SLP Insights: Interview w/ Dr. Carl Erik Fisher

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I recently had the pleasure of speaking to Columbia University’s Dr. Carl Erik Fisher. His new book, “The Urge: Our History of Addiction,” was released January 25, 2022. According to promotional materials, “The Urge combines an eye-opening history of ideas with the author’s own personal story of addiction and recovery. It’s an urgent call for a more expansive, nuanced, and compassionate view of one of the most intractable challenges we face today.”

Carl Erik Fisher is an addiction physician, bioethicist and assistant professor of clinical psychiatry at Columbia University, where he works in the Division of Law, Ethics, and Psychiatry. He also maintains a private psychiatry practice focusing on complementary and integrative approaches to treating addiction. His writing has appeared in The New York Times, Nautilus, Slate, and Scientific American MIND, among other outlets. He also hosts the Flourishing After Addiction podcast.

I think it’s significant that Carl uses “our” (instead of “the”) in the subtitle of his new book. The word choice is consistent with an overarching theme of the book that addiction isn’t simply something that exists “out there,” exerting its influence on us. It is ours. Addiction is a human creation. Societies across time and space have shaped addiction with the meanings and actions they bring to it.

I could say more, but I think it best if I let Dr. Fisher speak for himself. Read on. 

SLP: I’ll begin with the obvious question of why you wrote this book. Specifically, I’m interested in what compelled you to write about the history of addiction.

CEF: One of the great lessons from studying the history of addiction and mental disorders generally is that they are not static entities that exist unchanged across space and time. I believe strongly that there is a thing called addiction. I’ve seen it in myself and I’ve seen it in my family. And at the same time, addiction is also an idea. It’s not outside the historical process. It exists in conversation with cultural and social factors.

What I consider addiction doesn’t necessarily map onto what Benjamin Rush – one of the founding fathers of “addiction” (a word not actually used back in his day) – would have described. It doesn’t necessarily map back onto ancient Chinese or Greek conceptions of what we today would call mental disorders.

I felt like we needed those other realms of human understanding like philosophy and sociology and art and literature and even theology, which in a way were precursors to much of our psychology today.

SLP: Promotional materials for The Urge indicate you make the case that we should stop calling addiction a “disease.” You also suggest addiction exists on a spectrum, and that the common binary view that contrasts “normal” with “addict” is overly simplistic.  Could you elaborate on what you mean ?

CEF: It’s best to take those issues in turn. We can even separate out the question of whether addiction is a disease from the question of whether it is a brain disease. I address those separately in the book.

Let’s take disease first. I worry about addiction being called a disease for a lot of reasons, but the bottom line is that writ large, it’s imprecise and it’s misleading to call it a disease. It’s an equivocation – in the true philosophical sense of the term – in that it’s using one term to refer to multiple things. We might assume it’s a term that originated in medicine, but when I looked at the history, I learned it [addiction] came from theology. It came out of early Protestant writings on will and self-control. Then it evolved through the English language in a way that reflected inputs from other realms of human understanding.

In the end, I recognize that disease is a double-edged sword, and I discuss how there may be wholesome and beneficial uses of the term. I understand that viewing it as a disease can be a plank for advocacy. I also understand that some people who are in recovery, including some of my friends and fellows, get a lot of strength out of the disease notion. But in general, when we study addiction scientifically across all populations, there may also be harms from labeling it as a disease, such as increasing fatalism, pessimism, or social distance.

A binary disease model of alcoholism may make it harder for people to recognize harmful drinking. Some studies find that a firm belief in the disease model of addiction actually predicts relapse. There are many reasons for this. One is the failure to recognize the nuances along the continuum. Many of the harms of drinking come from mild to moderate cases of problematic use, and people [who drink moderately] may or may not identify with the notion of addiction as powerlessness or a loss of self-control.

I wouldn’t want to go out and police every single person’s use of language and be too arrogant about it. But at the very least I think we need a lot more caution about the way we use the term disease, and I would like discussions of the term to be a stimulus for deeper consideration and exploration.

SLP: Given your concerns about describing addiction as a disease, I hesitate to ask how you feel about the allergy analogy found in Alcoholics Anonymous literature. 

CEF: Allergy is funny because in the early 20th century when the notion of allergy got into Alcoholics Anonymous literature, there was a lot of interest in physiological explanations for mental health phenomena including alcoholism and addiction. That was a time when the vast majority of the medical profession really neglected addiction. My profession is guilty of terrible neglect.

The American Medical Association came out against the treatment of addiction in the context of opioid addiction around that time. For much of the 20th century including through the WWI era and the mid-century, the house of medicine had to be forced – and still today has to be forced – to treat people with addiction with compassion and humanity.

At that time, words like allergy and disease had a purpose. They were used to force open the doors that were closed to people with addiction, because of that stigma. But I think that on balance, those terms have outlived their usefulness. Maybe they were appropriate for a particular time, but now we need more nuance.

SLP: And could you elaborate on what you mean when you say addiction exists more on a spectrum than as a binary “either/or” condition?

CEF: I love the psychiatrist George Vaillant’s description of this. Valliant said alcoholism is a bit like light, from the standpoint of physics. It’s a particle and a wave. It exists in two states simultaneously.  He did a series of landmark studies, that I describe in my book, on the “natural history of alcoholism.” I think he was on the Alcoholics Anonymous board of trustees for a time. You can fact check that.

[SLP fact check: According to Wikipedia, George Vaillant joined the board of trustees of Alcoholics Anonymous as a Class A (non-alcoholic) trustee in 1998. For readers interested in more about the history and development of AA, chapter 7 of The Urge highlights Marty Mann, a PR strategist who played a crucial role in midcentury alcoholism advocacy and the rise of AA.]

CEF: I’m not nearly as strong on the notion of addiction as a continuum as I am with calling it a disease. But I think there’s a lot of evidence for broadening our view beyond a stark binary. I think it’s probably too much to say that alcoholism or addiction only exists in one state and that it’s unitary – meaning everyone is alike and experiences it the same way – and that it’s always permanent – meaning that it lasts forever for all people – and it’s progressive – that it always worsens in the same way. Those sorts of ideas I think are too rigid, though they may be true for some.

And at the same time, I recognize that addiction is a really powerful source of identification for many people, including myself. There is something about the shared experience of being a person with addiction that distinguishes us from the rest of the population. This is why I had to go to arts and literature to make sense of all of this.

In a way it gets metaphorical: we can be united in a shared kind of suffering that is simultaneously contiguous with the rest of human suffering. I wouldn’t want to go farther than that. I don’t think we should be too rigid about saying addiction is absolutely a continuum or absolutely a unitary phenomenon. I think right now in 2022 we have to be humble about it.

SLP: I’m interested in how you think the perspective on addiction you offer in your book might inform the way we treat the individual, or the decisions we make about public policy strategies to address substance use disorders. Could you elaborate on that?

CEF: That’s a really good question. When I set out to write the book I did so to answer a personal question. It was a book I wanted myself to make sense of my own problem and my family’s problem. And I think those investigations have important public policy implications.

Going back centuries, one of the things that struck me is that societies tend to get organized into limited policy responses to addiction. We have this hunger for single, simple solutions to mental health problems. My own imperfect shorthand classification for that includes four different responses to addiction.

There could be a reductionist approach that tries to explain addiction in scientific terms. There could be a therapeutic approach that seeks clinical solutions. There’s a prohibitionist approach that tries to crack down with law-and-order and supply-side regulation.

At other times there’s been a predominantly mutual help approach where the reigning model was non-clinical, but more about seeking some sort of fellowship. And even before AA there were analogous programs. For example, in the 1840s there was this massive movement called the Washingtonians that I spend a little time on in my book, a sort of precursor to AA.

The four broad historical approaches to addiction Fisher outlines in The Urge:

·      The Prohibitionist Approach has sought to control addiction through punishment and law enforcement.

·      The Therapeutic Approach has sought to handle addiction through medical treatment.

·      The Reductionist Approach has explained addiction in scientific terms and sought biology-based cures.

·      The Mutual Help Approach has sought community healing and grassroots fellowship.

We tend to orient as a society around one response and miss the bigger picture. The bottom line is I think we need all four. We need a healthy dose of each of those things, even prohibition.

Prohibition has become a dirty word because for so long because we’ve often been harmfully oriented toward exclusively supply-side policies and cracking down, which is clearly ineffective and harmful in isolation. But at the same time, we do need common sense regulation of certain markets. We see that in alcohol. As I would argue, and I think most scholars who study alcohol would argue, alcohol is underregulated in this country and there is a lot of regulatory capture by this powerful industry.

Prohibition doesn’t need to be trying to stamp out drugs; “just say no;” wipe drugs from the face of the earth. A prohibition approach could also imply commonsense regulation that tries to find that healthy middle ground that Mark Kleiman, the public policy scholar, called “grudging toleration.”

SLP: What are your thoughts on moving toward more of a harm reduction approach?  I’m thinking in particular of things like safe injection sites such as those that recently opened in New York City, and decriminalization of drugs in the manner of Oregon’s ballot Measure 110 .

CEF: Let me answer this way. I’ve been spending a lot of time in Portugal this year. A lot of your readers will know Portugal is internationally famous as a place that combined decriminalization with some other initiatives to combat a really dangerous wave of drug problems and overdoses.

Sometimes Portugal is held up as this example of why decriminalization is good, full stop. But I think that’s a bit too simplistic. Part of the reason I wanted to get on the ground is the fact that’s often missed is that the Portuguese experience of decriminalization was married with extremely supportive interventions around employment and housing and treatment.

It just drives home the point – and this goes along with my policy answer too –that all of these elements operate in concert. I’m fully in favor of harm reduction. I think we’ve neglected it as a medical profession and as a public policy lever for far too long. Many parts of the rest of the world have been very comfortable with safe consumption sites for decades and decades.

I think it’s just a no brainer that we should at least be trialing those types of interventions. We can’t miss the fact that we also need to provide for basic health justice, health equity, people’s human needs, housing, food security and employment. By employment I mean employment as a means of support but also employment as a form of meaningful engagement in work and providing a purpose in life.

So I’m all in favor of harm reduction, and coupled with those types of concrete, lifesaving interventions like syringe service programs, overdose prevention sites, and so forth, we must also ask, “then what,” and think about all the other factors that impinge on health and wellness and recovery.

SLP: I frequently read that addiction still carries significant stigma within the medical profession, and that medical schools provide relatively little training in addiction medicine. Do you find that the study and treatment of addiction are more accepted in psychiatry, or would you say addiction is still somewhat marginalized among peers in your area of medicine? 

CEF: I think you’re onto something important. Even today, the attention given over to addiction in medical schools is really lacking. There’s an urgent need for more education, more experience and more respect for the diversity of addiction and recovery treatments and resources.

I had a great experience at Columbia Medical School. In my Columbia residency I had incredible supporters and supervisors. I benefitted from the fact that Columbia has one of the best divisions on substance use disorders. It’s well developed and really diverse within that division with many different perspectives from harm reduction to otherwise.

But even then, when I was coming up, I got very, very little education about addiction. I even had the experience that I describe a bit in my book. When I was roughly a year or two sober, I was back under supervised treatment in residency and doing well. I was able to start providing outpatient therapy. As part of that we do intakes for our outpatient clinic.

I interviewed a graduate student as part of the intake process for the clinic who was a young guy in a different academic program. He was having trouble with drinking. He was drinking about four or five drinks a night and struggling with anxiety. He was having a hard time, and I really felt an identification with him, and I was motivated to work with him and thought it would also be a good opportunity for me to start treating people with substance use disorders and getting some supervision on my own biases by working with that population.

But, my supervisor at the time didn’t let the person in the clinic. They said the person’s drinking was too severe. But this guy was way more healthy than I was when I was at my worst. And I wondered, why was that? That’s not to say my supervisor was a bad person. She was great. She was compassionate. She was really experienced. It was because substance use disorders are tremendously marginalized within psychiatry and still subject to this kind of separate system where people with substance use disorders are often made to go to a totally separate clinic.

There are so many barriers to access. That’s a form of structural stigma; stigma not at the individual level but at the level of policies and institutions that prevent people from accessing meaningful care. I’m happy to say, as far as I understand, Columbia has come even further in the time since I graduated the residency. There are a lot of great people working to mainstream care, which is encouraging. But as a profession we still have a long way to go.  

SLP: You mentioned you were under supervised treatment. Does that mean your struggles with addiction came to light while you were in school or in your residency?

CEF: Yeah. I write about this a bit in the book. I was the beneficiary of tremendous privilege, not just because I was white and middle class, but also because as a physician I was encouraged to enroll in a Physician Health Program (PHP). Most, but unfortunately not all, states have these. It was a voluntary agreement where I submitted to urine monitoring and worksite monitoring and treatment monitoring and other measures to ensure that I could go back to work safely.

I had a complicated relationship to the type of coercion that was in place there. It was voluntary but it was still coerced. In fact, I’ve written about coercion more broadly. Most people in substance use disorder treatment are under some form of coercion. It’s probably more common to be under informal coercion in the form of a spouse or a family member.  I don’t know that there are easy answers here in terms of coercion. It’s such a big topic I don’t know that we have time or space to get into it right now.

SLP: As someone who has experienced informal coercion, including submitting to the monitoring that comes along with voluntary participation in outpatient programs and sober living (recovery residence) programs, I understand the feeling of coercion. I have mixed feelings too, but I think the coercion probably served a valuable purpose for me at the time.

You said one of the reasons you wrote the book was to gain a better understanding of your family and of your own experiences with addiction. Has addiction been a consistent thread throughout your career? If so, to what extent would you say that is related to your own experience?

CEF: I had a complicated relationship to addiction because both my parents were alcoholics. Very early in my life, before I can even remember, they both went to alcoholism treatment in the early 1980s. Both of them were highly resistant to it. The entirety of my childhood was watching them struggle in various ways with alcoholism.

So I actually was pretty averse to addiction for a while. Just as I defined myself in opposition to my parents and said I would never be like them, I also felt some aversion to the professional study of addiction. I was more drawn to basic neuroscience research and to general psychotherapy. I always felt some discomfort with looking closely at addiction as a professional pathway.

In part, I think some of that aversion was because before I got sober, I knew that I had a bigger problem than I was admitting to myself. I was engaged in some self-deception and rationalization about how bad my own issues were. So that made it really uncomfortable to look closely at, and to think closely about, addiction. So it was really only after I got sober that I started to explore it in more detail.

I did have the benefit of being at Columbia. Some supervisors were really interested in addiction and I did get good experiences there. But I think really, it was my forensics fellowship – when I did an extra year after residency, a fellowship in psychiatry and the law. I did placements in prisons, in jails, providing treatment evaluations for incarcerated populations, doing evaluations for the courts.

I saw the tremendous burden of both our misguided drug policies and of addiction itself in our incarcerated populations that prompted me to look deeper. I had the personal interest and the psychotherapeutic interest. And there was also this public health, and even bordering on humanitarian, crisis of the way we treat addiction among incarcerated individuals.

There’s a lot of “me-search” in psychiatry, meaning, people study what has personal resonance for them. It’s not always true, but there is some truth to that. I think it can be dangerous, of course, in terms of bias and people taking their own lived experience and projecting it onto other people. And I try to be very rigorous that I don’t assume my personal understanding of addiction and recovery is the right model for everyone.

The lesson of the book ultimately is that I don’t have the answers. There is no one right answer. We need pluralism and respect for multiple pathways to recovery. I think if those types of biases are managed and people are thoughtful about them, then there’s really tremendous value in lived experience.

My own lived experience helped me to step into that role and feel less ashamed about being a person with addiction who is also a clinician. I really feel today like it’s a tremendous gift to be able to do combine those parts of myself. I’m glad for everyone who is able to find that connection between their personal life and their work.

SLP: In part because of my own recovery journey, I’ve become interested in how people manage their identity as a person with a substance use disorder and a person in recovery. Could you talk a bit about how you’ve managed that part of your identity in your personal and professional life?

CEF: The way I manage or relate to my identity as a person in recovery is still an evolving process for me. When I first exited treatment and went back to residency, I got the advice that you can’t un-ring that bell if you go out and disclose something that you later regret. So I was very careful in the beginning. I thought it was good advice while I thought through my own identity.

Writing the book was a process of making sense of my identity. I needed to do some of that work before I could be more confidently public with it. I appreciate the advice that you should write about your scars and not your wounds. I think there’s some truth to that.  

My relationship to my identity as a person in recovery has been ultimately led by the book. I had this really strong feeling that I wanted to write this book and that I wanted to explore these topics of addiction across history. To be honest, and to keep it connected to the human relevance of it, I wanted to write about my own story, if nothing else but to disclose my own biases and think out loud about my relationship to the story. From there it just almost automatic that I was going to disclose my identity at some point. I didn’t want to sit on it for decades and decades.

In the general mental health field, some writers have waited longer. Kay Redfield Jamison did really pivotal bipolar disorder research, and only much later in her life came out with the memoir “An Unquiet Mind.”

Elyn Saks, a person with schizophrenia, worked as a distinguished law professor for many, many years, then later wrote a memoir about living with schizophrenia.

I have tremendous respect for both of those writers. And the sense I get is that’s what they had to do in their time. But now I would like to think that there’s more acceptance of people with mental disorders, including addiction.

I just had a gut sense that it felt right to me to be more public about it. So I just followed my work where it led and tried not to think about it too much. It seemed like it was useful to do and so now I’m just doing it.

__________

SLP: After I turned off the recorder, I thanked Carl for his time, and for targeting a general audience with his podcast and his book. His response? “If there’s anything COVID has taught us is that there is a need for high quality, reputable public communication about science.” Well said Dr. Fisher. Thank you!

And that’s a wrap for now. Stay tuned for next month’s installment of SLP Insights interview series.

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