Author Maia Szalavitz first injected cocaine in the mid-1980s at the age of twenty. “My mind was rapidly overcome by a crystalline euphoria,” she writes, “a bliss that was surprisingly satisfying.” She’d recently been suspended from Columbia University in New York City for dealing drugs, and within weeks of her first injection she was doing “speedballs,” an intravenous combination of cocaine and heroin.
That fall she was arrested by plainclothes narcotics agents for possession of more than two kilos of cocaine. Two years later, while out on bail, she chose to get treatment, and she completed a twenty-eight-day inpatient rehab program in 1988. Over the next four years, while she attended twelve-step meetings and made court appearances, she received her undergraduate degree in psychology from Brooklyn College and freelanced for The Village Voice and Spin.
The charges against Szalavitz, which carried a fifteen-year minimum sentence, were eventually dropped. She acknowledges that her status as a privileged white woman contributed to this outcome and writes about feeling “obligated to do all I can to make sure that others are able to be treated with similar mercy.”
Today the fifty-two-year-old is a columnist for Vice and freelancer for such publications as Time, The New York Times, The Washington Post, and Scientific American, specializing in neuroscience and addiction-related issues. Her “detour,” as she calls it, through the world of drug addiction has allowed her to cover the topic with empathy and the insight of firsthand experience.
Born on New York City’s Upper West Side, Szalavitz was diagnosed with attention deficit hyperactivity disorder while still in preschool and prescribed Ritalin. She cried frequently as a child, preferred to be alone, and was hypersensitive to sights, sounds, smells, tastes, and textures. She was also a “little professor,” regaling anyone who would listen with facts and figures about her latest fascination. (When she was four, it was volcanoes.) Today, Szalavitz says, her younger self would be placed on the autism spectrum. She believes the social isolation and distress she experienced as a child helped put her on the path to addiction. Another risk factor was her family history: her father, a Holocaust survivor, was predisposed to depression, a condition that also ran in her mother’s family.
Szalavitz had her first drug experience — smoking hash — at the age of seventeen and says that getting high “broke down the wall of fear that kept me from reaching others or accepting myself.” She writes about it in her latest book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction. Part scientific reporting and part memoir, the book denounces the “war on drugs” mentality that Szalavitz says has only filled prisons and made drug treatment less effective. She avoids the term “addict,” preferring “person with addiction.” Though she admits to having been helped by twelve-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) — which emphasize going to meetings, looking to a “Higher Power” for help, and addressing moral shortcomings — she is also critical of them. Addiction, she insists, is not a moral failing but a disease — a learning disorder, to be precise. She hopes this understanding might affect policy and lead to improvements in prevention and treatment.
Szalavitz is the author or coauthor of several other books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids; Born for Love: Why Empathy Is Essential — and Endangered (with Bruce D. Perry, MD); and a guide to recovery cowritten with Joseph Volpicelli, MD. She’s received the American Psychological Association’s Addiction Division Award and the Drug Policy Alliance’s Edward M. Brecher Award for Achievement in Journalism. When I spoke with her several times this past winter, she had an infectious laugh and offered sharp and convincing arguments for changing the way we view drug use and addiction.
Cooper: How do you define addiction?
Szalavitz: I define it as a compulsive behavior that continues despite negative consequences. This is also the definition used by the National Institute on Drug Abuse. A negative consequence could be anything from falling down drunk, to losing a job, to going to jail. People usually respond to negative consequences by changing their behavior, but when addiction is involved, they are more likely to try to avoid making the connection between the drug use and the consequences.
Now, in order to succeed in life, you need to be able to persist despite negative consequences in many situations. I couldn’t survive as a writer, for example, if I weren’t able to deal with rejection. It’s only when the behavior becomes compulsive and divorced from reality that it’s a problem.
It’s also true that if there are no negative consequences, there’s no addiction. You might say, “I’m addicted to TV,” but unless you’re losing your job and your wife and your cat as a result of your TV watching, it’s not an addiction.
Frankly, I don’t care if people are engaging in some kind of compulsive behavior, even if it involves drugs, as long as it’s not doing them or someone else harm.
Cooper: Even heroin?
Szalavitz: Sure. If you’re a rich person with no responsibilities and an infinite clean supply and a spouse who doesn’t mind, you probably would not be considered addicted under this definition. Of course, I’ve never encountered anyone like that in real life. Most people who use heroin every day — or other opioids like morphine, oxycodone, and opium — are unable to rein in their use when they need to, and that’s a negative consequence in itself.
Cooper: You have likened addiction to a developmental or learning disorder, “similar to autism, attention deficit hyperactivity disorder (ADHD), and dyslexia.” How is this understanding different from the definition you’ve already given?
Szalavitz: It’s more an elaboration on it. We do learn, in life, through negative feedback: if something hurts, we won’t do it again. If you have a compulsive behavior that persists despite negative consequences, it means you have a problem learning from certain types of experiences.
When I say it’s a developmental disorder, I mean that addiction typically starts at an age when the human brain is still developing its capacity for self-control. Some 90 percent of all addictions begin during the person’s teens or early adulthood. There’s something about the brain at that time that makes it vulnerable.
Understanding addiction as a learning disorder should allow us to make use of what we know about the psychology of education in treatment. For example, we know learning occurs best in an environment of caring and support. This doesn’t mean you don’t challenge people, but the most effective teacher gives both love and discipline. And kids learn the most when they want to please the teacher and experience the satisfaction of doing well.
Cooper: Is recovery sometimes a matter of trading a harmful addiction for a less harmful, more socially acceptable one, like smoking?
Szalavitz: There are certainly situations where somebody replaces compulsive heroin use with, say, compulsive running. If this compulsive running is doing less harm, then you’re at least better off. If it’s doing no harm, you have achieved recovery.
People often refer to the “high” they get from activities like running or sky diving. We eventually have to wrestle with the fact that human beings will always want to get high. Every culture has intoxicants. Either we can recognize this and make available the least-harmful substances in the least-harmful settings, or we can go on destroying people’s lives and creating cartels in Central and South America by continuing prohibition. The war on drugs is not going to solve the problem. If it were, the problem would no longer exist.
Cooper: You’ve said that the use of mood-altering substances probably predates humanity. What’s the evidence for that?
Szalavitz: The example I give is cats and catnip. There’s a certain chemical in catnip that attracts a cat to the plant. One theory is that rolling around in catnip helps discourage parasites, but clearly cats are not using the catnip because it might get rid of parasites. They’re drawn to it because they like how it makes them feel.
Google “animals getting high,” and you’ll find many other examples. Horses are known to seek out a plant called locoweed, which causes them to act in bizarre ways; they’ll even return to it after having been sickened by it. And Siberian reindeer eat hallucinogenic mushrooms.
As for human beings, the desire to alter our consciousness is persistent throughout history. We often do not like the way we feel, and if we find a substance that can change that, we’re going to try it. This isn’t necessarily a problem. For those of us who suffer from depression, having a drug that alleviates it is an asset. There have certainly been times when, if I did not have antidepressants, I couldn’t function. Before I started taking them, my state of mind was often unbearable.
Human beings will always want to get high. Every culture has intoxicants. Either we can recognize this and make available the least-harmful substances in the least-harmful settings, or we can go on destroying people’s lives and creating cartels in Central and South America by continuing prohibition.
Cooper: The term “self-medicating” gets thrown around a lot. What’s your feeling about it?
Szalavitz: It’s an apt description of many addictions. If you are coping well in life, have no major problems, and can connect socially with others, you probably won’t become addicted, even if you discover a drug you enjoy. There are rare cases in which somebody has such a genetic predisposition for addiction to, say, alcohol that just one drink means trouble. But most people who experience euphoria from a drug do not go on to sacrifice their job or their marriage or their kids or everything they’ve worked for to keep taking it. It’s typically when your life is going badly and you don’t have anything to lose that a euphoric experience becomes incredibly appealing.
Addiction isn’t only about euphoria, though. What heroin really did for me was make me feel safe and comfortable and let me stop thinking everybody hated me. Today I get that same effect from Prozac. The euphoria was nice, but what really hooked me was just being able to feel OK. It was a classic case of self-medication.
A Harvard professor named Edward Khantzian developed the theory of self-medication, and for many years it was brushed aside because people insisted addiction was caused by genetics, even though they couldn’t explain how genes played a role. The self-medication idea became popular among people trying to treat alcoholism. There’s a school of thought that says alcoholism is caused by a vicious cycle: people drink to excess, get depressed about the consequences of their drinking, and then self-medicate their depression with more alcohol. Of course, that assumes everything was fine until you started drinking to excess. Maybe that happens sometimes, but the more logical explanation is that you’re anxious or depressed or unhappy in one of ten million ways, and the drug makes you feel good, so you continue taking it to the point that it makes you feel bad again.
Cooper: Is there any evidence of a genetic predisposition for addiction?
Szalavitz: There’s a strong genetic factor with alcohol addiction. If the children of parents with alcoholism are adopted by nonalcoholic parents, those kids still have pretty much the same risk of developing an alcohol problem as they would have if they’d been raised by their biological parents. There are also genetic predispositions toward traits that cause addiction, such as depression, impulsivity, or anxiety. But for the most part there isn’t a single gene for alcoholism. All the ones we’ve discovered account for just a tiny variation in rates.
Cooper: You’ve written that “no drug takes effect without context.” What does that mean?
Szalavitz: Psychedelics are the classic example of this. In fact, the terms for understanding these effects — set and setting — come from LSD pioneer Timothy Leary. Set is your mind-set or expectation or mood, and setting means the environment you’re in. The classic example is that the CIA gave people LSD expecting it to make them compliant interrogation subjects. You can imagine how different that experience was compared to taking LSD with a friend in a natural setting.
Cooper: Is this true for every drug?
Szalavitz: Yes, every drug. If you drink alcohol in a new setting or have a different drink than you typically do, you will get more intoxicated than if you were in a familiar place having your usual drink. That’s because tolerance is partially learned. This phenomenon can have deadly consequences when it comes to opioids. A lot of overdoses occur because the person was taking the drug in an unfamiliar setting, so the cues that create tolerance weren’t there.
Set and setting can sometimes explain placebo effects, too. In one study people were given cigarettes that they thought might or might not have nicotine. When they were told that a cigarette had no nicotine — even when it actually had the normal amount of nicotine — the subjects wouldn’t get the nicotine high they were expecting, and scans of their brains showed this. That’s mind over matter right there. This is why the idea that “heroin does X” is wrong. Heroin does X in some situations and Y in others. Take the famous studies in the late 1970s: rats were put either in solitary confinement or in rat “paradise,” and both were given drugs. Not surprisingly the rats in paradise weren’t especially interested in the drugs; they engaged in normal activities like finding mates and having babies. The rats in solitary, meanwhile, became addicted.
Cooper: You’ve claimed that drug use is so common, it’s really nonusers who are abnormal.
Szalavitz: In the United States about 80 percent of the population drinks alcohol at some point. Something like 50 percent of us are physically dependent on caffeine. People love their coffee. Now, are they addicted to it? Maybe, if it causes negative consequences. It’s certainly a psychoactive substance that alters mood. We used to have nearly 50 percent of our population addicted to cigarettes. Thankfully that percentage is much lower now.
We also use other means besides drugs to alter our moods. I don’t think there’s anybody — except perhaps deaf people — who doesn’t use music that way. Music, to me, is one of the most sublime experiences. That’s probably why religious groups are often trying to ban certain types of music and dancing — because of the connection to ecstasy. Our drug laws, too, are left over from the country’s puritanical beginnings. It’s like the old joke: Puritanism is the fear that someone, somewhere, is having a good time. [Laughter.]
Cooper: Besides religious puritanism, what cultural biases have influenced public attitudes toward drugs in the U.S.?
Szalavitz: The drug laws we have are based entirely on cultural biases. Maybe the FDA now makes rulings based on science — and, to be fair, it usually does — but the laws around recreational drugs often arise from racist panic. Marijuana wouldn’t be illegal, for example, if racism hadn’t led to its being associated with jazz and black men and Mexicans in the early twentieth century.
Cooper: That makes me think of the crack-cocaine epidemic in the late 1980s.
Szalavitz: The news media told us crack was going to leave the inner city and come to the suburbs to kill our middle-class kids, but that never happened. Middle-class people did become addicted to crack, but most managed to get treatment or to quit without help. The suburbs never saw the same rates of addiction that poorer neighborhoods did.
The current opioid problem presents a much greater danger than crack. Overdosing on crack is rare, but the death rate from opioid addiction is horrifying. It’s not just the drug that causes the problem. Only about a third of the people who try powerful opioids find them appealing, and only 10 to 20 percent become addicted. So there are people who love opioids but do not become addicted to them. It’s when your life is extremely stressful and you don’t have other ways to cope that heroin becomes attractive.
Cooper: Is that why poorer people are at a higher risk for addiction?
Szalavitz: Yes, if you’re poor, you tend to be under more stress. Also, when you develop an addiction, you’re likely to lose your job and end up poor.
We shouldn’t forget that middle-class people are at risk for addiction, too. And if you are extremely wealthy, you have an increased risk — perhaps because you have so much unstructured time. Rich people have unstructured time if they don’t have to work, and poor people have it if they don’t have a job. Too much idleness is also bad for someone with a mental illness, and about half of people with an addiction have a mental illness that exacerbates it.
Most people who compulsively seek to escape through drugs do so because they find their consciousness unbearable. That’s the real source of addiction. It’s not a property of the drug. You can get rid of the substance, but as long as people are feeling miserable, something will come along to replace it.
Cooper: You titled a chapter of your book “The Myth of the Addictive Personality.” Why do you call it a myth?
Szalavitz: The theory of the addictive personality is that if you are addicted to one thing, you are prone to be addicted to everything: food, alcohol, gambling, shopping, whatever. But the reality is that many people can control their shopping but not their gambling, or can control their drinking but not their cocaine use.
The other side of the addictive-personality theory — and I think this is the more pernicious and dangerous aspect — is the idea that people with addictions are typically selfish, cruel, callous, uncaring, and devious. And that is not true. Many different traits raise the risk for addiction, but not all addicted people have all of them. Some have none.
Addiction can also be associated with talents and benefits. After all, the ability to persist in some activity despite negative consequences is a strength in healthy situations. One of my friends who had an addiction and now runs a treatment center likes to point out how every morning he would wake up in need of drugs, and by the end of the day he would have them, no matter what. That shows determination and ingenuity, even if it was put to bad use.
Cooper: You mentioned that most people who experiment with strong opioids don’t become addicted, and of those who do, most recover, many without treatment. Why does drug education avoid discussing this?
Szalavitz: Obviously educators want to give a simple message to children: “Don’t do drugs; they’re bad and will kill you.” And it’s true that children might not be good at assessing the risks involved. If you tell kids, “Four out of five people who try heroin don’t get addicted,” the kid might think, Wow. Those aren’t bad odds. But would you get on a plane that crashed one time in five? [Laughter.] Some teenagers who believe they have a 90 percent chance of becoming addicted to heroin will still try it.
The issue is really what’s driving the teen’s desire to experiment. Part of being a teenager is separating from your parents and trying to find your place in the world. Your hormone levels change, making you more attracted to risk. I don’t think there will ever be a society in which teenagers don’t make dumb choices. What we can do is reduce the harm from the dumb choices they do make. Unfortunately drug-prevention efforts are doing the opposite. Zero-tolerance laws, for example, discourage kids from calling an ambulance if a friend overdoses, making a dangerous situation even more deadly.
Cooper: Let’s talk about reducing harm. It’s the approach you prefer for drug policy.
Szalavitz: Yes, the goal of drug policy should be not to reduce drug use but to reduce the harm caused by it. With the harm-reduction approach, it doesn’t matter if you get high and are safe. It only matters if you are at risk for overdosing, becoming addicted, or harming yourself or others in some way.
A lot of parents who don’t want their kids to drink and drive, or to ride with someone who’s been drinking, will tell them: “Call me at two in the morning, and I’ll pick you up. I might yell at you, but I want you safe.” That’s basic harm reduction, and we need to extend it to other substances.
I don’t personally think the government should care whether or not I experience euphoria. The euphoria-inducing chemicals released in my brain when I inject cocaine are pretty much the same ones I might get from sky diving. Why should one be illegal and the other legal? We need regulations on sky-diving instructors to keep people safe, but making sky diving illegal would be absurd — as absurd as the idea that I’m breaking a law by sitting around my house, smoking weed, and not hurting anyone.
Cooper: What countries have adopted successful harm-reduction policies?
Szalavitz: Portugal is one. It decriminalized all drugs in 2001. Since then, it has seen fewer overdose deaths, less crime, less disease, and more recovery. There was a slight increase in drug use, but it was the same as in the rest of that part of Europe, which didn’t decriminalize.
Vancouver, British Columbia, opened safe-injection facilities, which allow IV-drug users to inject in hygienic environments. There hasn’t been a single overdose death in a safe-injection facility there since they started operating.
The opioid-addiction treatment for which we have the most evidence is maintenance use with methadone and buprenorphine. These two drugs, used indefinitely — possibly for life — cut the relapse and death rates of opioid addiction by 50 percent.
Cooper: Isn’t maintenance drug use still an addiction?
Szalavitz: Not at all. The consequences are not negative, so the user has moved from being addicted to being physically dependent.
Cooper: What’s the difference?
Szalavitz: Physical dependence doesn’t mean you’re addicted. It just means you need something to function normally. You can be physically dependent on antidepressants or blood-pressure medication. In fact, some prescription medications will cause death if you abruptly stop taking them, but we don’t say the people who take those medications are “addicted.”
In the 1980s people thought cocaine wasn’t addictive because it doesn’t produce physical dependence. There’s no withdrawal — no puking and shaking — when you stop using it, only psychological symptoms such as irritability and cravings. We have a cultural bias that says psychological withdrawal isn’t “real,” whereas physical withdrawal is.
But if physical dependency were all that kept someone addicted, you could solve opioid addiction by locking the person in jail for two weeks. Clearly that doesn’t work. I went through opioid withdrawal six times, and I never relapsed while I was sick and puking, because I knew the symptoms would eventually go away. It was only a couple of weeks or months later that the psychological craving would become too much, and I would tell myself, “It won’t hurt to use on weekends.”
Most people who compulsively seek to escape through drugs do so because they find their consciousness unbearable. That’s the real source of addiction. It’s not a property of the drug. You can get rid of the substance, but as long as people are feeling miserable, something will come along to replace it, the way heroin has replaced oxycodone in the current opioid epidemic.
Cooper: Why has that happened?
Szalavitz: Because the government started cracking down on the pharmaceutical opioid supply, and the illegal drug market stepped in to fill the demand. While we are shutting down “pill mills” and telling doctors to write fewer prescriptions, we should also offer addicted people maintenance treatment instead of just letting them suffer.
We keep making the same mistakes over and over and over because of politics and America’s greatest shame: racism. When a white person says, “Oh, I’m not your typical addict,” what that means is “I’m not black.” Of course, whites have always suffered from addictions, too. But our image of people with addictions is virtually identical to our negative stereotypes of minorities, particularly black people. Nobody wants to confront the role that racism plays in our thinking about addiction, so we end up calling it a “disease” but still locking up people of color and poor people for having it.
Now that the middle class are losing their jobs and their hopes for the future, more white people are turning to drugs. Suddenly the criminal-justice system isn’t as eager to send someone to jail for having an addiction. This is good, but I just wish the problem didn’t have to devastate white populations for us to do something about it.
Our image of people with addictions is virtually identical to our negative stereotypes of minorities, particularly black people. Nobody wants to confront the role that racism plays in our thinking about addiction, so we end up calling it a “disease” but still locking up people of color and poor people for having it.
Cooper: Did you have a racist attitude about addiction when you were using?
Szalavitz: I certainly picked up many of our culture’s awful stereotypes, and I am not proud of that. At the time I was not educated about the history of our drug laws, and I bought into the myth that the typical person with an addiction is a poor person of color. That’s never been true, but our drug policy-makers want it to be, because our drug laws are really about controlling people of color and the poor. They’ve got nothing to do with helping people overcome addictions. Remember, addiction is defined as engaging in compulsive behavior despite negative consequences. You can’t use a negative consequence like jail time to fix it.
Cooper: You object to calling people “addicts” because it reduces them to their addiction. Do we also need a better word than addiction?
Szalavitz: No, I like addiction because at least people have a clue what it means. Dependence is a bad substitute, because it implies that if you depend on anything outside of yourself — a medication, a person — there is something wrong with you. By that definition, everybody’s “addicted” to oxygen. It becomes meaningless. It also pathologizes pain patients, because if you take opioids for pain long enough, you will become physically dependent.
Cooper: Does your objection to dependence extend to codependence — the idea that some people who are trying to help an addicted loved one are themselves addicted to the role of caretaker and enabler?
Szalavitz: The only correct thing about the notion of codependence is that some people do use other people’s problems to escape from their own. For example, I might become obsessed with trying to solve my kids’ problems because I don’t want to deal with the fact that my marriage is screwed up — which it isn’t. [Laughter.] But if I were to do that, then it would be bad for me. Is it a disease? No. Am I enabling the addiction because I need it to continue distracting me? Maybe. But that doesn’t really tell us much. It says that there are relationship issues that need to be managed, but it’s not useful in determining what’s best for the person with the addiction.
Obviously if someone I love wants to get high all the time, and I don’t want to do that anymore, I might have to cut that person out of my life. I empathize with family members who cannot watch their loved ones destroy themselves. It’s like when you’re on an airplane and the flight attendant tells you to put your oxygen mask on first before helping someone else do it: if you can’t take care of yourself, you can’t take care of someone with an addiction. But the idea that simply trying to take care of someone with an addiction means you’re sick? That’s pathologizing human kindness. And if you do have to cut off a relationship, don’t assume it’s going to help the other person.
Cooper: That’s the point of view often taken by interventions: that family members have to cease all contact with an addicted person who won’t go into treatment.
Szalavitz: Exactly: the “We know what’s best for you” approach. It rarely works. Even with a two-year-old, when you say, “We’re going to make you do this,” you immediately get resistance.
There’s a better approach called Community Reinforcement and Family Training, or CRAFT. It moves people toward treatment in a kinder way and is about twice as effective as a traditional intervention, which is likely to backfire. When you deliver that ultimatum — “Go into treatment, or else” — maybe you are thinking it will fix this person, but people have died after having been cut off. Musician Kurt Cobain killed himself after a failed intervention. And if you can help the person in a way that’s respectful and doesn’t risk backfiring, why wouldn’t you do that instead?
Sometimes people will go into treatment when they’re threatened, but the best way to motivate loved ones who need help is to offer them hope and safety and comfort and to allow them to make the best possible choices. They’re much more likely to stick with recovery if they’re doing it because they want to do it, rather than because they think they have to do it for you.
Going into treatment can be frightening. It helps if your friends and family tell you, “I will be there for you. If you try one treatment and it’s not right, I’ll help you find something else.” Just that message — that your family and friends aren’t going to let anything bad happen to you — can make you feel safer.
Many people with addictions have experienced trauma, powerlessness, and helplessness in the past, and they are scared to go into treatment and lose their autonomy. In order to overcome that, they need to feel that they are in control. When you take choices away from traumatized individuals and push them to do what you want, the results are often not good. There are cases in which people’s lives may be at risk if they continue using, but it’s still hard to say whether forcing them into treatment is going to hurt or help.
Cooper: We’ve talked here about addiction as a “disease.” Dr. Benjamin Rush, a signer of the Declaration of Independence, was one of the first people to call alcoholism a “disease of the will.”
Szalavitz: Rush did bring medical language to the discussion, but he still saw addiction as a defect of character — the “will.” Throughout the twentieth century we gave lip service to the idea that addiction is a disease. Even now, when you go into treatment, the majority of your care involves twelve-step programs that advise you to surrender to a “Higher Power” and make amends. Not that there’s anything wrong with clearing up the moral messes you’ve made. The problem is we don’t require this spiritual approach for depression or diabetes. We don’t treat cancer with prayer — at least, not as part of mainstream medicine.
Cooper: Did you complete a twelve-step program?
Szalavitz: Yes, I was involved in twelve-step programs when I first got into recovery because they were the only option available. I found aspects of them very helpful, but I don’t think they should be mandatory, because they moralize addiction. Taking a moral inventory and making amends to the people I’ve harmed might be good for me, but it’s part of my spiritual life and should not be mandated by the government or a medical program. The social-support aspect of the twelve steps would be OK by itself. If an oncologist told you about a nonreligious cancer support group, you might try it. But if your oncologist said that your treatment for cancer was to go to confession, you’d likely find a different doctor.
Cooper: Still, when you took “moral inventories” in twelve-step programs, did it work for you?
Szalavitz: I found it liberating and chose to use it as a way to put my past behind me. And that’s a valuable thing to do voluntarily. But forcing people to do it is like brainwashing. In my book Help at Any Cost I wrote about a teen drug-treatment program called Straight Inc., which used moral inventories to brainwash kids: you confess your sins, and then you get attacked for not having confessed enough. And they use your confessions to find your weak spots.
My argument is that we should separate the social-support aspect of twelve-step groups from the spiritual element that some people find helpful, just as we do for every other medical and psychiatric condition. Medical treatment for addiction should focus on evidence-based therapies, many of which, when compared head-to-head with the twelve steps, do just as well in fewer sessions and without the religious baggage.
As I said, maintenance treatment cuts the death rate for opioid addiction in half, which is better than any other method that’s been studied. If you went to a cancer center and weren’t even offered the treatment that reduced your risk of death the most, you would have grounds for a malpractice case. Yet most residential addiction-treatment centers do not offer maintenance treatment and, in fact, oppose it, saying it’s not “real” recovery.
Cooper: What’s the success rate for AA?
Szalavitz: For those who like AA, the success rate is high, but if you randomly assign people to it, it doesn’t do any better than other treatment methods. I think people who are really motivated to recover will find something to like about AA and go to it diligently, as I did, and declare that it saved their life. That’s what is known as a “selection effect.”
Again, there’s nothing wrong with AA, so long as it’s not mandated as addiction treatment. You should do whatever works for you. I just don’t think people should be forced to participate in it by the criminal-justice system.
Cooper: How frequently are twelve-step programs used in sentencing?
Szalavitz: It is extremely common for courts to mandate participation in twelve-step programs. Pretty much anyone with a DWI can be forced to attend AA meetings. Nearly 80 percent of drug treatment is based on twelve-step programs, so if the courts mandate treatment of any kind, they are de facto mandating twelve-step programs. Because AA is religious, sentencing people to attend meetings amounts to state-sponsored religion. Yet they continue to mandate it because they don’t have many alternatives.
Cooper: Aside from the spiritual aspect of the twelve steps, you also take issue with the first step: “We are powerless over alcohol.” Why is that?
Szalavitz: If you can’t safely have one drink without having ten, that’s a good thing to know about yourself, but if you believe you are “powerless” and you relapse, as many people do at some point, it can make your relapse worse. If you’re powerless, once you’ve had that first drink, you might decide there’s no point in trying to stop.
Telling women, poor people, and minorities they’re powerless is especially hurtful. If I’m convinced I’m powerless over everything except myself, that means I probably won’t be politically active. People with addictions need to recognize the power they do have.
I also object to taking away someone’s progress in recovery after a relapse. The traditional twelve-step view is that if you relapse after ten years of sobriety, it’s the same as if you never had any recovery at all: you’re back to zero days. That’s absurd. Those ten years don’t just go away. If I were in charge of twelve-step programs, I would say, once you got another ninety days together after your relapse, you’d get your ten years back. That all-or-nothing policy is not essential, and it ends up creating a lot of harm.
Cooper: The conventional wisdom is that recovery begins after you’ve hit rock bottom.
Szalavitz: People think that in order to recover, you have to realize that your life is the worst it’s ever been. This is great for telling a tale of sin and redemption, but recovering from an addiction is not a linear process. The majority of people relapse at least once. So if you relapse, do you have to find a new bottom that is even lower than the first?
In the rock-bottom myth, maintenance treatment is “enabling”: you’re giving drugs to the user. But when we do that in a controlled setting, we find that people tend to move toward abstinence or stability. Their health improves because they have a safe supply. Their criminal activity drops because it’s now legal for them to use. When you go to a clinic every day to get your fix, it’s kind of dull. It doesn’t occupy your mind the way chasing heroin on the street does. There are no cops and robbers. You’ve got what you thought you wanted — a steady supply — and your problems are still there. That’s a realization that encourages recovery.
Also if you are marginalized and stigmatized and rejected, as most people with addictions are, and someone says, “Here: I know this is what you want; you can have it. I want you to live,” you might feel more respected as a human being and start to form relationships, which help heal addiction. You need medication, but you also need attachment. With addiction you fall in love with a drug rather than a person. To give up the drug, you’re going to have to find love somewhere else. That doesn’t mean you need to get married or be in a romantic relationship, but you do need people in your life who care about you.
Social support is critical to recovery. We’re a social species, and the primary way we manage stress, going back to infancy, is to seek comfort from others. It calms us. That’s why solitary confinement is so harmful: you don’t get that social contact and physical touch that you need to thrive. This is true even for those who may have a hard time dealing with others. Everyone needs a good friend.
Cooper: What about peer support as part of treatment? Are people who have had addictions themselves better able to give advice on recovery than the experts with degrees?
Szalavitz: Peer support can be enormously helpful, and people who have been addicted are often fabulous at empathizing and connecting with others. But studies show that the recovery status of a counselor doesn’t influence whether the client gets better. What does matter is how empathetic and supportive the counselor is.
I will say that, given two equally qualified job candidates, one with a history of addiction and one without, we should hire the addicted person, because the treatment field is one of the few places someone won’t be discriminated against for an addiction in his or her past.
Cooper: The World Health Organization has announced that it supports complete decriminalization of all personal drug use and possession.
Szalavitz: That’s a no-brainer. I don’t think even prohibitionists these days believe that locking people up for drug possession is a good investment. Why waste the resources? Even the hard-liners who used to say, “We have to send the right message,” will now force people into treatment instead of putting them in jail.
We can argue about whether it should be legal to sell heroin and cocaine. I really worry about commercialization. I do not want Philip Morris selling crack. That would be bad.
Cooper: Would it be as bad as criminalization?
Szalavitz: It would probably be slightly better, but still it would not be good. Look at what’s happened since drug companies were allowed to market opioid painkillers. They should not be permitted to advertise them to doctors — or advertise them, period. At the same time, some pain patients get amazing relief from these drugs, so we can’t outlaw them.
We should absolutely legalize the sale of marijuana. It is the least harmful psychoactive substance we have, with the possible exception of caffeine — although you can actually overdose on caffeine. And caffeine causes a mean physical dependence, whereas marijuana does not. But marijuana is intoxicating, and caffeine isn’t.
Anyway, it would be better for marijuana to be legally available as an alternative to opioids and alcohol. People have limited intoxication budgets. The more of those budgets they spend on marijuana, the better off we will be as a society.
Cooper: Let me end by asking about something you wrote in The New York Times: “If addiction is like misguided love, then compassion is a far better approach than punishment.”
Szalavitz: The fundamental truth about addictions is that most people who have one are struggling socially in some way. One reason opioids are so appealing to them is that our brains release natural opioids in certain situations. Getting a hug, for example, triggers opioid receptors in the brain. If you don’t get that high from normal social interaction, then opioids will be incredibly attractive to you. Also if you were neglected or traumatized as a child, your brain might not be producing enough natural opioids.
This is why compassion is important. People need to feel connected and wanted in order to be at their healthiest. That’s true whether you have an addiction or depression or schizophrenia or cancer. This doesn’t mean that compassion is going to cure your cancer, but you will be better equipped to deal with any disease if you have a supportive social environment. Your support group is not your doctor, but your support group may be what allows you to seek the medical care that you need.
I wrote a whole book about this with Bruce Perry called Born for Love. The point was to look at how the brain’s stress-release system depends on social support. The best way to relieve stress is not yoga or meditation — although those can be wonderful — but human contact. We need each other.