V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12(6), 367-374.

“SYTYCD- Kayla and Kupono- Addiction by Mia Michaels.” Date published: July 14, 2009.  Date viewed: 11 January 2010. Stable URL: http://dancejam.com/videos/1054605418-sytycd-kayla-kupono-addiction-by-mi

 

Addiction and the Humanities, Vol. 6 (1) - The evolution of anti-drug ads from Fried Egg to Shoulders

This is your brain. This is drugs. This is your brain on drugs. Any questions? These words, part of a 1987 Partnership for a Drug-Free America (PDFA) public-service announcement, are synonymous with the American anti-drug movement of the 1980’s. Although the PDFA credits Fried Egg with helping to persuade Americans that drugs are dangerous and addictive (The Partnership for a Drug-Free America, 2006), many ridicule the ad because of its overly simplistic, fear-based, and unrealistic tone (Alexander, 2000).

How have anti-drug messages changed during the two decades since Fried Egg? The good news is that producers of anti-drug ads have relied more on social science to develop their message content and delivery. For example, research indicates that fear-based messages like Fried Egg are ineffective unless they are accompanied by a viable means for reducing one’s fears (Job, 1988). As a result, when the Office of National Drug Control Policy (ONDCP) produced the What’s your Anti-Drug? campaign, part of a $1.4 billion effort that spanned the years 1998-2005, some of the ads showed teenagers engaged in positive alternatives to drug use. But, the campaign also included several ads that exaggerated the potential consequences of smoking marijuana. For example, in one ad, teenage marijuana smokers run over a small child with their car; in another, a pot smoker accidentally shoots his friend in the head.

Sometimes, the effect of anti-drug messages is unintended. For example, results from a multi-wave study indicated that the What’s your Anti-Drug? ads might have done more harm than good. Teenage respondents who had more exposure to the ads were less likely to avoid marijuana and more likely to believe that many of their peers used marijuana (Hornik, Jacobsohn, Orwin, Piesse, & Kalton, 2008). Some observers suggest that the ads might inadvertently have communicated the message that “everyone’s doing it” (Hornik et al., 2008). Another study revealed that teenage survey respondents judged six of the ads from the What’s your Anti-Drug? campaign to be less effective than a control program in reducing drug use (Fishbein, Hall-Jamieson, Zimmer, von Haeften, & Nabi, 2002). The particularly ineffective ads tended to be seen as unrealistic, uninformative, and fear-based—much like Fried Egg (Fishbein et al., 2002).

In 2005, the ONDCP shifted its strategy and, together with the PDFA, launched Above the Influence, a multi-media campaign developed using extensive qualitative and quantitative research with teens (Denniston, 2006). This campaign encourages its target audience to rise “above the influence” of drugs and risky sexual activity (The Partnership for a Drug-Free America, 2005). For instance, the Human Puppet ad shows a teenage girl passed out under the influence of an unknown substance while her friends draw on her face and position her arms as if she were a puppet. The tagline is If you’re not in control, who is? Shoulders takes the message of personal autonomy one step further by poking fun at traditional anti-drug messages. Its protagonist is a teenage boy trying to decide whether to accept a marijuana joint offered to him at a party. A series of pro-drug characters, led by the devil, appears on his left shoulder imploring him to accept the joint. Meanwhile, a series of exaggerated anti-drug characters appears on his right shoulder demanding that he refuse to accept it. These include a stern roll-model astronaut, members of the boy’s basketball team, and even Shakespeare. As the protagonist makes his decision, a voice-over declares, The only voice that matters is yours. Eventually the boy makes his decision to reject the joint, and the message to viewers is that they can still maintain their personal autonomy even if they decide to reject drug use. In this way, the campaign is consistent with research indicating that adolescents place a high value on personal autonomy and often react against prevention messages that seem too “preachy” and directive (Kelly, Comello, & Slater, 2006). Interactive features of the campaign’s website also aim to change normative beliefs about how many adolescents use drugs, perhaps in response to earlier findings.        

The ONDCP ad Shoulders, available at http://www.mediacampaign.org/

Is Above the Influence working? As evidence of their ads’ effectiveness, the ONDCP frequently points to downward national trends in teenage drug use (e.g. Johnston, O'Malley, Bachman, & Schulenberg, 2004). But, Hornik and colleagues (2008) note the existence of larger declines in tobacco and alcohol use by teens, which suggest that there is a broad influence of widespread cultural shifts that goes beyond the ONDCP/PDFA campaigns. During the coming years, the ONDCP plans to collect new data that will allow them to generate more specific conclusions about the campaign’s effects on drug-related attitudes, beliefs, and intentions; they intend to use this information to refine their future messages. Successfully refining the marketing strategy will be a challenge, because it is very difficult to market health information to teens. However, by empirically evaluating outcomes and generating evidence-based messages, the ONDCP is taking a big step forward from This is your brain on drugs.

--Heather Gray

What do you think? Please use the comment link below to provide feedback on this article.

References
Alexander, E. (2000). Famous fried eggs: Students debate effectiveness, accuracy of well-known anti-drug commercial.   Retrieved January 4, 2010, from http://www.cnn.com/fyi/interactive/news/brain/brain.on.drugs.html#%27Good%20persuasive%20information%27

Denniston, R. (2006). From "What's Your Anti-Drug?" to "Above the Influence": Rationale and results from branding research for the National Youth Anti-Drug Media Campaign. Paper presented at the The 134th Meeting of the American Public Health Association, Boston, MA.

Fishbein, M., Hall-Jamieson, K., Zimmer, E., von Haeften, I., & Nabi, R. (2002). Avoiding the boomerang: Testing the relative effectiveness of antidrug public service announcements before a national campaign. American Journal of Public Health, 92, 238-245.

Hornik, R., Jacobsohn, L., Orwin, R., Piesse, A., & Kalton, G. (2008). Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal of Public Health, 98, 2229-2236.

Job, R. F. S. (1988). Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health, 78, 163.

Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2004). Monitoring the Future National Survey Results on Drug Use, 1975-2003: Volume 1: Secondary School Students. Bethesda, MD: National Institute on Drug Abuse.

Kelly, K. J., Comello, M. L. G., & Slater, M. D. (2006). Development of an aspirational campaign to prevent youth substance use: 'Be under your own influence.' Social Marketing Quarterly, 12, 14-27.

The Partnership for a Drug-Free America. (2005). ONDCP Launches New Teen Brand.   Retrieved January 7, 2010, from http://www.drugfree.org/Portal/About/NewsReleases/ONDCP_Launch 

The Partnership for a Drug-Free America. (2006). The Partnership's "Fried Egg" TV message.   Retrieved January 4, 2010, from http://www.drugfree.org/Portal/About/NewsReleases/Fried_Egg_Message

Addiction & The Humanities, Vol. 5 (10) - Beyond the family secrets in Mackenzie Phillips' High on Arrival

    Several celebrities have recently published “addiction memoirs.” Carrie Fisher, Andre Agassi, and former child stars Jodie Sweetin and Melissa Gilbert have all written candidly about their substance abuse. (We reviewed Fisher’s Wishful Drinking in the last edition of Addiction & the Humanities.) None of their stories has garnered as much attention as Mackenzie Phillips’ revelation of her incestuous affair with her father John Phillips, founder of The Mamas & the Papas, as detailed in her new memoir High on Arrival. Indeed, High on Arrival is replete with stories that illustrate the power of addiction to warp relationships. However, the most compelling aspect of Phillips’ story is not what happened during the depths of her addiction to cocaine and heroin. What is more interesting is her understanding of how she fell into the abyss, and how she got out.
 

        Mackenzie Phillips was born into a world of fame, fortune, and serious drug abuse. She thought her father was distant and irresponsible, and he has admitted that he lived a life of drug-fueled hedonism during this time. As a child, Phillips believed that modeling her father's drug use could help her secure a place for herself in his world. As a result, she was rolling marijuana joints at age ten, bringing cocaine to school while in the sixth grade, and regularly consuming LSD, Quaaludes, and cocaine by age thirteen. She never fit in with non-users; she writes that when around “normal” kids, she felt like an “oddly privileged outsider” (p. 15).
        Although Phillips’ early drug use might shock many readers, she seemed to manage it during her early teenage years without major adverse consequences. She achieved success in the hit sitcom One Day at a Time and attended a high school for the performing arts. However, during her late teenage years, the frequency and quantity of drug use escalated. Drugs quickly became a disruptive force in her life. For example, she lost weight and was constantly late for work. Often, she showed up for work still reeling from the effects of the previous night’s abuses. Her job—what she saw as the most stabilizing force in her life—was in jeopardy. Here again, the drug use isolated her. Of her descent into the life of a drug addict, she writes, “I alone knew that I had crossed a line that people don’t cross, and it made me different. I was a fragment of a person, and my secret isolated me” (p. 168). She coped with her sense of isolation and shame by getting high. She was fired from her job and started injecting cocaine and heroin on a daily basis.
        The bulk of High on Arrival is a graphic description of what happened next. For the next thirty years, over the course of three marriages, several trips to rehab, and the birth and rearing of one child, Phillips and those around her experienced the harmful consequences of her self-described out-of-control drug use. The consequences are innumerable and shocking. There was the incestuous relationship with her father, which she describes as “a series of twisted, blurry memories that I had no desire to see by the light of day” (p. 169). There is also the time that Phillips shot-up in front of her young brother, and the time she brought her own newborn son to a crack house in the middle of the night. Getting and taking drugs became more important than everything else.
        These episodes in Phillips’ life have attracted the most media attention. And yet, for people who want to understand addiction and recovery, what really matters is Phillips’ quest for recovery and redemption. She seems to understand this. She writes that, “… the power of drugs is a given. The real questions are how far an individual goes, and why, and what, if anything, gives her the power to stop” (p. 172). For Phillips, recovery and redemption remain elusive. She attended rehab and attained sobriety for about a decade; during this time, she successfully transitioned into the life of a working actress and mother. But not long after her father’s death, she started to slip back into addiction. Before long she was living with drug dealers, smoking heroin and shooting cocaine. An 2008 arrest compelled her to seek treatment again. In the conclusion of the book Phillips expresses a sense that she has attained long-term sobriety. She remains aware, however, that the “monster” of her addiction might re-awaken at any point. 
        There are many aspects of Phillips’ story that are extraordinary. She counts rock stars and television stars among her friends and family, and her sitcom salary financed her drug addiction. However, many aspects of her story are all too ordinary. For instance, as a child Phillips experienced family discord and a lack of parental supervision. Her family history also suggests she might carry a genetic risk for substance abuse. According to the syndrome model of addiction (Shaffer et al., 2004), these psychosocial and neurobiological risk factors increase the vulnerability to addiction. Because Phillips was exposed to drug use -- as opposed to, for instance, gambling -- and because she found the drug use pleasurable, she was especially susceptible to drug addiction. Some of the expressions of her addiction are specific to drug abuse: these include her track marks and dramatic weight loss. However, many of the consequences she experienced are not specific to drug addiction. For example, in terms of psychosocial consequences, people who experience chemical addiction (like Phillips) and people who experience behavioral addiction (e.g., pathological gambling) are both vulnerable to feelings of shame, guilt, and social isolation (as reviewed by Shaffer et al., 2004). Moreover, like Phillips, people with different types of addiction share a tendency to experience neuroadaptation (e.g., tolerance and withdrawal; Shaffer et al., 2004). During one of Phillips’ early stints in rehab, her counselors did not view addiction as different manifestations of the same underlying syndrome. Because the counselors viewed alcohol addiction as an entirely different disorder, they allowed patients with drug addiction to continue drinking alcohol. As a result, Phillips began to drink excessively. She writes that “the booze helped fill the hole that cocaine… had left. But the hole was deep, so it took a lot of booze to fill it” (p. 146). Now scientists know that it is common for people to “hop” from one addiction to another before successfully recovering from the root of their addiction (Shaffer et al., 2004).

    In the end, the keys to Phillips’ current period of sobriety are probably not extraordinary. She attributes her recovery to the support of her family and friends and, perhaps more importantly, to her own developing awareness of the role that drugs have played in her life. High on Arrival will likely attract readers interested in its celebrity gossip and salacious family secrets. However, there is much in this book that might offer insight and even hope to everyday people struggling with addiction and its various consequences.

--Heather Gray

What do you think?  Please use the comment link below to provide feedback on this article.

References Cited

Phillips, M. (2009). High on arrival: A memoir. New York: Simon Spotlight.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple manifestations, common etiology. Harvard Review of Psychiatry, 12(6), 367-374.

Addiction & the Humanities, Vol. 5 (9) - “Putting the monster in the box”: Mental illness, substance abuse, and self-medication in Carrie Fisher’s "Wishful Drinking"

Although Carrie Fisher is best known for her iconic portrayal of Princess Leia in the Star Wars films, she is also a successful novelist and screenwriter. In 2008 she published Wishful Drinking, a history of her life, first as the child of celebrities, and then as a celebrity in her own right. In it, she candidly (and comically) details her ongoing struggle with substance abuse and mental illness. In this week’s Addiction and the Humanities, we discuss how Fisher’s thoughtful description of her substance abuse and mental illness brings to life accumulated scientific knowledge related to the tendency for people to self-medicate the symptoms of their mental illness with drugs and alcohol.

Carrie Fisher has bipolar disorder. The disease, she says, makes her highly emotional. Fisher presents this insightful description of her unusual emotional intensity: it “revs up the motor of misery, guns the engine of an unpleasant experience, filling it with rocket fuel and blasting into a place in the stratosphere that is oh-so-near to something like a suicidal tendency—a place where the wish to continue living in this painful place is all but completely absent” (p. 14). Her depressive episodes are offset by bouts of mania, during which she talks non-stop, shows remarkable creativity, and makes poor (and lasting) decisions for herself.

When she was first diagnosed as having bipolar disorder at the age of 24 (five years after she first donned her Princess Leia side-buns), Fisher refused pharmacological treatment. Instead, she controlled her psychological pain—and her emotional intensity—with the help of drugs and, to a lesser extent, alcohol.  She writes that her mood disorder was “at least in part why I ingested chemical waste—it was kind of a desire to abbreviate myself. To present the CliffNotes of the emotional me, as opposed to the twelve-volume read” (p. 117). The drugs were partly successful in suppressing her symptoms; they allowed her to “put the monster in the box” (p. 117).

 
Unfortunately, as generally happens, Fisher built up a tolerance to the “chemical waste,” having to consume more and more to achieve the same psychological state. She accidentally overdosed at age twenty-eight. The overdose convinced her that her drug and alcohol addiction—not her bipolar illness—was her main problem. So, she dedicated herself to achieving and maintaining sobriety. But then her bipolar symptoms re-emerged. She writes that “without the substances I had used to distort and mask my symptoms, it was now all too clear that I was a bone fide, wild-ride manic-depressive” (p. 121). In other words, the monster was back out of the box. After a year of “erratic sobriety” she finally decided to address her bipolar illness head-on. Over the next twenty-plus years, Fisher has relied on a combination of psychotherapy, drug therapy, and electro-convulsive therapy to manage her mental illness. She has had “four or five” episodes of drug-use relapse.

Fisher’s history of suppressing the symptoms of mental illness with substance abuse is consistent with the self-medication hypothesis of substance abuse (Khanztian, 1985, 1997). Khantzian (1985) first developed the self-medication hypothesis on the basis of a long series of conversations with patients struggling with substance use disorders. Khantzian often asked his patients, “What did the drug do for you when you first used it?” He discovered a trend in their responses: one after another, they indicated that they used substances in part to alleviate their psychological suffering. Subsequent research has supported this idea. For instance, there is a strong and consistent association between substance abuse and psychiatric disorders; people who are dependent on drugs or alcohol are disproportionately likely to experience psychiatric conditions (as reviewed by Khantzian, 1997). This is especially true in the case of bipolar disorder (see Weiss et al., 2004). Of course, simple co-occurrence does not indicate whether substance abuse is a cause or a consequence of mental illness. Patients’ retrospective reports of using substance abuse to relieve psychological distress (Weiss et al., 2004) provides support for the notion that, at least in some cases, people use drugs to “put the monster in the box.”

Several other aspects of Fisher’s story coincide with trends identified in the scientific literature. First, the self-medication hypothesis states that people choose the particular classes of drugs that are most successful in ameliorating their painful feelings. Khantzian (1997) specifically predicts that opiates will be the drug of choice for people who seek to attenuate their intense emotions. Consistent with this, Fisher mainly used opiates to calm her moods after experimenting with a range of other drugs.  Second, the self-medication hypothesis predicts that a particular character trait—a tendency to be unable to tolerate discomfort—helps set the stage for substance abuse (Khantzian, 1997). Along these lines, Fisher observes that her “compulsion for comfort ” (p. 105) helped propel her toward drug abuse. She has long struggled to deal with life’s minor setbacks and through therapy she has learned to tolerate discomfort. Finally, Fisher consistently uses humor as a potent coping mechanism. She discusses how finding something humorous about a painful experience takes some of harm out of it. “If my life wasn’t funny,” she writes, “it would just be true, and that is unacceptable” (p. 17). The scientific literature is replete with references to the use of humor to cope adaptively with the stress of negative life events (e.g., McCrae, 1984).

In summary, Carrie Fisher’s Wishful Drinking presents a refreshingly honest and insightful glimpse into the world of an individual struggling with both mental illness and substance abuse. It moves the reader out of the solitary clinical setting and into the rich and complicated life of a single individual. In doing so, it provides an in-depth illustration of the self-medication hypothesis. In the next edition of Addiction and the Humanities, we will explore the themes in another celebrity memoir, Mackenzie Phillip’s High on Arrival, and how they relate to the scientific literature on addiction. 

--Heather Gray

What do you think?  Please use the comment link below to provide feedback on this article.

References:

Fisher, C. (2008). Wishful Drinking. New York: Simon and Schuster.

Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142(11), 1259-1264.

Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-244.

McCrae, R. R. (1984). Situational determinants of coping responses: Loss, threat, and challenge. Journal of Personality and Social Psychology, 46(4), 919-928.

Weiss, R. D., Kolodziej, M., Griffin, M. L., Najavits, L. M., Jacobson, L. M., & Greenfield, S. F. (2004). Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence. Journal of Affective Disorders, 79(1), 279-283.

Addiction & the Humanities, Vol. 5(8) - Addiction recovery as TV drama: A&E’s “The Cleaner”

During recent years, television-based portrayals of mental health problems, particularly addiction, have exploded, both in terms of the number of shows addressing these issues and in their viewership.  Leading the way is the A&E network whose prime time hit, “Intervention,” is a reality program that documents individuals and families struggling with addiction. During the show, protagonists prepare for, and execute, a Vernon Johnson style Intervention method.  Influenced by the early success of this show, A&E now airs the reality programs “Obsessed,” which tracks the lives and treatment of those with anxiety disorders, and “Hoarders,” which follows individuals who obsessively accumulate possessions.  “The Cleaner,” which attracted 1.1 million viewers aged 18-49 during 2008, is the first original scripted drama to appear on the network in many years.  Its plot features the efforts of William Banks, who is in recovery from drug addiction, as he assists others who are dealing with addiction to attain sobriety.  This week’s Addiction & the Humanities examines this show and whether it is representative of the addiction recovery process in popular culture; further, this issue assesses if the portrait of recovery presented in “The Cleaner” is accurate and helpful. 

The Show
The life of the show’s executive producer, Warren Boyd, inspired the development of “The Cleaner”; this fact is displayed at the start of each episode.  The show’s protagonist, Banks, is an “extreme interventionist” willing to secure the sobriety of his charges by any means necessary.  As an episode which aired August 4, 2009 demonstrates, these means include restraining a nurse and prominent surgeon as they experience the withdrawal symptoms associated with sudden termination of amphetamine use.  This pair arrives under the care of Mr. Banks as a result of an ultimatum by the hospital administrator who has hired Banks – get help or lose your job.  Both characters are incredibly ambivalent about change, sometimes extremely resistant, and at other times eager for terminating use.  By the end of the episode, the nurse, having been abducted and forcibly detoxified in a garage, chose to end her relationship with the surgeon, who is once again using amphetamines.  Similar storylines have punctuated the majority of the series. This common storyline highlights Mr. Banks and his team’s attempts to engage their clients in discussions about their addictions, but ultimately they employ secretive, deceptive and coercive means to engage their clients in the detoxification process.

 

The Cleaner and A&E logos are owned by A&E.

Representation of Recovery
Although “The Cleaner” makes for a good television drama, it has a number of fundamental flaws that create unnecessary problems and make for a misleading representation of addiction and the recovery process.  First, the language of each episode is peppered with references to “addicts,” “junkies,” and “getting clean.”  Such language devalues the people referenced in this way and contributes to the stigma associated with addictions, particularly substance abuse.  Even the show’s title is a subtle reinforcement of the idea that those with addiction problems are “dirty” and must “get clean” – a stigmatizing suggestion.  The role of stigma in addiction treatment and recovery is complex and still under investigation; Luoma et al. reported that individuals in treatment for drug and alcohol abuse evidenced high levels of stigma (Luoma et al., 2007). They also found that the shame associated with the stigma of being a substance abuser negatively correlated with measures of quality of life and psychological functioning (Luoma et al., 2007).  Perceived stigma also has been shown to be a barrier that keeps substance abusers from seeking treatment.  In one study, 49.2% of drug abusers and 54.3% of alcohol abusers reported delaying treatment because of stigma (Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993).  By consistently using derogatory terms for those with addiction problems, “The Cleaner” contributes to the stigma associated with being a substance abuser. This stigma might discourage individuals from seeking treatment.

The role of William Banks as an extreme interventionist derives from the Johnson Intervention model of motivating – some might argue coercing—those struggling with addictions to enter treatment.  Using this traditional intervention model, friends, family members, and others within the close social network of the individual work with a professional interventionist to encourage and motivate the individual to immediately seek treatment to remediate their addictive behaviors (Fernandez, Begley, & Marlatt, 2006).  Studies of the utility of the Johnson Intervention model have produced mixed results and wide-ranging rates of treatment engagement (Logan, 1983; Miller, Meyers, & Tonigan, 1999).  A number of less confrontational, social network centered intervention approaches have been developed, such as the CRAFT (Community Reinforcement and Family Training). The CRAFT relies on Motivational Interviewing and behavioral techniques employed by the social network to encourage treatment engagement by the individual with addiction problems.  In a randomized control trial that directly compared treatment engagement after utilizing the Johnson Intervention or the CRAFT approach, treatment engagement for Johnson Intervention participants was 23% compared to 64% for CRAFT participants (Miller et al., 1999). 

The interventions presented in “The Cleaner” deviate from both the Johnson Intervention and the CRAFT model in a number of key ways.  Primarily, Banks and his team are often strangers to the clients they are attempting to help, and broad social networks are absent from the process of encouraging individuals to seek help.  Furthermore, the interventions depicted are substantially more confrontational than those that current research would support.  Mr. Banks and his team often strong-arm those “nominated” for their services into accepting on penalty of losing their jobs, their children, or things they are expected to value more than their addictive behavior.   Evidence does not support this aggressive, provoking approach to behavior change. In fact, research indicates that such methods can be deleterious (Allen, Sprenkel, & Vitale, 1994; Miller, Benefield, & Tonigan, 1993).

The most serious flaw in “The Cleaner” is that the individuals targeted by Mr. Banks’ interventions are not the agents of their own recovery.  Flying in the face of the well-established stages of change model for behavioral change, the show seems to imply that individuals can be forced and/or coerced into sobriety through means of deception, threats and even abduction. Once free of thought clouding substances, these newly detoxified people readily will choose to remain sober.  Without the active engagement of those that are addicted, and a fundamental desire to modify the behaviors associated with the addiction (e.g. drug or alcohol use) sustained recovery is unlikely (Shaffer, 1992).  Empirical evidence shows that, for those in substance abuse treatment, the personal motivation for behavior change is a critical component of recovery by (Laudet, Magura, Vogel, & Knight, 2003; Laudet & White, 2008).  Portrayals of recovery that stem from coercion rather than active engagement by those living with addictions are not only misleading, they potentially can be damaging.  A&E advertises the show as being “inspired by actual events”; this illusory representation might provide viewers with the false notion that all individuals can be forced into recovery.  While coercion might work for some, it is not a solution for all.  Additionally, “The Cleaner” provides no room for the possibility that those with addiction issues will abandon their addictive behaviors independently.  Exclamations of “this is your only chance” and similar phrases often are declared. The show ignores the fact that many individuals can, and do, initiate their own recoveries.  By consistently downplaying the role of those with addiction as primary influences in their recovery – such as being passively “cleaned up,” while strapped down to a gurney in a garage – “The Cleaner” presents an inaccurate picture of the recovery process. This image is unlikely to be helpful for the majority of those with addiction issues.  

“The Cleaner” also fails to address the agonizing ambivalence of those with addiction problems (i.e., the conflict between feelings of wanting to continue to engage in addictive behaviors while simultaneously wanting to quit).  This is a key component of the addiction experience that must be managed to more forward with recovery (Shaffer, 1992).  While the show portrays moments of denial and ambivalence, the Cleaner does not address these matters within the current theoretical understanding of addiction recovery.  Rather, ambivalence is portrayed as moments of personal weakness.  While the surgeon in the aforementioned example notes that he uses amphetamines to enhance his performance at his incredibly demanding job, he also expresses the desire to terminate his drug use.  Only the latter is relevant to Mr. Banks.  Although acknowledging and working through this ambivalence is key to a successful recovery for the doctor, here it is largely minimized and ignored.  This portrayal is yet another misrepresentation of recovery perpetuated by “The Cleaner.”

The treatment portrayed ends when the individual has completed the detoxification process with the assistance of Mr. Banks and his team.  There is minimal reference made to continued recovery or relapse prevention once sobriety is achieved; recovery groups, inpatient treatment and sober living are only mentioned marginally throughout the show’s second season.  Given the marginalized role of treatment and recovery beyond the initial detoxification, viewers of the show might infer that addiction recovery is as easy as a single forced episode of sobriety.  In reality, addiction recovery typically is a long-term process punctuated by multiple attempts at treatment and relapses to use (Dennis, Scott, Funk, & Foss, 2005; McLellan, Lewis, O'Brien, & Kleber, 2000).  For many with addiction problems, the path to recovery is long and is made possible by emotional support from social networks, learned stress and temptation reduction strategies and, above all, the motivation to change addictive behaviors (Laudet & White, 2008).  The minimized portrayal of the extended recovery process by “The Cleaner” falsely represents the true experiences of many in recovery from addictions.

Conclusion
Although “The Cleaner” bills itself as based in fact, its portrayal of addiction recovery is pure fiction.  Evidence suggests that social-network based and less confrontational approaches to recovery initiation have greater success rates for treatment engagement than more confrontational approaches. The process of recovery is impossible without the user’s active engagement and desire to disengage from addictive behaviors.  Individuals rarely can be coerced to abandon behaviors with immense biological and psychological components.  Individuals respond most effectively when they can choose to engage in the recovery process.  Additionally, managing ambivalence is a critical component of the stage-change pathway that must occur before recovery can endure.  The propensity of the “The Cleaner” to downplay ambivalence is detrimental to the show’s viewers who might interpret such ambivalence as unusual.  It is unclear why “The Cleaner” takes such a heavy-handed and unrealistic approach to portraying the recovery process.  The show is built on the premise that assisting individuals in engaging in recovery is a good and noble thing.  Why, then, does the show continually refer to those with addiction problems in stigmatizing ways and portray recovery in unrealistic terms?  As a work of dramatic fiction, “The Cleaner” has the potential to entertain audiences, but as an accurate portrayal of recovery, the show misses the mark.  By touting itself as being based in fact, “The Cleaner” does disservice to its viewers.

Editor’s Note:  After the writing of this Addiction & the Humanities article, the A&E network announced that it has cancelled “The Cleaner.”  It is unclear why the network has taken this action, but perhaps audiences reacted to the errors of the show by tuning in less and less.

-Erica Marshall

What do you think?  Please use the comment link below to provide feedback on this article.

References

Allen, D. N., Sprenkel, D. G., & Vitale, P. A. (1994). Reactance theory and alcohol consumption laws: further confirmation among collegiate alcohol consumers. J Stud Alcohol, 55(1), 34-40.

Cunningham, J. A., Sobell, L. C., Sobell, M. B., Agrawal, S., & Toneatto, T. (1993). Barriers to treatment: Why alcohol and drug abusers delay or never seek treatment. Addictive Behaviors, 18(3), 347-353.

Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. J Subst Abuse Treat, 28 Suppl 1, S51-62.

Fernandez, A. C., Begley, E. A., & Marlatt, G. A. (2006). Family and peer interventions for adults: past approaches and future directions. Psychol Addict Behav, 20(2), 207-213.

Laudet, A. B., Magura, S., Vogel, H. S., & Knight, E. L. (2003). Participation in 12-Step-Based Fellowships Among Dually-Diagnosed Persons. Alcohol Treat Q, 21(3), 19-39.

Laudet, A. B., & White, W. L. (2008). Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Subst Use Misuse, 43(1), 27-54.

Logan, D. G. (1983). Getting alcoholics to treatment by social network intervention. Hosp Community Psychiatry, 34(4), 360-361.

Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., et al. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav, 32(7), 1331-1346.

McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. Jama, 284(13), 1689-1695.

Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. J Consult Clin Psychol, 61(3), 455-461.

Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. J Consult Clin Psychol, 67(5), 688-697.

Shaffer, H. J. (1992). The psychology of stage change: the transition from addiction to recovery. In J. H. Lowinson, P. Ruiz, R. B. Millman & J. G. Langrod (Eds.), Substance abuse: a comprehensive textbook (Second ed., pp. 100-105). Baltimore: Williams & Wilkins.

 

Addiction & the Humanities, Vol. 5 (7) - Maybe it’s just me: The common relapse experience

Relapse is common for multiple paths of recovery from addiction (e.g., self-guided, treatment assisted, etc.). Various studies have shown that most expressions of addiction  carry a significant chance of relapse. For instance, in one 2003 study, 50% of marijuana smokers fit the criteria for relapse (Moore & Budney, 2003). Two other 2005 studies found high relapse rates among those recovering from alcoholism (i.e., 82% of outpatients and 73% of inpatients) (Marlatt & Witkiewitz, 2005)) and quitting smokers (40% of smokers who successfully abstained for one year and 90-97% of smokers who quit alone, (Shiffman, Kassel, Gwaltney, & McChargue, 2005)). 

Illustrating people’s propensity for relapse, Nic Sheff, author of the addiction and recovery memoir, Tweak, (Addiction & the Humanities Vol. 4 (9) – Addiction is more than just science) suffered two relapses during May and October of 2008; these relapses were 3 and 8 months, respectively, after the publication of Tweak. Sheff explained that his relapse episodes were the result of a difficult personal situation and his attempt to deal with this situation alone. The specific difficulties of relapse that Sheff describes (see Table 1) are similar to those often reported for other addictive behavior: common characteristics of relapse include, negative automatic thoughts, mild depressive thoughts, negative emotions, cravings, and dangerous behavior (Marlatt & Witkiewitz, 2005; McKay, Rutherford, Alterman, Cacciola, & Kaplan, 1995).

Relapse prevention programs, self-management programs intended to facilitate maintained recovery ("Preface," 2005), attempt to account for many of the common difficulties associated with relapse. The foundation of relapse prevention is to encourage and assist treatment seekers as they work towards harm reduction, abstinence and moderation ("Preface," 2005) by focusing on the behaviors and environmental factors that make up each individual’s situation. Relapse prevention falls under the Cognitive Behavior Therapy (CBT) umbrella; its focus on individual factors means that each person’s treatment program should adapt to their learning and progress. Research suggests that relapse prevention is often effective for the treatment of addictive behaviors, including stimulant use disorders (e.g., Sheff’s methamphetamine addiction) (Carroll & Rawson, 2005). Table 1 presents some of the parallels in Sheff’s thoughts and behavior regarding his relapse (Bonifield, 2008; Sheff, 2008), and typical relapse prevention treatment efforts.

Table 1: Parallels between Sheff’s relapse and Relapse Prevention Treatment.

Conclusion
Recovery from substance use disorders is difficult because of the prevalence of relapse and the associated problems that accompany relapse episodes. In our last post about Nic Sheff, we interviewed a high school teacher who stated that reading about Sheff’s more difficult experiences (e.g., detox, AA and NA use, near deaths) was beneficial and made the dangers of drug use more evident to her students. Sheff’s public admission to relapsing twice shows readers that, even with successful periods of abstinence, recovering from substance use and remaining drug-free is a difficult struggle that can take many years to resolve.

- Ingrid Maurice

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References

Bonifield, J. (2008). Relapse a constant threat, 'Tweak' author says, CNNhealth.com: CNN.com.

Carroll, K. M., & Rawson, R. A. (2005). Relapse Prevention for Stimulant Dependence. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.

Marlatt, G. A., & Witkiewitz, K. (2005). Relapse Prevention for Alcohol and Drug Problems. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.

McKay, J. R., Rutherford, M. J., Alterman, A. I., Cacciola, J. S., & Kaplan, M. R. (1995). An examination of the cocaine relapse process. Drug Alcohol Depend, 38(1), 35-43.

Moore, B. A., & Budney, A. J. (2003). Relapse in outpatient treatment for marijuana dependence. J Subst Abuse Treat, 25(2), 85-89.

Preface. (2005). (2005). In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (pp. 416). New York: The Guilford Press.

Sheff, N. (2008). After relapse come terror, hope, CNNhealth.com: CNN.com.

Shiffman, S., Kassel, J., Gwaltney, C., & McChargue, D. (2005). Relapse Prevention for Smoking. In G. A. Marlatt & D. M. Donovan (Eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Second Edition (2 ed., pp. 416). New York: The Guilford Press.