One of the most difficult things about being a therapist, especially working with a high acuity sexual trauma survivor population, is the likelihood and frequency of suicide attempts among a certain subset of this population.

I was still an intern, only a few months into my on-the-job training, when I first had to experience a client's choice to die. I had only seen him in person a couple of times, and spoken with him by phone a handful of times, but when I was notified it felt as though I had been punched in the stomach. I liked him, and I felt that I understood him, so despite his history and his situation, I was hopeful for a significant increase in his functioning and quality of life. Other circumstances intervened and I never had a chance to see what was possible for him.

Since then I have had many clients attempt suicide, and a couple nearly succeed, and I have learned to distinguish between wanting to die and not wanting to live. I have learned that my ability to prevent such a choice is limited at best. Still, each time it happens I feel sad that a person's life, a person whose fate I have come to care about, felt to desperate and hopeless that death seemed the best option. I feel sad because I have been in that place . . . and was able to talk myself out of it.

Because I know what that hopelessness feels like, I am accepting of the client, compassionate with the pain that led them to that choice. Even while the client often feels guilty or ashamed for making the attempt (or for failing), I try (gently) to move the client to a perspective from which s/he can feel compassion for the part of them that wanted to die, and if possible, to be curious about that part of themselves - to befriend it rather than fear it.

How therapists respond to a client's suicide attempt is the subject of the open access paper presented below. This is an important topic because how clinicians respond to clients has a lot to do with the effectiveness (or not) of the therapy.

Full Citation:
Yaseen, ZS, Briggs, J, Kopeykina, I, Orchard, KM, Silberlicht, J, Bhingradia, H, and Galynker, II. (2013, Sep 22). Distinctive emotional responses of clinicians to suicide-attempting patients - a comparative study. BMC Psychiatry, 13:230.
doi: 10.1186/1471-244X-13-230

Distinctive emotional responses of clinicians to suicide-attempting patients - a comparative study

Zimri S Yaseen, Jessica Briggs, Irina Kopeykina, Kali M Orchard, Jessica Silberlicht, Hetal Bhingradia, and Igor I Galynker - Author Affiliations

Abstract

Background

Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians’ emotional responses to them have not been examined.

Methods

Clinicians’ responses to their patients when last seeing them prior to patients’ suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups.

Results

Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients.

Conclusions

Clinicians’ emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians’ emotional responses to suicidal patients and suicide risk. 

Background

When treating patients at risk for suicide, clinicians often struggle to identify signs, symptoms, or precipitating events that might afford opportunities for them to intervene. Clinically, we remain largely unable to accurately distinguish between patients who will attempt or die by suicide and patients who will not [1,2]. Clinicians’ emotional responses to patients (broadly speaking, their countertransference) have long and increasingly been recognized as an important factor in treatment outcome [3,4], however they have received relatively little attention in the literature on suicidal patients. Rather, current research on acute suicide prediction has focused largely on warning signs that are patient-dependent, such as precipitating events [5-9], behavior changes [10,11], or intense affective states [12-19]. Yet, even though they are easily identified retrospectively, such findings may be difficult to utilize clinically; these markers may be masked and/or minimized by the patient, or misattributed/misinterpreted by the therapist [20-22], and in some cases overzealous efforts at intervention, such as those that prematurely push an unready patient towards independence, even appear to precipitate patient suicide [5].

A potential factor contributing to these difficulties, beyond the general difficulty of predicting human behavior, and external constraints of the current mental health care system (e.g. [23]), may lie in clinicians’ own emotional responses to the suicidal patient. While clinical judgment is ultimately a conscious process, the suicidal patient elicits powerful responses that may not become directly conscious [4,24]. Indeed, neuroimaging studies suggest activation of brain regions primarily involved in unconscious processing during emotional as compared to cognitive empathy tasks [25]. Without (and even with [26]) tremendous experience, unaided conscious integration of unconscious emotional responses is likely to fail. A systematic assessment of these responses, however, has the potential to ameliorate the inherent distortions of the clinician’s judgment without discarding the data inherent in his or her interpersonal experience with the patient.

Clinician-focused research supports distinctive patterns of reaction to various patient types [27-29], and there is a relatively large body of literature examining clinicians’ reactions following patient suicide (e.g., [22,30-32]) and unexpected death [33] which observe prominent reactions of grief and mourning on the one hand [30], and guilt and anger on the other [32,34]. Similarly, clinicians confronted with patients’ desire for death in studies of physician assisted suicide (also only qualitative), elicited anxious, helpless, and overwhelmed responses most prominently [35]. Clinicians’ emotional responses to suicidal patients have not been the subject of many research studies. Since Maltsberger and Buie’s seminal 1974 paper [24], which elaborated an array of emotional experiences and behaviors rooted in different defense responses to negative countertransference towards the suicidal patient, only a few empirical studies have been conducted. These retrospective clinical studies have focused almost exclusively on countertransference hate and/or negative countertransference in general, finding feelings of anxiety and hostility as those most prominently elicited by suicidal patients [34,36]. The studies share a common conclusion that emotional responses must be recognized and acknowledged, and present evidence that the management of the clinicians’ emotional response is correlated with therapeutic outcome [3,22,37]. Quantifying clinicians’ emotional responses may thus potentially enhance suicide risk assessment.

The present preliminary study, though conducted retrospectively, assessed clinicians’ reported emotional responses toward their patients in the encounter preceding their suicide attempt, completed suicide, or unexpected (non-suicide) death, with a focus on quantifying differences in the patterns of clinician response to patients with differing levels or types of suicidality. The goal was to identify potential significant differences in clinicians’ emotional responses to the patients that were at imminent risk for suicidal behavior, compared with those who were not. Ultimately, a thorough understanding of characteristic emotional responses to imminently suicidal patients might allow clinicians to better recognize those responses to their patients that might interfere with taking appropriate measures to prevent imminent suicidal actions, or that in themselves may serve as warning signs of imminent suicidality.
 

Methods

An anonymous web-based survey (implemented through the surveymonkey.com website) was distributed to psychiatrists, psychologists, and social workers at the Beth Israel Medical Center in New York City via a department-wide email message requesting participation including the link to the anonymous survey. Participation occurred on a voluntary basis and participants had the ability to discontinue at any time. Participants were informed of the nature of the study in the email message inviting them to complete the survey. The study was approved by the Beth Israel Medical Center Institutional Review Board.

The survey consisted of the Therapist Response/Countertransference Questionnaire (CQ) – a 79-item self-report measure designed for clinicians which provides a validated instrument for assessing countertransference patterns in the psychotherapeutic setting [29], as well as questions regarding the demographic and clinical characteristics of the clinicians and the patients they reported on. The CQ has eight defined subscales (found to be independent of clinicians’ theoretical orientation): overwhelmed-disorganized (coefficient alpha = 0.90) “marked by items indicating a desire to avoid or flee the patient and strong negative feelings, including dread, repulsion, and resentment”, helpless-inadequate (coefficient alpha = 0.88), “describing feelings of inadequacy, incompetence, hopelessness, and anxiety”, positive (coefficient alpha = 0.86), “indicating the experience of a positive working alliance and close connection with the patient”, special-over-involved (coefficient alpha = 0.75), “describing a sense of the patient as special, relative to other patients, and … ‘soft signs’ of problems in maintaining boundaries”, sexualized (coefficient alpha = 0.77), “describing sexual feelings toward the patient or … sexual tension”, disengaged (coefficient alpha = 0.83), “describing feeling distracted, withdrawn, annoyed, or bored”, parental-protective (coefficient alpha = 0.80), “describing a wish to protect and nurture the patient in a parental way… beyond normal positive feelings”, and criticized-mistreated (coefficient alpha = 0.83), “describing feelings of being unappreciated, dismissed, or devalued” [29]. The CQ was used to assess countertransference in clinicians across four different patient categories: suicide completers, high-lethality suicide attempters (as indicated by clinical judgment and/or necessity for hospitalization), low-lethality suicide attempters (as indicated by clinical judgment), and patients who suffered sudden (unexpected) non-suicide death. The order of patient category presentation was randomized for each respondent. In each patient category the clinicians were prompted to fill out the questionnaire based on their experiences in regard to “the patient you remember best” in the last session preceding their suicide attempt or death. This prompt was chosen to elicit what, in the absence of prospective data, should be the most reliable. [38] If a clinician reported having treated a patient in more than one category, a separate CQ was filled out for each patient category individually. Clinicians were instructed to rate each item on the questionnaire as 1, 3, or 5, based on the extent to which it was true in their work with the patient in question; 1 = not true at all, 3 = somewhat true, and 5 = very true.
 
Statistical analysis

Two group comparisons were performed: 1) any suicidal behavior versus unexpected deaths (SA vs. UD), and 2) high lethality and completed suicide attempts versus low lethality attempts (HL vs. LL). The first comparison was chosen to address the primary aim of the study, identification and quantification of any distinctive clinician response to patients presenting with imminent suicidality. The second comparison addresses a secondary question – ‘are there clinician responses distinctive of high lethality attempters versus low-lethality ones?’ in light of extensive literature suggesting clinical and biological differences between these groups [39]. High lethality attempts and completed suicides were combined as completed suicides result, by definition, from highly lethal attempts.

Unpaired two-tailed t-tests were used to compare group means on each of the eight defined CQ subscales. To assess clinician effects, these group comparisons were repeated restricted to the subsets of clinicians who reported on patients in both groups in each comparison. In the repeated analysis means were compared pair-wise by clinician using paired two-tailed t-tests. We report both conservative estimates of significance, using Bonferroni correction of criterion alphas, and uncorrected estimates, as the Bonferroni correction has been considered inappropriately stringent for medical research, biasing results towards type II error, and thus potentially obscuring useful findings [40].

To identify an effective subscale of items that might best discriminate between suicide attempters and non-attempters, and high versus low lethality attempters, stepwise linear discriminant analyses were used with a threshold p = 0.05 for variable inclusion and p = 0.10 for exclusion in the linear discriminant analysis. In the analysis, cases with no missing values for any scale item were used. Leave-one-out cross-validation of the discriminant function provided a measure of the difference between groups in their responses on the CQ that is robust to over-fitting of the data (and thus false positive findings). All of the above analyses were carried out using the SPSS software package.

In secondary analysis, to account for possible chronic differences in level of suicidal capacity [41] between patients who attempt suicide and those who do not, findings from the above analyses were stratified by presence or absence of a past history of suicide attempt, as a control for the effect of past history of suicidality.

Post hoc power analyses indicate that for the achieved sample sizes the study had 80-95% power to detect moderate to large effects (Cohen’s d = 0.63-0.84) for the “High versus Low Lethality (HL vs. LL)” comparisons of means, and large effects (Cohen’s d = 0.70-0.92) for the “Any Suicidality versus Unexpected Death (SA vs. UD)” comparisons of means at the p < 0.05 probability level. Given the necessarily high level of interpersonal variability in clinicians’ emotional reactions to patients, large effects are those of greatest clinical interest.
 

Results

Sample characteristics

Two hundred clinicians received the invitation email with the survey link. 83 (42%) clinicians began the web-based survey, and 40 (20% of those approached, 48.2% of those responding) provided CQ reports on a total of 82 patients. The clinicians assessed in the study showed a near equal split between males and females, and held a variety of higher-level degrees; though the most common by far was an MD (50%). A small majority of the clinicians assessed had been in practice for less than five years or more than twenty; those who had been practicing for between five and twenty years were slightly less likely to complete the questionnaire (See Table 1).

Table 1. Clinician demographics

Of 82 reports assessed, 16 were regarding patients that died unexpectedly, 26 were on patients who made low lethality suicide attempts, 28 were on patients that made high lethality suicide attempts, and 12 were on suicide completers. Patients who made suicide attempts (of any lethality level) were generally younger than those who completed suicide or died unexpectedly (independent groups t-test 2-tailed p = 0.01). Those who made low lethality suicide attempts were predominantly female (76%), while those in the other three groups were closer to evenly split along gender lines (chi square p = 0.04). In all four groups, the patients assessed were predominantly white (no significant differences using chi square statistics). Finally, the groups of patients who attempted suicide had more members with a history of past suicide attempt than members without such a history. Conversely, more of the patients who died unexpectedly did not have a history of suicide attempt, and the patients who completed suicide were evenly split. These group differences were not statistically significant (using chi square statistics) however (See Table 2).

Table 2. Patient demographics

Group contrasts -- SA vs. UD

For the SA vs. UD group comparison of the mean scores on each of the eight defined subscales of the Therapist Response/Countertransference Questionnaire, one subscale differed significantly and one approached significance. Mean scores were 5.95 points (p = 0.005, criterion alpha corrected for 8 comparisons = 0.0063) higher on the “Overwhelmed/Disorganized” subscale, and 2.54 points (p = 0.054) higher on the “Hostile/Mistreated” subscales for the SA group. No differences approached significance on the other subscales. Thirteen clinicians reported on both SA and UD patients. T-test comparison of SA versus UD means for each subscale paired by clinician replicated the overall results with mean difference 7.00 points (p = 0.023) on the “Overwhelmed/Disorganized” subscale and 2.77 points (p = 0.056) on the “Hostile/Mistreated” subscale, and no differences approaching significance (p < 0.1) on the other subscales.

Eight individual questionnaire items differed significantly (using uncorrected criterion alpha = 0.05) between the SA and UD groups. The strongest effects were found for positive (in the sense of affiliative or approach-promoting) therapist response items, which, though generally rated highly, had significantly lower ratings for suicidal patients. Likewise, negative (in the sense of aggression or withdrawal-promoting) therapist response items were rated more highly for suicidal patients than for non-attempters, though in both cases the means fell between “somewhat” and “not at all”. For suicidal patients, mean score on the item “I liked him/her very much” was higher than that for any other item differing significantly from non-attempters. Self-report of sexualized therapist response was very low for all groups of patients; it was lower for patients that attempted or completed suicide than for non-attempters, however this difference may be driven by outliers in light of the small variances in the samples. No items differed with p-value less than criterion alpha corrected for 79 comparisons (alpha = 0.0006) (See Table 3).

Table 3. CQ items differing most strongly for SA vs. UD comparison

When analysis was stratified by history of past suicide attempts we found that of these eight items, among patients with no past history of suicide attempt, the differences remained statistically significant for all but two items: “24. I felt guilty about my feelings toward him/her” and item “5. I returned his/her phone calls less promptly than I did with my other patients”. Among patients with a past history of suicide attempt, no difference in means was statistically significant. This analysis was limited by the small number (4 patients) of patients in the UD group with a history of past suicide attempt(s).

Stepwise linear discriminant analysis for the SA vs. UD group comparison produced a discriminant function derived from scores on five items: “1. I am very hopeful about the gains s/he is making or will likely make in treatment”, canonical discriminant function coefficient 0.498, SA > UD, “23. S/he makes me feel good about myself”, coefficient −0.939, SA < UD, “52. I feel hopeless working with him/her”, coefficient −0.672, SA < UD, “70. I return his/her phone calls less promptly than I do with my other patients”, coefficient 0.629, SA > UD, and “79. I talk about him/her with my spouse or significant other more than my other patients”, coefficient 0.563, SA > UD. The discriminant function thus describes a combination of greater avowed hopefulness combined with more negative feelings about self, avoidance of the patient, and comfort seeking behavior by the clinician in treating suicidal patients. This discriminant function classified SA vs. UD patients with an 87.8% cross-validated correct classification rate (Chi-squared = 23.58, p < 0.0001), with 90% sensitivity and 56% specificity for suicidal patients (See Table 4).

Table 4. Discriminant analysis classification table: UD vs. SA

T-test comparison of SA versus UD means for discriminant function score, paired by clinician, replicated the overall results with a highly significant mean difference 1.77 points (p = 0.0003).

Further, when this analysis was stratified by history of SA, the discrimination was significant both when history of SA was present and when it was not. When history of SA was present, the cross-validated correct classification rate was 97.1% (Chi-squared = 21.71, p = 0.001), with sensitivity of 100% and specificity of 66.7% for suicidal patients. When history of SA was not present, the cross-validated correct classification rate was 78.8% (Chi-squared = 12.76, p = 0.026), with sensitivity of 84.0% and specificity of 62.5% for suicidal patients.
 
Group contrasts -- HL vs. LL

In the HL vs. LL group comparison of the mean scores on each of the eight defined subscales of the Therapist Response/Countertransference Questionnaire, no significant differences were found. The greatest difference in means was found for the “Positive/Satisfying” response scale, which was 2.6 points higher for the HL group (p = 0.18).

In clinician-wise paired t-tests on matched cases from 17 clinicians reporting on both HL and LL patients no significant differences were found. The greatest mean difference was found for the “Parental/Protective” subscale which averaged 3.1 points higher for the HL group (p = 0.07).

Comparison of the mean scores on each item of the Therapist Response/Countertransference Questionnaire found one item – “49. I felt sad in sessions with him/her” that differed with p < 0.05 between HL and LL groups (means 2.69 and 1.82, respectively; p = .024). In clinician-wise paired t-test means for this item were 2.82 and 1.94 respectively, p = 0.039. When analysis was stratified by history of past suicide attempts, we found that the mean score on item “49”differed significantly between HL and LL groups only for patients who had a past history of SA (means 3.00 and 1.43, respectively; p = .001). No items differed significantly after Bonferroni correction for 79 comparisons.

Four CQ items describing depression, guilt and helplessness had strong correlations (r > 0.5) with this item: “18. I feel depressed in sessions with him/her” (r = 0.665), “28. I feel guilty when s/he is distressed or deteriorates, as if I must be somehow responsible” (r = 0.575), “24. I feel guilty about my feelings toward him/her” (r = 0.528), and “26. I feel overwhelmed by his/her strong emotions” (r = 0.508). Group means for these items did not differ between groups at the 0.05 significance level, however, and they were thus excluded from the discriminant analysis.

Stepwise linear discriminant analysis for the HL vs. LL group comparison thus produced a discriminant function derived from scores on the single item – “49. I felt sad in sessions with him/her” – that classified high lethality suicidal behavior (high lethality attempts and completed suicides) versus low lethality suicide attempts with modest but statistically significant power. The cross-validated correct classification rate was 66.7% (Chi-squared = 5.19, p = 0.023), with sensitivity of 70% and specificity of 61.5% for high lethality and completed suicide. Application of the discriminant function to patients with unexpected non-suicide death resulted in random assignment of predicted group membership (50% predicted to each group) (See Table 5).

Table 5. Discriminant analysis classification table: HL vs. LL

When this analysis was stratified by history of SA, the discrimination was significant only when a past history of SA was present. Among patients with a past history of suicide attempts, the cross-validated correct classification rate was improved to 76.5% (Chi-squared = 10.86, p = 0.001), with sensitivity of 75% and specificity of 78.6% for high lethality and completed suicide.
 

Discussion

To the best of our knowledge, this is the first published study to provide a quantitative comparison of clinician responses to acutely suicidal patients versus non-attempters and to patients who made high lethality versus low-lethality suicide attempts.

Such investigation is important, as problems in the management of countertransference (or emotional reactions in general) to patients may hamper treatment efficacy and even contribute to patient suicide in a small but significant proportion of cases [5,36]. To date though, the literature has focused almost entirely on the development of qualitative treatments of the subject. A thorough literature search using the PsycINFO database resulted in our conclusion that there are no analogous studies in the literature. (Searches conducted using varied combinations of terms including “countertransference”, “suicide”, “therapist response”, “clinician response”, “predict”, “prevention”, “comparison”, and “quantitative” identified no peer-reviewed publications reporting on quantitative comparisons of clinician responses to suicidal versus non-suicidal patients or of patients with differing levels of suicidality). The only quantitative comparative work we have been able to find on the subject has been a small series of unpublished dissertations, which found no significant differences in negative therapist responses to suicidal versus “difficult” non-suicidal patients [42]. While rich qualitative data are an essential starting point, this preliminary study aimed to pilot a much-needed quantitative and comparative approach using a validated instrument and easily replicable quantitative methodology.

This study found that clinicians treating imminently suicidal patients recalled, on average, moderately positive feelings towards these patients (though less so than for non-attempters), with higher hopes for treatment, while finding themselves more overwhelmed, distressed by, and, at low levels, avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who had unexpected non-suicide deaths, and cross-validated classification by discriminant analysis remained statistically significant both when a past history of suicide attempt was present and when it was not. This finding of ‘paradoxical response’ is consistent with the higher scores observed on the “overwhelmed-disorganized” subscale of the CQ in clinician recollections of their encounters with suicide attempters.

In our second comparison, we found no clear evidence of differences between clinicians’ responses in encounters with patients preceding either completed suicides or highly lethal suicide attempts and their responses in encounters preceding low lethality suicide attempts. Despite a trend towards a slightly more positive emotional responses overall, clinicians also recalled experiencing more sadness in encounters with patients preceding either successful or highly lethal suicide attempts than in encounters preceding low lethality suicide attempts. This difference in recalled sadness was found to be a modest discriminator between patients that went on to exhibit high and low lethality suicidal behavior. It is worth noting, however, that this difference appears attributable specifically to recalled responses to patients with a history of previous attempts; among these patients sadness in session was a significant discriminator of attempt lethality while among first-time attempters clinicians’ experience of sadness in the session prior to suicide attempt did not differentiate between lethality levels. This finding has not been supported or opposed in the literature, as the difference in emotional response to high and low lethality suicide attempters has not previously been explored. Further, interpretation is limited by significant risk of type-1 error given the small n’s and multiple comparisons involved.

Thus our findings, while grossly consistent with the qualitative literature findings of negative responses to suicidal patients [34,36], differed in the important respect that the levels of recalled negative reactions to patients prior to their suicide attempts were, on average, fairly low, and even when significant, the magnitude of the differences in positive and negative responses elicited by suicidal versus non-suicidal patients was small. Maltsberger and Buie [24] were the first to describe in detail the negative countertransference (“countertransference hate”) that clinicians may experience in response to suicidal patients, and provided a theoretical framework which might account for our quantitative findings. First, as noted, we found that clinicians recalled fairly low levels of negative feelings towards their suicidal patients, though positive response was attenuated compared to non-attempters. This finding may be consistent with their predictions of repression of “countertransference hate”. On the other hand, our findings of distress and self-directed negative feelings combined with paradoxical hopefulness may be consistent with their predictions of turning of the countertransferential hate against the self and of reaction-formation against it, respectively. Indeed, our findings seem to suggest that the defense mechanisms described by Maltsberger and Buie may operate in concert.

Our findings point to the potential clinical utility of self-assessment of emotional response in the treatment of suicidal patients. This is a matter of some importance as both Modestin [36] and Marcinko et al., [22] have used observational evidence to support the theory that emotional responses to suicidal patients that are not properly managed can have harmful consequences. The latter group concluded that negative emotional response probably contributes to or correlates with negative patient outcomes [22], while Modestin, further indicates how the failure to control these reactions (hostility, hate, and aggressiveness in particular) may in some cases help push patients to suicide [36].

We should note, however, that while both emotional responses and judgments of suicide risk reside in the clinician, they are not the same. Indeed clinical judgment has been found to be a poor predictor of critical patient behavior such as suicide [1] and violence [43]. While clinical judgment is ultimately a conscious process, emotional responses may not become directly conscious [4,24]. Thus systematic assessment of these responses, even in using self-report measures may reveal patterns generated by the clinician’s unconscious processes such as the “paradoxical hopefulness” identified using discriminant analysis. Quantitative self-report assessment may thus reveal data inherent in the clinician’s interpersonal experience with the patient that could potentially augment suicide-risk assessment.

Limitations

The results of this preliminary study must be considered in light of several important limitations. Most prominently the study is subject to several kinds of recall bias.

First, many clinicians that have experienced a patient’s death by suicide report severe distress [32] and/or feelings of grief and self-doubt [31] stemming from treatment decisions that seem, in retrospect, to have been based on inaccurate assessments of the patient’s acute risk. Differences between such responses to patients’ suicide deaths, attempts of different severity, and unexpected non-suicide deaths have not been studied and are poorly understood [33]. It is possible that the differences in recalled reaction to patients in the encounters preceding such events are attributable to their recollection being colored differently by those very events. Furthermore, individual items in the CQ might be differently subject to such effects thereby increasing or decreasing their apparent discriminatory power in our results.

Second, clinicians’ recollection of their responses to their patients in the encounters immediately preceding such events are almost certainly significantly combined with the rest of their preceding experience with those patients. Thus our findings cannot be interpreted as necessarily indicative of a “pre-suicidal” countertransference or emotional response.

Third, we are unable to control for the possible effects of clinicians’ reporting on their best-remembered patient of each type. Additionally, we were not able to control for the effects on recall of time elapsed since the events.

Fourth, as we were unable to obtain responses on each category of patient from most clinicians, it is possible that clinicians responding on suicidal patients we more likely to treat suicidal patients and thus represented a distinct group from those responding regarding non-suicidal patients only. Thus it is conceivable that differences in response are attributable to clinician differences rather than patient ones. However, the consistency between aggregate group findings and the within-clinician findings, for those clinicians who reported on patients belonging to different comparison groups, makes such an interpretation less likely.

Further, because the survey was distributed only within one institution, and was completed voluntarily, we cannot say that it accurately represents all clinicians who have experienced a patients’ completed suicide, attempt, or unexpected death.

Finally, limitations of sample size did not allow for reliable analysis of potential mediators and moderators of differences in therapist responses to patients of different types. Nonetheless it should be noted that no statistically significant differences in the rates of any diagnostic or demographic characteristics were observed between groups.

In sum, our findings must be viewed as preliminary results that justify further research. In order to more definitively verify our conclusions, the study will need to be repeated with a wider, larger sample. Additionally, prospective replication is necessary to confirm the findings.
 

Conclusions

We find preliminary quantitative evidence consistent with Maltsberger and Buie’s theory of countertransference hate in the treatment of suicidal patients. Though our study does not speak to the ability of the differences in response to influence or predict a patient’s outcome, it is the first to quantify the differences in clinicians’ emotional responses to suicidal patients versus non-attempter patients. Our findings thus provide a starting point for further research that may change the way that clinicians assess their suicidal patients’ acute risk, and may justify further research on the use of the CQ or other conceptually similar scales as predictors of suicide risk.
 
Competing interests

The authors declare that they have no competing interests.
 
Authors’ contributions
IK, KMO, JS, HB & IIG participated in the design of the experiment. IK and IIG collected the data. ZSY designed and performed the data analysis. JB and IK prepared the data. ZSY, JB, and IIG participated in the writing of the manuscript. All authors read and approved the final manuscript.
 
Authors’ information
 
Jessica Briggs is co-first author.
 
Acknowledgements
The authors would like to thank the reviewers, Dr. Philip Batterham and Dr. Evan Kleiman for their very helpful editorial input.

References available at the BMC Psychiatry

Jonathan Rowson - The Brains Behind Spirituality (The RSA)

This essay from Dr Jonathan Rowson, Director, RSA Social Brain Centre, was published back in July on the RSA site. Somehow I missed it then. In essence, this essay states the problem and offers a solution - from which they will develop workshops and other events through to test their model. And for what it's worth, it is a very Wilberian model. although his name is not mentioned at all in this essay (from The Marriage of Sense and Soul: Integrating Science and Religion, 1998). Here is a passage:

The spiritual injunction is principally an experiential one, namely to know oneself as fully as possible. For many, that means beginning to see beyond the ego and recognise oneself as being part of a totality, or at least something bigger than oneself.

Such self-knowledge is a deeply reflexive matter. The point is not to casually introspect, but rather to strive to connect our advanced third-person understanding of human nature with a growing skill in observing how one’s first-person nature manifests in practice, and to test the validity and relevance of this experience and understanding in second-person contexts. In this sense, spirituality is about I, we and it, and this process of trying to know oneself more fully, both in understanding and experience, is therefore no mere prelude to meaningful social change, but the thing itself.

These sentences resemble similar lines one might find in Ken Wilber's The Marriage of Sense and Soul, so it would be nice to credit the source, even if only in passing.

It will be interesting to see how they implement these ideas in practice over the coming year.

The Brains Behind Spirituality

July 22, 2013 by Jonathan Rowson
Filed under: Social Brain

The Summer issue of the RSA Journal features the following essay outlining the intellectual context for a new project by the Social Brain Centre. We are examining how new scientific understandings of human nature might help us reconceive the nature and value of spiritual perspectives, practices and experiences. Our aim is to move public discussions on such fundamental matters beyond the common reference points of atheism and religion, and do so in a way that informs non-material aspirations for individuals, communities of interest and practice, and the world at large.

We are currently completing our background research for a series of forthcoming workshops and public events, culminating in a final report in 2014.

The Brains Behind Spirituality

Immanuel Kant said that the impact of liberal enlightenment on our spiritual life was such that if somebody were to walk in on you while you were on your knees praying, you would be profoundly embarrassed. That imagined experience of embarrassment is still widely felt in much of the modern western world, not merely for religious believers, but for the silent majority who consider themselves in some sense ‘spiritual’ without quite knowing what that means. This sense of equivocation is felt when we hear the term ‘spiritual’ referred to apologetically in intellectual contexts. Consider, for instance, ‘the mental, emotional or even spiritual qualities of the work’, or ‘the experience was almost spiritual in its depth and intensity’.

This unease with public discussions of spirituality is not universal and clearly varies within and between countries. Perhaps the embarrassment is a peculiar affliction of western intellectuals, since ‘spiritual’ appears to convey shared meaning perfectly well in ordinary language throughout most of the world. This intellectual unease matters because spiritual expression and identification is an important part of life for millions of people. But it currently remains ignored because it struggles to find coherent expression and, therefore, lacks credibility in the public domain.

“many, perhaps most people, live their lives in a tepid confusing middle ground between strong belief and strong disbelief” – Andrew Marr

Andrew Marr astutely opened a recent BBC discussion by referring to the “increasingly hot-tempered public struggle between religious believers and so-called militant atheists, and yet many, perhaps most people, live their lives in a tepid confusing middle ground between strong belief and strong disbelief”. There is some empirical backing for this claim. Post-Religious Britain: The Faith of the Faithless, a 2012 meta-analysis of attitude surveys by the thinktank Theos, revealed that about 70% of the British population is neither strictly religious nor strictly non-religious, but rather moving in and out of the undesignated spaces in between. While the power of organised Christian religion may be in decline, only about 9% are resolutely atheistic, and it is more accurate to think of an amorphous spiritual pluralism that needs our help to find its form.

The point of rethinking spirituality is not so much to challenge these boundaries, but to clarify what it means to say that the world’s main policy challenges may be ultimately spiritual in nature. When you consider how we might, for instance, become less vulnerable to terrorism, care for an ageing population, address the rise in obesity or face up to climate change, you see that we are – individually and collectively – deeply conflicted by competing commitments and struggling to align our actions with our values. In this respect, we are relatively starved for forms of practice or experience that might help to clarify our priorities and uncover what Harvard psychologist Robert Kegan calls our immunity to change. The best way to characterise problems at that level is spiritual.

There are so many dimensions to spirituality that it is necessary to qualify what we are talking about. Personally, I think of it principally as the lifelong challenge to embody one’s vision of human existence and purpose, expressed most evocatively in Gandhi’s call to be the change you want to see in the world. Others may place greater emphasis on the forms of experience that inspire the changes we want to see, or the realities we need to accept.

Personally, I think of the spiritual principally in terms of the lifelong challenge to embody one’s vision of human existence and purpose, expressed most evocatively in Gandhi’s call to be the change you want to see in the world.

Being spiritual can mean safeguarding our sense of the sacred, valuing the feeling of belonging or savouring the rapture of intense absorption. And then there is the quintessential gratitude we feel when we periodically notice, as gift and revelation, that we are alive.

Such experiences do not depend upon doctrine or on institutional endorsement or support. They are as likely to arise listening to music, walking in nature, celebrating the birth of a child, reflecting on a life that is about to end, or losing oneself – in a good sense – in the crowd. With such a rich range of dimensions, it is regrettable that spirituality is still framed principally through the prism of organised religion. But it is perhaps no less unfortunate that those who value spiritual experience and practice are often suspiciously quick to disassociate themselves from belief in God and religion, as if such things were unbearably unfashionable and awkward, rather than perhaps the richest place to understand the nature of spiritual need.

Spiritual but not religious

While there has been a growing normalisation of the idea that a person can be ‘spiritual but not religious’, this designation may actually compound the problem of intellectual embarrassment. It does nothing to clarify what spirituality might mean outside of religious contexts, nor how religion might valuably support and inform non-believers. People in this category get attacked from both sides; from atheists for their perceived irrationality and wishful thinking, and from organised religion for their rootless self-indulgence and lack of commitment. And the category of spiritual but not religious hardly does justice to the myriad shades of identification and longing within it and outside it. What are we to make, for instance, of the fact disclosed in the same Theos report, that about a quarter of British atheists believe in human souls?

Such findings highlight that spiritual embarrassment is grounded in confusion about human nature and human needs. We struggle to speak of the spiritual with coherence mostly because it has been subsumed by historical and cultural contingency, and is now smothered in an uncomfortable space between religion and the rejection of religion. Surely religions are the particular cultural, doctrinal and institutional expressions of human spiritual needs, which are universal? In this respect, is it not the sign of a spiritually degenerate society that many feel obliged to define their fundamental outlook on the world in such relativist and defensive terms? Compare the designations: ‘educated, but not due to schooling’ or ‘healthy, but not because of medicine’.

There must be a better place to begin the inquiry. The categorisation spiritual but not religious still tacitly assumes the most important question to interrogate is which version of reality we should subscribe to, rather than what it might mean to grow spiritually in a societal context where for most people belief in God need feel neither axiomatic nor problematic. The writer Jonathan Safran Foer highlighted the depth of this point on BBC Radio 4’s Start the Week programme when he responded to the question of what he believed by saying: “I’m not only agnostic about the answer, I’m agnostic about the question.”

Reconceiving spirituality 


One major challenge in making the spiritual more tangible and tractable is, therefore, to enrich our currently impoverished idea of what it means to believe. To believe something is often assumed to mean endorsing a statement of fact about how things are, but that is both outdated and unhelpful.

Consider the story of two rabbis debating the existence of God through a long night and jointly reaching the conclusion that he or she did not exist. The next morning, one observed the other deep in prayer and took him to task. “What are you doing? Last night we established that God does not exist.” To which the other rabbi replied, “What’s that got to do with it?”

The praying non-believer illustrates that belief may be much closer to what the sociologist of religion William Morgan described as “a shared imaginary, a communal set of practices that structure life in powerfully aesthetic terms”. Within the same discipline Gordon Lynch suggests this point needs deepening: “The unquestioned status of propositional models of belief within the sociology of religion arguably reflects 
a lack of theoretical discussion… about the nature of the person as a social agent.”

It is therefore time to question the common default position that emphasises the autonomous individual striving to consciously construct their own religious belief system as a guide to how they should act in the world. It is not just about sociality. The emerging early 21st century view of human nature indicates we are fundamentally embodied, constituted by evolutionary biology, embedded in complex online and offline networks, largely habitual creatures, highly sensitive to social and cultural norms, riddled with cognitive quirks and biases, and much more rationalising than rational.

It is time to question the common default position that emphasizes the autonomous individual striving to consciously construct their own religious belief system as a guide to how they should act in the world.

Such a shift in perspective is important because every culturally sanctioned form of knowledge contains an implicit injunction. The injunction of science is to do the experiment and analyse the data. The injunction of history is to critically engage with primary and secondary sources of evidence. The injunction of philosophy is to question assumptions, make distinctions and be logical. If spirituality is to be recognised as something with ontological weight and social standing, it also needs an injunction that is culturally recognised, as it was for centuries in the Christian west and still is in many societies worldwide.

The spiritual injunction is principally an experiential one, namely to know oneself as fully as possible. For many, that means beginning to see beyond the ego and recognise oneself as being part of a totality, or at least something bigger than oneself.

Such self-knowledge is a deeply reflexive matter. The point is not to casually introspect, but rather to strive to connect our advanced third-person understanding of human nature with a growing skill in observing how one’s first-person nature manifests in practice, and to test the validity and relevance of this experience and understanding in second-person contexts. In this sense, spirituality is about I, we and it, and this process of trying to know oneself more fully, both in understanding and experience, is therefore no mere prelude to meaningful social change, but the thing itself.

The spiritual injunction is principally an experiential one, namely to know oneself as fully as possible.

There are many ways to illustrate how new conceptions of human nature might revitalise our appreciation for the spiritual. The psychiatrist Iain McGilchrist’s work on the competing worldviews of the two brain hemispheres offers a new perspective on the challenge of creating balance in one’s thought and life. Daniel Kahneman, the Israeli-American psychologist, has suggested that we can’t really do anything about our innumerable cognitive frailties, but this questionable claim is challenged by mindfulness practices, where we can see and feel the root cause of some of our mental tendencies and biases more viscerally. And cognitive scientists George Lakoff and Mark Johnson’s idea that thinking is fundamentally grounded in bodily metaphors gives us new appreciation for our need to be touched, moved or inspired on a regular basis.

The point of reconsidering spirituality through such lenses is not to explain away spiritual content. We do not want to collapse our deliciously difficult existential and ethical issues into psychological and sociological concepts. The point is rather to explore the provenance of those questions and experiences with fresh intellectual resources.

Returning to Kant, if enlightenment in his view was about humanity emerging into adulthood, one corollary is that unquestioning subservience to organised religion may now be condemned as immature. However, the deeper implication is that we need to rediscover or develop mature forms of spirituality, grounded both in what we can never really know about our place in the universe, and what we can know – and experience – about ourselves.

By Dr Jonathan Rowson, Director, RSA Social Brain Centre. Follow @Jonathan_Rowson

Mark Vernon - The Evolution of Consciousness (The Institute of Art and Ideas)

 

Cool video talk from philosopher, author, blogger Mark Vernon from the 2012 How the Light Gets In Conference sponsored by The Institute of Art and Ideas.

An Author and ex-clergyman, Mark Vernon is now agnostic. He’s written books on friendship, well-being, God, spirituality, science and the philosophy of the everyday. His articles and reviews on religious, philosophical and ethical themes have appeared in many newspapers and magazines. He has degrees in physics, theology and a PhD in philosophy, and regularly contributes to debates and festivals, also teaching at The Idler Academy in London.


He is the author of several books, including How To Be An Agnostic (2011), What Not to Say: Philosophy for Life's Tricky Moments (2009), and 42: Deep Thought on Life, the Universe, and Everything (2008) [gotta love a philosopher who pays homage to Douglas Adams in his book title]. 


Here are links to all of Mark Vernon's videos at the IAI: Sex Machines, Buddhists in Suburbia, Gods and Monsters, How to be Agnostic, and The Evolution of Consciousness.

The Evolution of Consciousness

Mark Vernon

We understand that our bodies evolve, but does consciousness evolve too? Mark Vernon investigates the transformative ideas of Owen Barfield.

"Thoughtful, accessible, lucid" ~ Julian Baggini

Tracy Brandmeyer and Arnaud Delorme - Meditation and Neurofeedback

This is a very cool open access article from Frontiers in Psychology: Consciousness Research on the interplay of meditation and neurofeedback. In addition to discussing the current uses of neurofeedback devices for clinical and contemplative training, they also touch on the limitations of the current technology, which relies almost entirely on electro-encephalography (EEG) measures that are not highly reliable , so far, in either clinical or contemplative uses.

But with better technology, good things are possible:

Assuming that reliable and reproducible EEG signatures are associated with specific meditation practices, we may expect that training subjects to reproduce these signatures would support and strengthen their meditation practice. Clinical neurofeedback protocols are aiming toward comparing patients' EEG with large EEG data sets from normal subjects in order to produce a neurofeedback algorithm which rewards subjects (patients) whose EEG becomes closer to that of the normal population (Thornton and Carmody, 2009). Similarly, it might be possible to train users to make their EEG brainwaves similar to the brainwaves of an expert practitioner in a given meditation tradition.

The article is worth a few minutes to read.

Full Citation: 
Brandmeyer T, and Delorme A. (2013, Oct 7). Meditation and neurofeedback. Frontiers in Psychology: Consciousness Research, 4:688. doi: 10.3389/fpsyg.2013.00688

Meditation and neurofeedback

Tracy Brandmeyer [1,2] and Arnaud Delorme [1,2,3,4]

1. Centre de Recherche Cerveau et Cognition, Paul Sabatier University, Toulouse, France
2. CerCo, Centre National de la Recherche Scientifique, Toulouse, France
3. Swartz Center for Computational Neuroscience, Institute of Neural Computation (INC), University of California San Diego, San Diego, CA, USA
4. Institute of Noetic Sciences, Petaluma, CA, USA

Dating back as far as 1957, the academic investigation of meditation and the Asian contemplative traditions have fascinated not only the likes of philosophers and religious scholars, but researchers in the fields of neuroscience, psychology, and medicine. While most of the contemplative traditions are comprised of spiritual practices that aim to bring the practitioner closer to self-actualization and enlightenment, from a neuroscientific and clinical perspective, meditation is usually considered a set of diverse and specific methods of distinct attentional engagement (Cahn and Polich, 2009).

Over the last decade, we have witnessed an exponential increase in the interest in meditation research. While this is in part due to improvements in neuroimaging methods, it is also due to the variety of medical practices incorporating meditation into therapeutic protocols. With the general aim of understanding how meditation affects the mind, brain, body and general health, particularly interesting findings in recent research suggest that the mental activity involved in meditation practices may induce brain plasticity (Lutz et al., 2004).

With its increasing popularity, many people in Western societies express an interest and motivation to meditate. However, for many it can often be quite difficult to maintain a disciplined and/or regular practice, for various reasons, ranging from a lack of time to general laziness. It is possible that machine assisted programs such as neurofeedback may help individuals develop their meditation practice more rapidly. Methods such as neurofeedback incorporate real-time feedback of electro-encephalography (EEG) activity to teach self-regulation, and may be potentially used as an aid for meditation.

While Neurofeedback and Biofeedback have been used since the 1960's, previous neuroscientific and clinical research investigating its efficacy has been limited, lacking controlled studies and significant findings (Moriyama et al., 2012). However, a recent overview of the existing body of literature on neurofeedback research has now led the American Academy of Pediatrics to recognize Neurofeedback, as well as working memory training, as one of the most clinically efficacious treatments for children and adolescents with attention and hyperactivity disorders (ADHD) (Dename, 2013). Neurofeedback has been used to treat a wide variety of other disorders such as insomnia, anxiety, depression, epilepsy, brain damage from stroke, addiction, autism, Tourette's syndrome, and more (Tan et al., 2009; Coben et al., 2010; Cortoos et al., 2010; Messerotti Benvenuti et al., 2011; Mihara et al., 2013). As with all therapeutic interventions it is important to note that individuals who are seeking neurofeedback for diagnostics or for clinical and medical purposes seek qualified and licensed practitioners, as adverse effects of inappropriate training have been documented (Hammond and Kirk, 2008).

Interestingly, many of the conditions that benefit from Neurofeedback treatment are consistent with the conditions that improve with regular meditation practice. For example, both ADHD patients and individuals diagnosed with depression benefit from meditation training (Hofmann et al., 2010; Grant et al., 2013) as well as neurofeedback training protocols (Arns et al., 2009; Peeters et al., 2013). In addition, both meditation and neurofeedback are methods of training mental states. Thus, it is plausible that the mental training involved in meditation may be fundamentally no different than other types of training and skill acquisition that can induce plastic changes in the brain (Lazar et al., 2005; Pagnoni and Cekic, 2007).

One hypothesis to explain the similarity between meditation and neurofeedback is that both techniques facilitate and improve concentration and emotion regulation, for which both attentional control and cognitive control are necessary. When one aims to alter attentional control, one must learn to manipulate the amount of attention that is naturally allocated to processing emotional stimuli. Similarly, when an individual is attempting to exercise or gain some form of cognitive control they must alter their expectations and judgments regarding emotional stimuli (Braboszcz et al., 2010; Josipovic, 2010). These core principles are central to both meditation and neurofeedback, with the distinguishing feature being that meditation is self-regulated, and neurofeedback is machine aided. It is worth noting that the alpha and theta frequency bands trained in most cognitive enhancement neurofeedback protocols (Zoefel et al., 2011) share many similarities with the EEG frequency bands that show the most significant change during the early stages of meditation practice (Braboszcz and Delorme, 2011; Cahn et al., 2013).

The integration between meditation and neurofeedback has already happened in popular culture. Numerous neurofeedback companies already provide so-called “enlightenment” programs to the public. The programs developed by these companies, however, are not all based on the scientific study of meditation and/or neurofeedback, and the reliability and accuracy of signal detection in many of the portable devices currently on the market remains questionable. While many of these companies are relying on the intuitions of their founders for various neurofeedback protocols, it is necessary for these programs to adopt a more rigorous scientific approach, such as those developed for clinical patients being treated using neurofeedback (Arns et al., 2009).

Assuming that reliable and reproducible EEG signatures are associated with specific meditation practices, we may expect that training subjects to reproduce these signatures would support and strengthen their meditation practice. Clinical neurofeedback protocols are aiming toward comparing patients' EEG with large EEG data sets from normal subjects in order to produce a neurofeedback algorithm which rewards subjects (patients) whose EEG becomes closer to that of the normal population (Thornton and Carmody, 2009). Similarly, it might be possible to train users to make their EEG brainwaves similar to the brainwaves of an expert practitioner in a given meditation tradition. Note that we do not argue that the task of the user should be only to up-regulate or down-regulate their EEG. Instead, they would perform a meditation practice and the neurofeedback device would act in the periphery, providing users with feedback on how well they are doing. For this to be feasible, there needs to be a clear identification of the EEG neural correlates of specific meditation techniques and traditions. As evidenced in the literature, there are an abundant number of meditation traditions and styles, many which have vastly differing techniques, methods, and practices. As the mental states associated with particular meditations differ, so does the corresponding neurophysiological activity (Cahn and Polich, 2006). Recent research suggests that complex brain activity during meditation may not be adequately described by basic EEG analyses (Travis and Shear, 2010). Thus, more research and the use of more advanced signal processing tools are needed in order to understand the differences in meditative techniques, and to better define a normative population which EEG brainwaves could be used in a neurofeedback protocol.

Another type of neurofeedback program could help detect mind-wandering episodes. In all of the meditation traditions, practitioners often see their attention drifting spontaneously toward self-centered matters. These attentional drifts are termed mind wandering, and have recently been focused on in neuroscientific research (Braboszcz and Delorme, 2011). Interestingly, in this study on mind wandering, EEG changes in the alpha and theta frequency bands have been observed. A neurofeedback device could provide an alarm to users when their mind starts to wander, therefore supporting and improving upon their meditation practice. Although future research should assess the reliability of these measures to detect single mind wandering episodes, such a neurofeedback system might help support users in their meditation.

Most neurofeedback systems provide auditory or visual feedback that fully engage and demand the attention of the subject. For neurofeedback-assisted meditation, the goal would be to provide subtle cues that do not disturb the subjects' meditation. For example, white noise could be made louder as the subject's EEG departs from the EEG of the normative population of meditators. Similarly, the same white noise amplitude could also reflect the likelihood of the subject's mind wandering. As mentioned earlier, the neurofeedback device would not be a substitute to meditation practice, but rather a means to facilitate and support it in its early to middle states of practice.

Over the last century, and ever more so at present, machines have become extensively integrated into a vast range of human activity. The practice of meditation requires sustained attention that is often hard to achieve for novices, as compared to more advanced practitioners (Brefczynski-Lewis et al., 2003). Therefore, an inspiring application of machine-aided learning may be to help offer alternatives for beginners who struggle with maintaining a regular meditation practice. Learning how to meditate faster and more easily may facilitate access to meditation techniques to a wider audience. Still, it may also be beneficial for more experienced meditators who are interested in deepening their meditation practices. Even the Dalai Lama has publicly stated that he would be the first to use this type of technology, and believes that neuroscience will improve Buddhist practices (Mind and Life Institute, 2004).

This type of application also has the potential of reaching the masses as neurofeedback could be introduced to the domain of smartphones and apps (Szu et al., 2013). In fact, some EEG systems are already compatible with portable and smartphone technology, and it will not be long before we start seeing neurofeedback-based programs for smartphones. Community building over social media using cloud based computing could help users support one another and their meditation practices. In addition to supporting meditation practice, neurofeedback applications can help track the progress of users over weeks and years and assess changes that users may not be consciously aware of, thus encouraging users to pursue their practice. Using neurofeedback to learn meditation truly reflects new, cutting edge science, and via real time feedback we may be able to develop a precise ways to rapidly learn and achieve deeper states of meditation.

In conclusion, it is our belief that mobile neurofeedback systems and protocols that are derived and extend upon meditative traditions and practices offer a promising new direction and platform in mobile technology. These technologies would be not only for people who have taken interest in these kinds of practices or people who have already established themselves in a meditative practice, but for people who are looking for new methods to train, improve, and develop attention and emotion regulation. We want to emphasize that neurofeedback should be used as an aid to meditation while people perform their meditation and not as a replacement to meditation, and that while these devices may aid and assist those in their meditative practices, the goal of these practices themselves is ultimately the decrease of reliance on objects and constructs that provide support. This type of research should also integrate neurophenomenological approaches that take into account first-person reports of subjective experience in conjunction with the experimental investigation of brain activity (Braboszcz et al., 2010; Josipovic, 2010). Real time feedback of brain activity as implemented in neurofeedback may help develop new frameworks for the scientific investigation of embodied consciousness and the interactions between mind and body.

Acknowledgments

This research was supported by a grant from the Agence Nationalle pour la Recherche (ANR-12-JSH2-0009-03).

References available at the Frontiers site.

Owen Flanagan - The Shame of Addiction

 

From the open source Frontiers in Psychiatry: Addictive Disorders and Behavioral Dyscontrol, philosopher Owen Flanagan, author of The Really Hard Problem: Meaning in a Material World and The Problem Of The Soul: Two Visions Of Mind And How To Reconcile Them, among others, this is an interesting examination of the notion of shame and addiction.

According to Flanagan (from the Abstract), addiction involves twin normative failures:

A failure of normal rational effective agency or self-control with respect to the substance; and shame at both this failure, and the failure to live up to the standards for a good life that the addict himself acknowledges and aspires to. 

Flanagan feels that feeling shame around an addiction is a natural part of the addiction and should not be dismissed as a part of the motivation to heal. 

Like other recent attempts in the addiction literature to return normative concepts such as “choice” and “responsibility” to their rightful place in understanding and treating addiction, the twin normative failure model is fully compatible with investigation of genetic and neuroscientific causes of addiction. Furthermore, the model does not re-moralize addiction. There can be shame without blame.

This is a lengthy piece, but it is very interesting.

Full Citation:
Flanagan, O. (2013, Oct 8). The shame of addiction. Frontiers in Psychiatry: Addictive Disorders and Behavioral Dyscontrol; 4:120. doi: 10.3389/fpsyt.2013.00120

The shame of addiction

Owen Flanagan

Department of Philosophy, Duke University, Durham, NC, USA

Abstract

Addiction is a person-level phenomenon that involves twin normative failures. A failure of normal rational effective agency or self-control with respect to the substance; and shame at both this failure, and the failure to live up to the standards for a good life that the addict himself acknowledges and aspires to. Feeling shame for addiction is not a mistake. It is part of the shape of addiction, part of the normal phenomenology of addiction, and often a source of motivation for the addict to heal. Like other recent attempts in the addiction literature to return normative concepts such as “choice” and “responsibility” to their rightful place in understanding and treating addiction, the twin normative failure model is fully compatible with investigation of genetic and neuroscientific causes of addiction. Furthermore, the model does not re-moralize addiction. There can be shame without blame.

“Dear friends, be men; let shame be in your hearts … Among men who feel shame, more are saved than die.” Ajax to his troops in Homer’s Illiad

The Twin Normative Failure Model of Addiction

I propose a twin normative failure model of addiction in which the self-regarding reactive attitudes of bewilderment, disappointment, and shame play a constitutive role1. The addict cannot pass her own survey because she self-interprets, and self-interprets correctly, that she fails to execute normal powers of effective rational agency, she decides not to use and uses; she also fails to live up to the hopes, expectations, standards, and ideals she has for a good life for herself because of her addiction. It is possible and desirable to understand addiction as a normative failing in both these respects, one of rational effective agency, the second of moral quality broadly construed, without also moralizing addiction. Recognition of these twin normative failures is a powerful source of desperation and motivation to heal on the part of the addict and an immensely valuable tool for the therapeutic community to keep in view and use non-moralistically, as it tries help the addict to heal. In earlier times, it may have been that most addicts died for reasons related to addiction. Now, perhaps, with much deeper knowledge of the causes, components, effects, and nature of addiction we can make Ajax’s maxim true for addicts: “Among men who feel shame, more are saved than die.”

I intend the twin moral failure analysis to be true to the perspective of the addict, his close relations, as well as from the perspective of the professional and non-professional therapeutic communities that work and live with addicts. I also intend the analysis to describe normal and reliable features of addiction. The exceptions, the cases where there is no shame on the part of the addict descriptively, and where shame would be unwarranted normatively involve abnormal psychiatric conditions, e.g., schizoid personality disorder, or unusual social conditions where there are no choice-worthy options for a good human life, or where the addict has a certain social status, social permission (opiate addicts in hospice), and/or financial resources to be an addict with impunity.

To many, the view will seem too strong in two respects. First, some addicts are willing and not ashamed, so the view is descriptively false. Second, the view is reactionary: despite my claim that the twin normative failure model does not moralize addiction because it acknowledges shame without endorsing blame, it nonetheless returns us to the view that addiction is a moral failing. After spelling out the view more fully, I reply to these and several other objections.

Addiction is a Normative Disorder

In a seminal paper in philosophy and cognitive science, “Intentional Systems,” Dennett (1) distinguished between three stances we commonly take toward ourselves and other human beings, the “intentional stance,” the “design stance,” and the “physical stance.” From the perspective of the intentional stance we deploy psychological or mental vocabulary to describe, explain, and predict our own mental states and actions and those of others. We think of ourselves and our fellows as “intentional systems,” as human individuals chock full of beliefs, desires, emotions, and goals. And we think of a particular integrated suite of embodied intentional states and dispositions as what makes an individual tick, what makes them who they are, what’s behind the personality and character they display. The design stance goes below the intentional or person level and uses concepts related to normal or proper function: drinking a cup of coffee involves a perceptual system that registers that there is a cup of coffee, a system that computes desire and eventuates in a decision to drink it, which sends a signal to the motor system to move the hand in the right way, lift-to-lips, and drink. The physical stance goes lower still to the level of actual physical realization. The physical stance is especially useful when there is breakdown of proper function: Ann drinks coffee through a straw because in the bike accident she badly sprained both wrists.

Higher levels depend upon and are implemented by the lower levels. One could take the physical stance description lower: sprains are implemented on wrists, specifically on ligaments, which are made of flesh, which is eventually, like everything else, implemented on bosons and fermions2. But higher levels also have emergent properties in one perfectly natural sense. Wiffle balls are round, but the molecules that compose them are not. A hard hit wiffle ball can cause a bruise, but a hard hit polymer atom in a wiffle ball cannot cause a bruise. Wholes have properties that their parts don’t. So too persons have properties that their parts, brain parts, and gene parts do not. Addiction is a person-level phenomenon. Neither brains nor genes are the sole cause of addiction; nor do brains or genes become addicted. That said genetic and neural malfunctions are clearly an important part of the explanation of how and why some people, some intentional systems, become addicts and suffer addiction.

At the intentional stance level, but not at lower levels, persons, whole persons, are normative creatures in two senses, one constituted by our power to assess or evaluate ourselves as rational or reason-responsive agents in a broad sense and to do what we decide is best to do all things considered; the other constituted by our power to assess or evaluate ourselves morally or from a moral point of view. Normative governance consists of two complex and highly interactive capacities, rational governance and moral governance. Rational governance refers to the capacity of persons to determine what we have reason to do, what makes sense to do given our aims, interests, and the way(s) the world is. Moral governance is the capacity to judge some of the things we do (or intend to do) as good or bad, right or wrong.

Our power to assess or evaluate ourselves as rational or reason-responsive agents is both episodic and diachronic. Episodically, at any one time or period in a life, there is always a set of possibly true answers to two sorts of questions. One set concerns what a person is doing here and now (at this time or within this period of time); the other set concerns why the person is doing it. As to the question of what I myself am doing, suppose what I am doing here and now is driving my car through the Holland Tunnel from Manhattan to New Jersey. As to why, the reason is that I believe that for someone in my physical position, in lower Manhattan, with a car, and wanting to get to Jersey, the best or most convenient way to get to Jersey is to take the Holland Tunnel. My physical position and my desire to get to Jersey give me good reason to drive through the Tunnel. I am responding to that reason in driving through the Tunnel. Normally, when a person has reason to Φ, she Φ’s. Addicts are puzzling including to themselves. When it comes to their drug of choice (DOC), what David Foster Wallace types as “the Substance,” they are performatively inconsistent (2). They resolve not to use and use. Many addicts report that the resolve and the action that undermines it occur at the same time, virtually in the same instant.

Our lives are also lived and led in diachronic psychological space and not just in the moment or in brief episodes. We experience ourselves as someone who was there in the past and we conceive ourselves as someone who will be there in the further future, short-term and long-term. We experience ourselves as not just being alive, but as having a life to lead, self-direct, or control, where a life is conceived as “the sum of one’s aspirations, decisions, activities, projects, and human relationships” [(3), p. 5]. Most of us probably do not have a blueprint for our whole life, what Rawls (4) called a “life plan,” but we do have for ourselves multifarious projects and plans nested together in various, possibly ever-adjusting, relations of priority and expansiveness. For many, most, perhaps all of us persons, we develop a narrative self-interpretation of ourselves as persons and perpetually evaluate how well we are doing in becoming who we aim to be and in accomplishing what we aim to accomplish. A basic way in which to understand the inter-relationships between our past, present, and future is to conceive of the lives we lead “as an unfolding story” (5, 6)3. There comes a time in every addict’s life when he comes to see that his “self-represented identity” and his “actual full identity” are on divergent paths, likely far apart, possibly inconsistent (7)4.

Finally, our lives are lived in social space as gregarious social animals. Most humans have natural desires for companionship and most of us recognize, even if only inchoately, that we cannot survive, develop ourselves as persons, or live good lives, that is, lives which are happy as well as meaningful and fulfilling, without situating ourselves in complex socio-moral relationships with other persons. And despite wide cultural variation in the exact norms governing social practices we all typically engage in normatively governed practices of “lending and borrowing, promising and consenting, buying and selling, making friends, entering into marriage, establishing a family, offering and accepting aid, and so forth” [(8), 20]. Reliably gaining the goods associated with these practices – security, self-esteem, self-respect, social trust, friendship – involve broadly moral evaluation diachronically by oneself and others5.

This picture of levels of explanation and of persons as normative beings in the twin – rational self-interpretation and self-control sense, what I call, the “rational effective agency sense”, and “the moral sense” – has implications for thinking realistically and humanely about addiction. Addiction is a person-level disorder – actually a person-in-a-particular-social-world disorder – in which there is failure of normative governance by rational norms of narrative or biographical integration and moral norms. The result is first bewilderment on the part of the agent that she has lost some of her normal capacities to direct her behavior by what she judges as her considered desires and reasons (for example, to drink like a normal person; not to drink to blackout), and eventually deep shame, as well as a host of other reactive attitudes, at the fact that she is not doing well by her own and often widely shared standards6. The model of addiction, the “twin normative failure model,” and of the addict, I propose rejects reductive models of addiction that claim that addiction is a design or physical level disorder. Addiction occurs in creatures with brains and genes (and bosons and fermions) but it is not a disorder of brains and genes (or bosons and fermions). It might involve disorders of either or both (9–11)7. Persons are addicts. Addiction is a person-level disorder, a diachronic intra-personal and inter-personal disorder; it is a disorder of persons that involves normally and reliably shame in one’s own eyes, and thus losses of self-respect and self-esteem, as well as social shame, a sense that even if one is not actually seen for who and how one is by others, one would be judged weak, weird, undisciplined, untrustworthy, and scary if one were seen for how one is as a person-in-the-grip of an addictive behavior pattern. Addiction fully engages the reactive attitudes of the addict, even if neither he, nor his community, judges him harshly or moralistically8.

One consequence of my view of addiction and its relationship to the experience of being an addict is that it accepts rather than resists the idea that addiction really is, in the eyes of the addict, and those with whom she is in community, a normative problem. The addict has trouble with respect to her addiction putting her reasons, her best thinking, in reliable control of her actions, and she has trouble (perhaps for this reason) abiding by the moral norms upon which her sense of her own integrity and self-worth turns. It is disrespectful to the phenomenon of addiction, to addicts who experience their addiction as involving these twin normative failings, and to the wider community, which judges addiction as bewildering, sad, and shameful to deny that it is a straightforward normative disorder. It is equally extremely shortsighted and inhumane to think that the problem that an addict has is a straightforward problem that can be solved by a psychopharmacological intervention to stop the desire to use or the effects of using. What most don’t see because of the meager dialectical offerings – addiction is either a moral or a brain/gene disorder – is the prospect that one can see addiction as involving biographically interpretative assessment of one’s own reason responsiveness failings as well as moral failings without either the addict herself or her community moralizing and blaming her. The theory is that at the level of persons, social persons, addiction is a failure in two highly interactive normative systems at once. One can think this, just as one can think that addiction involves some choice and some responsibility without blaming the addict and moralizing addiction. Let me explain.

DSM 5 on Substance Abuse and Addictive Disorders

Technically DSM 5, (12) like its predecessors, is only a diagnostic manual. It offers a classificatory scheme. DSM 5 taxonomizes and conceptually disciplines disorder. It doesn’t claim to explain (indeed it positively refuses to provide etiologies), or to offer treatment or therapeutic regimens. What DSM 5 is not agnostic about is that the symptom cluster it uses to diagnose substance-related disorders will yield to neuro-specification9. The manual is full of strong hints that it expects its symptom clusters to be filled in by neuro-specifics. We learn that all drugs of abuse have in common “direct activation of the brain reward system;” that people with “impairments of brain inhibitory mechanisms may be particularly predisposed to develop substance use disorders.” The section on substance abuse disorders, like the rest of DSM 5, is filled with “maybes” about connections to genes and the brain. The facts are that there must be such connections; humans are genetically endowed animals and our nervous systems are involved in everything we do. But it is a mistake to think that all properties of persons reduce to properties of parts, even especially important parts. I could argue that all the winks and nods to neuroscience (and to a lesser extent, to genetics) is part of the mindless cultural spread of neuro-enthusiasm (and what Rob Wilson calls “smallism”), which although true, would distract from my aim to describe what addiction is in a way that is true to the phenomenon and that is also therapeutically useful, recognizing the many roles that shame and related reactive attitudes can and do play in healing from addiction.

It is also a mistake – a related one – to think that all the essential features of addiction are features that can be revealed in non-human animal models of addiction. The brain reward system of non-human animals has interesting similarities to the human reward system, but the social ecologies of mice and humans are entirely different, as are the capacities served by culture and an enormous prefrontal cortex. A rodent cannot consciously resolve, possibly in consultation with fellow mice, to refrain from consuming a drug because its life is not going well, because it is causing communal harm. A rodent cannot relapse, and then regret and feel ashamed or guilty for its failure to maintain abstinence. Animal models may teach us about how dangerous and imprudent it can be to suddenly reverse preferences over time, but the full character of human addiction is no mere preference reversal or oscillation. It normally involves an interpretation and evaluation of oneself as having let oneself down; of having broken promises to one’s own self (and others). Non-human animals, at least the ones studied in addiction labs, are not self-interpretatively normed. They don’t see themselves as leading a life. Nor are they moved by thoughts of what counts as a good person/rodent, nor puzzled or disturbed by feelings of guilt, shame, and embarrassment. The moral virtue or value of self-control and of responsibility for self is irrelevant to animal addiction. But with a human being, a person’s social relationships, the effects of his actions on others, his loyalties and friendships, his trustworthiness, are deeply relevant to his being an addicted human being10.

What is really interesting is that the DSM 5 criteria for substance-related and addictive disorders are very plausible and never mention, not once, the brain or genes. What they do mention, and rightly so, are normative impairments. Here is the list of diagnostic criteria for alcohol-related disorders [(12), pp. 490–491], which are representative of the substance abuses overall:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued alcohol use despite having persistent or recurrent social or inter-personal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal symptoms for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

The Phenomenology of Addiction

DSM is wisely explicit, despite the thick vein of neuro-enthusiasm that courses through it, that substance abuse involves “impaired control” and “social impairment.” The language it uses to depict addiction is the language of the intentional stance. The addict has trouble carrying out his “intentions” (1); he “desires” to control using and makes “persistent efforts” to do so (2); he spends “a great deal of time in activities necessary to obtain alcohol” (3); he has “persistent and recurrent social and inter-personal problems” (4–7). Understood in this way, it looks as if DSM 5 embeds something in the vicinity of the twin normative failure model in its description of the typical cluster of features that define, characterize, or constitute addiction.

But, truth be told, DSM 5 is unclear about whether it considers these features merely symptomatic (often that seems the implication) the way fever is with a flu, or whether it understands these features as constitutive, as necessary, or as part of the typical psychological profile of addicts. For any mental disorder we can distinguish among its causes, its components or constituents, and its consequences. Because humans are self-interpreting animals, classifications, components, and consequences are absorbed, recorded, reflectively assessed, and they change the person being classified, who as a consequence of his disorder and his comprehension of it causes myriad further effects on himself and others. If one examines the vast literature comprised of memoirs of addiction (13) as well as writings by therapists who work with addicts, most every entry on the DSM 5 list will be familiar as constitutive of addiction. When the addict feels shame before his own eyes, when he observes his control failures, when he understands that he is an addict not living up to his own standards or best interests, he changes, for better or worse. The story of who he is, what he is like, how well he is doing in the task of accomplishing what he intends, of living well, absorbs ever new material. There is narrative self-interpretative adjustment. Since narrative is partly constitutive of the self, he changes (7, 14). For the addict, along the descent depicted by DSM 5 steps 1–11, he is bewildering to himself, possibly terrifying – he can’t get a grip – he’s a disaster, a train wreck harming himself and those he loves. This first personal normative assessment does really capture the shape, the texture, and the phenomenology of addiction. Is there a mistake? No. Indeed, it is only by understanding these normative failings that the addict shows himself the self-respect he deserves as a person and leverages, normally with communal assistance, his remaining powers of agency to get back on track and repair himself as well as the situations and relations that have been damaged along the way.

Despite the fact that the DSM 5 list of symptoms includes failures in self-control and in reliability – in behavioral failures with respect to norms – it is missing any reference to normative feeling states, to reactive attitudes associated with these behavioral failures. The addict has “cravings,” and greater “tolerance” involves changes in the “effects” of the DOC. He continues to use despite “knowledge” that using causes him problems, etc. But there is nothing in 1–11 about the way the addict experiences his failures to rationally effectively and morally guide his life through and past the allure of alcohol, which consistently undermines, possibly defeats his attempts to live well and to be well11. Interpreting the DSM 5 criteria to include these reactive attitudes or extending its criteria to include the feelings associated with the twin normative failures it almost always involves, would capture better the psychology of addiction than any purely behavioral, neuroscientific, or genetic model.

The Interpretative, Reasons-Responsiveness, Effective Agency Failure

The twins that fail in addiction are fraternal, not identical. What I call the interpretive, reasons-responsiveness, effective agency failure is really a set of failures that include cognitive mistakes such as minimization (I don’t drink too much; I just need to stop at n, where n > what a normal person would think is wise), and rationalization (you’d drink a lot too if you had my _____). One failure that is most familiar to both addicts and those in relation to them is a failure to execute rational control, to be able to execute rational plans, the failure to be in charge. The simplest way to put this point is in terms of the performative inconsistency mentioned earlier, which every addict understands as constitutive of his situation: I will/decide/pledge/promise to myself (possibly to others as well) that I will moderate or stop using; and then I use. P and not P. The failure is one of effective agency, of leading one’s life and not just tagging along for the addicted ride. The addict like everyone else sees himself as a being with hopes, projects and plans, responsibilities and obligations, friendships, and loves, as an historical, enduring being, possessed of long-range interests. But his own defective agency gums up the works, the work of being and becoming the person he aims to be. He fails at reliably enacting in-charge selfhood. If his DOC, the Substance, is available he loses normal self-control against getting lost in a preference oscillating and the preference-reversing moment or episode. He is bewildered and ashamed.

According to DSM 5, this sort of complex failure begins in mild addiction at step 1, where the substance abuser uses more that he at first intends. And it gets worse as the problem becomes more severe. It is sometimes hard to tell from behavior where exactly a drinker is in terms of loss of the ability to stop in a normal reasons-responsive way, i.e., by making an all things/future me considered judgment that they should moderate or stop, and then doing so. The Big Book of AA written in 1939, not a scientific work, recognizes correctly a certain kind of “heavy drinker,” who if he has reason to stop (the liver, the job, the spouse) stops. And much recent work confirms that many people who drink heavily, possibly in binges, possibly regularly, at some point, in their lives stop (15, 16, 43). But there is a type of drinker who seems not to be like this. They try to stop but can’t. Caroline Knapp’s, Drinking: A Love Story, Pete Hamill’s, A Drinking Life, and Charles Jackson’s, The Lost Weekend are powerful depiction of such lives.

The brain basis of addiction, according to animal studies, lies, in significant part, in the mesolimbic dopamine and brain reward system. It is possible that this area is compromised in humans, not only in opiate addiction, but in alcoholism as well. Suppose it is, and that therefore a compromised mesolimbic reward system is a necessary condition of human addiction. It does not follow that it is sufficient or that it is the only necessary condition (42, 44). In humans, addiction is constituted not only by craving, compulsive use, and “jonesing” for the Substance, which may be subserved primarily by the compromised mesolimbic reward system, it is also experienced and treated just in case the person experiences herself as unable to stop given that she has reason to (the personal and social costs mentioned in DSM 5); and that she is ashamed that she is not able to live as she judges to be good. This sort of self-regarding reactive attitude is I claim is a normal part of the phenomenology of addiction but not mentioned in DSM 5. It is implausible that human beings control against consumption impulsivity and imprudent preference reversal only by virtue of some sort of inhibitory mechanism in the brain reward system. If they did, then it might be plausible to say that addiction represents a disorder of that mechanism, and of nothing else. But human sources of inhibition and self-control are known to be many and various. Human powers of deliberation, self-assessment, and reason responsiveness are subserved by neural systems, especially in prefrontal cortex, that differ in organizational complexity from those of rodents. Furthermore, human linguistic capacities put us in unusual touch with communal norms and with communal reasons for abiding by those norms. To be sure, the addict has trouble making her reasons effective and this may have to do with damage to the circuitry in the mesolimbic areas or in the areas that connect prefrontal cortex to lower regions. But the facts are that addict has her reasons to stop, wishes to stop, but can’t. And it is this experience of the failure to execute effective agency, according to my argument, that is also constitutive of human addiction, although almost certainly not of rodent addiction12. A human addict cannot in a situation in which he is considering if he can and should refrain from drug consumption, regard himself “as waiting to discover or to observe in which direction he will be moved” [(17), p. 51]. To be counted by him as a decision of whether or not to refrain, the state of deciding must be thought to conform to some standard of possessing a good reason. The question “Will I abstain?” is unavoidably indistinguishable from “should I abstain here and now?” The total situation I am in as an addict confronts me, and sets the problem. I may try to take account of things about myself that I believe are not in my power to change (because I lack the means or skill to change) and those things I believe I can change. The anxiety, felt need, impulse, the craving, the sudden passion to consume, when they occur, may feel like something that descends upon me. I may try to double back upon myself and think of myself as something more, or less, than I really am. “Can I, or can I not, free myself of this behavior?” “Perhaps I can.” But the fact is: there are normative elements in states of mind and types of conduct relevant to being an addict, and these normative elements cannot be reframed in the descriptions of neural inhibitory mechanisms operating in independence of a person’s own self-assessment and biographically reflective reason responsiveness. The key for the addict is to find some way – often with professional help or non-professional communal help – to leverage his remaining powers of agency, first and foremost in relation to his DOC, to stop using the Substance. Sometimes the first choice is to be tied like Ulysses to the mast for a time. But it is an important but underestimated fact that every addict who does not use any longer has done exactly that, moderated or stopped using (15, 16, 43). Such former addicts have rediscovered, reclaimed effective agency. And they are abundant.

The Moral Failure

Persons enter the world valuing certain things and not others and they exit the same way. We are creatures with ends. Some of these have to do with resource needs and acquisitive desires related to these needs – for food, clothing, and shelter; others have to do with social needs, with needs for company and affection. We are gregarious animals. No person, no matter what her conception of flourishing or well-being would choose a life without friends, says Aristotle13. When Strawson (18) calls attention to the reactive attitudes, the suite of emotions and sentiments that guide inter-personal commerce and that involve reactions to the good will, ill will, and indifference of others, he is careful to include affection, love, gratitude, and forgiveness, along with anger, resentment, and shame. According to Strawson, these emotional dispositions come with the equipment. He compares the reactive attitudes to induction. We cannot ask whether induction is rational. It is arational, part of our animal nature, not something we can give up. What we can do, however, in both the case of induction and the case of the suite of reactive attitudes is to adjust, moderate, modify, tune up and/or tune down as necessary both natural innate attitudes. We modify our original disposition to apply the straight rule of induction via feedback from its application. For example, when we apply the straight rule to small or unrepresentative samples we get poor predictions and we adjust the rule14. Eventually over world historical time, the methods of inductive logic, statistics, and probability theory develop. With respect to the reactive emotional attitudes, different social ecologies develop different norms for apt emotions (19).

A key idea in Strawson is that the reactive attitudes are not only essential to inter-personal relations, they are also essential to how we see, judge, and regulate our own mind and behavior; they are also intra-personal. I can experience, indeed I do experience, the reactive attitudes to my own mental states and actions. Anger at myself for what I did, as well as disappointment, pride, embarrassment, shame, and guilt are familiar components of a human life. Self-esteem is a general feeling that one is decent, worthy, doing well; self-respect involves knowing with some degree of confidence and proper humility that this feeling is warranted.

It is commonplace for modern people to think that ancient and superficial peoples ran on shame whereas we run on guilt. Williams (20) has turned this idea on its head. The idea that, for example, the Greeks were a shame culture not a guilt culture is true but not a weakness or superficial characteristic. Shame is not simply a feeling caused by being seen, naked as it were, by others. It also involves not passing one’s own survey. “Shame looks to what I am” [(20), p. 92]. Guilt, the modern emotion, is the narrow reactive attitude. It is largely internalized anger at certain actions and its roots are in what Williams calls “morality, the peculiar institution.” Morality, the peculiar institution, is the narrow normative domain that encompasses all and only the domains that the God of Abraham is interested in assessing each person on come Judgment Day (its secular version comes in Kant). Ethics, in the broad sense, prized by the Greeks, by Nietzsche, and by Williams, is concerned with living a good human life more generally. It involves aspirations to flourish, which involves living at the intersections of what is good, true, and beautiful, whereas modern moral philosophy focuses primarily on the good, and even there it is narrowly conceived.

Here is how this relates to addiction. Almost all addicts experience failures of basic agent capacities, for example, in the first criteria of DSM 5 there is a failure to do what one reflectively intends. The non-addict will get that the addict might fail if a drink or drug is right in front of her (we relate from chocolate candy type experiences). But the addict will decide, indeed she will resolve not to purchase alcohol or cocaine and then find herself driving to the liquor store or crack house. This is shameful and is experienced as such both on the way to score, although in something of a blur, and afterward. I am ashamed of who I am, not simply for what I did. And it builds. An addict is someone, who like everyone else, has educational, career, and inter-personal aspirations, and he reliably fails to achieve them; or he achieves them to some degree, and then his addiction undermines these accomplishments. Every alcoholic and every addict in rooms of AA and NA and most every memoir of addiction (even if the author is not inculcated into 12-step ways of speaking) will speak of extreme feelings of shame for who one is, who one has become in one’s own eyes, even if one has not yet been fully seen by others and even if objective failures are still in the “not-yet” category (2, 13, 21)15.

The main point is that the ongoing epistemic-interpretative failure that involves: (1) the inability to draw normal inferences about the harms one is doing to oneself or others (caused by various classical defense mechanisms); and (2) the inability to get one’s mind, body, and behavior to respond to decisions and resolutions in the normal ways; PLUS (3) the persistent failure to live as one expects oneself to live as a worthy human being undermine the basic goods of self-esteem and self-respect. One is ashamed of who one is. The alcoholic needs to put the “plug in the jug” (the crack addict needs to stop scoring eight balls; the smack addict to put down the needle). But the disease of addiction doesn’t end there and then. And the reason is simple. Addiction is not a synchronic disorder that ends with the end of taking one’s DOC. It is a diachronic molar person-level disorder and as such requires psychological, epistemic, moral, and narrative healing and reconstruction.

Social Capital

A consistent finding in the literature on human well-being is that the best predictor of well-being – better that income, better than health even – is social capital (22). Almost all the variance between Northern Europeans and North Americans on the one hand, and citizens of sub-Sahara Africa on the other hand, in well-being measures has to do with the fact that almost half of informants in sub-Sahara Africa say that if they fell off a bar stool (here used only metaphorically), there would be no one they could count on to help, not a friend, not their mother, father, brother, or sister.

In his important book, Bowling Alone, Putnam (23) plots some of the causes and consequences of breakdowns in community and loss of social capital in America. There are insights for those concerned with addiction in these sorts of studies. First, addictions increase when there is socio-economic displacement, breakdown in community, and the availability of drugs and alcohol. Second, healing individuals typically involves reintegration into community, often a community whose other members have also experienced the bewildering twin normative failures and the self-degradation that results, and who get, at a minimum, that this sort of thing can happen to otherwise decent, worthy people, and who have experience, strength, and hope to share about how to regain control of one’s self, one’s life. Eventually, actually at the same time, there is reintegration into the wider social community, doing school or one’s job as one is supposed to, being there for one’s friends and family in the way a good person is, an end to actual or psychological isolation and concealment that is a common accompaniment of addiction (2, 13, 16, 21, 24, 25). Self-esteem and self-respect return and shame dissipates, possibly pride grows.

Responsibility “Without the Sting”

Strawson (18) writes about the possibility of taking “the objective attitude” toward certain persons. The objective attitude is one that involves a surmise, possibly a conviction that the normal reactive attitudes are not deserved in certain cases and should be suspended. Children have temper tantrums and anger is not warranted. So we suspend, or try not to act on anger, even if we can’t help to feel it to some degree. We also can and do suspend or try to suspend our normal reactions to the insane, to those who suffer from compulsions, who have no rational control over their actions.

Can and should we take an objective attitude toward the addicts in our midst? Probably. Can or should addicts take an objective attitude toward themselves? Probably. But there are psychological limits to our abilities to overcome natural dispositions. Furthermore, the addict feeling shame and the wider community thinking it is a shame that his life is going so badly is a humane reaction. It need not be taken to warrant blame. It signals that both the addict and we recognize that he could do better and be better. Understanding that he is an addict is a humane way of saying that we get that he is in a terrible fix and that we sympathize (46–48).

The more we learn about the complex socio-psycho-biological nature of addiction, about the ways various cultures encourage heavy drinking, about the effects of SES and drug availability, about genetic propensities, about the effects of weird reinforcement regimens, and of brain glitches, we have reason to adjust full normal subjective engagement to the addict. Williams makes this interesting point: “What arouses guilt in an agent is an act or omission of the sort that typically elicits from other people anger, resentment, or indignation. What the agent may offer in order to turn this away is reparation; he may also fear punishment or may inflict it on himself. What arouses shame, on the other hand, is something that typically elicits from others contempt or derision or avoidance” [(20), pp. 89–90]. This seems right; the life of the addict is a source of both guilt and shame. And thus he receives an odd admixture of reactions from others; in part, there are the normal reactive attitudes that full blown autonomous agents receive, anger and indignation; but there is also something else, a set of reactions that indicate that you have put me – us – off. You are puzzling, weird, to be avoided16.

Williams goes on: “His (the person who is ashamed) reaction is a wish to hide or disappear, and this is one thing that links shame as, minimally, embarrassment with shame as social or personal reduction. More positively, shame may be expressed in attempts to reconstruct or improve oneself” [(20), p. 90].

Conclusion

All this seems about right. And in particular: shame is partly constitutive of addiction. The addict cannot pass his own survey. He is appalled by the twin normative failures from which he suffers, and shame is the appropriate, respectful, humane, first-person response to these failures. Shame begets using and more using begets more shame, and the vicious cycle is produced and maintains itself. Overcoming shame is part of overcoming addiction. Shame is also normally a crucial factor motivating the addict’s attempt to reclaim, reconstruct, and improve himself. It motivates the addict to want to get a grip. That said, there are many reasons for the addict to forgive himself and engage in the difficult project of reconstruction and improvement with the knowledge that his agentic capacities in relation to the Substance are compromised, deficient; and, at the same time and for the same reasons, there are reasons for others to keep the addict in the realm of the very usual, the puzzling, the not-so-nice-to-be-around, but to also engage him with sympathy and compassion, maybe with forgiveness. The more we know about addiction the more this becomes both possible and sensible. At the same time, both the addict and the community that is asked to understand and treat him with compassion need to acknowledge that the addict is a person who suffers twin normative failure. He will need to heal to once again be treated as a full-fledged normal agent. He must regain his full normative agency and regain traction in his quest to live well.

Four Objections and Replies

The Willing Addict Objection

The process or condition that you are calling addiction really includes matters characteristic of a certain kind of addict, a so-called unwilling addict. Some addicts, however, are willing, and do not feel shame or guilt over their addictive behavior patterns (26). Willing addicts don’t double back on themselves and wish that their behavior was otherwise or that they should control their impulses to consume. Pickard (25) offers a powerful version of this objection in correspondence. Based on her clinical experience and standard DSM understanding, she writes that among addicts “are some people who are severely personality disordered, really genuinely don’t want people or friends in their lives (this is part of having schizoid PD, diagnostically) and have a ‘relationship’ with drugs instead; some are so narcissistic and grandiose that the claim that they feel shame or look on their lives critically or think they could do wrong would require very deep, very inaccessible levels of the unconscious to make it true.”

The objection is that there are certain individuals with schizoid personality disorder, perhaps there are others in the manic phase of bipolar disorder, who are addicts in the sense that they have lost rational effective control over using, but do not feel shame, and thus do not suffer the twin failures and who thus are not, according to me, addicts. But they really are addicts. So the twin normative criterion is descriptively false.

Before I respond to the objection, I can strengthen it as an objection, by pointing to two recent memoirs where the protagonists might be addicts in the sense of satisfying condition no. 1 of the twin normative failure model – he can’t stop if or insofar as he tries – but he doesn’t feel shame. Narcopolis by Thayil (27) and The Wet and the Dry by Osborne (28) brilliantly present two different types of character who don’t seem to satisfy the shame condition. In Thayil’s semi-fictional memoir, the 1970s opium dens of Mumbai, then known as Bombay, are a romantic haven for souls who have almost no other options, plus opium is really cheap. He and they are addicted and they don’t give a shit. Even if Thayil is not proud to be an addict, he is not ashamed either. Osborne’s story meanwhile is a hilarious romp through the Middle East by a man who is a “drinker” and who is hoping that laws and social mores of Muslim countries that disapprove of drinking will help him at least temporarily to moderate. They don’t and he doesn’t.

So now the strengthened objection is this: there are at least four types of addicts that do not satisfy the shame condition: (1) people with personality disorders such as schizoid PD; (2) people in full blown mania; (3) people that have easy access to the Substance, to their DOC, and no other choice-worthy options are available [see Ref. (29, 30)]; (4) “Drinkers,” like Osborne – also think of Richard Burton, Richard Harris, Peter O’Toole, and Christopher Hitchens or a heroin user with resources to get reliably pure doses, a Keith Richards type. This latter may be an approved of life style among a certain mostly white elite in the UK, but probably not in the US.

Reply

No doubt cases of addiction are heterogeneous in many respects, and dimensional in depth, severity, and so on. Are there willing addicts?17 Surely, there are people who minimize and rationalize, and people who think they could stop if they decided to do so. Some of these probably do fall into the class of willing users, even willing abusers. They choose to use, but believe they could stop if they had sufficient reason to do so. They like using excessively, asocially, possibly even antisocially. Some of these people might be wrong that they could stop if they tried (in the normal reason-responsive way), in which case they would be wrong that they are not addicts because they do not satisfy the first normative condition, the effective agency condition. They do; they just don’t know that they do. The Big Book of AA says if you think you are not an alcoholic, you may be right. There is a test: try some controlled drinking and if you can do so reliably and without always feeling overwhelming desire to use, then you were right – you were just a heavy drinker not an alcoholic. On my view, if a person could stop if they decide to do so, they do not suffer the first normative failure of effective agency (nor would they be self-deceived, etc.). And such an individual would not be an addict according to the view on offer.

But what about the memoir cases and Pickard’s psychiatric case(s)? One thing to say about the two memoir cases is that in both cases some shame is experienced; Osborne, at least, is often embarrassed about the blackouts and some of the predicaments his drinking gets him in. The shame condition in the twin normative failure model does not specify how much shame needs to be experienced. This could also be said of people with bipolar disorder when they are not in the grandiose bullet-proof phase, during which down-times they do backtrack, second-guess, and so on.

But this doesn’t solve the problems with the Pickard case of schizoid personality disorder where no shame is experienced diachronically; where possibly there is pride instead. A response specifically to these cases might distinguish addicts who satisfy the first condition (call them addicts type-1) and those who satisfy both (addicts type-2). Another is to claim that even the people who don’t feel shame ought to, which concedes that the criterion is normative not descriptive. The option I am inclined to take is to restrict the twin normative failure model to people who do not have severe personality disorders (e.g., schizoid PD) and people who are not in the grandiose phases of bipolar disorder. This would still leave the model open to this objection: there are social environments that are so degraded that there is no shame in addiction descriptively – perhaps the addicts are literally and rightly hopeless – and in which shame, guilt, blame are normatively unwarranted. Shamelessly addicted is simply the way some people live. I accept this. In such environments the concept of addiction in my sense has at best only a weak grip, only the first condition of addiction would be met, and even that only in a weak sense: if the resigned or hopeless addicts in such worlds wanted to stop (they don’t), they couldn’t18. The twin normative failure model is a useful model in environments where there are multiple choice-worthy options, not otherwise.

The Essence and the Periphery Objection

The twin normative failure model of addiction is swollen and inflated. There is too much that you are including as proper parts of addiction or of an addictive behavior pattern. The essence of addiction is at the brain level. The presence or absence of shame and negative self-evaluative attitudes, of various moral attitudes and emotions, the failures of reason responsiveness are sequelae of addiction, not part of addiction.

Reply

First, if an essence involves characterizing the set of properties that are invariant or at least highly reliable accompaniments of a kind, then the two normative failure model has at least as much credibility as any other model. I claim that you will find evidence of both normative failures in most every addict’s first personal testimony and in the third personal testimony of professionals who work with addicts. The shame of addiction is shame that is directed to the content that [I cannot control my behavior in relation to the Substance] and that [because of my using the Substance I fail to live up to my ends, values, goals, and standards]. Those who favor only brain or genetic bases for the disease have yet to agree about what that single basis is, if there is one, or whether it is polyneural or polygenic, if there are several, and how exactly (and when) confirmation/disconfirmation might come for the various contender hypotheses. I claim that there is confirmation for the twin normative failure model right now. Second, although a less inclusive or thinner concept of addiction (a least common denominator conception, as it were) may work as an operational stipulation in the case of models of certain non-human animal behavior, it is without merit in the richer conceptual and normative world of human beings, at the person level. Third, and relatedly, the objection favors an unrealistic simplifying assumption requiring that we define the dysfunction of addiction synchronically rather than diachronically, and over some aspect that is hypothesized, but not yet shown to obtain over all creatures that can suffer addiction. But claiming that the hypothesized shared basis is the essence, and that all other features, especially ones that reliably appear in Homo sapiens are not, is to change the question. Fourth, the method of gaining insight into essences is unstable. We have already seen how some geneticists think they can reduce the neuroscientific base of addiction to a genetic one in DNA, and even RNA, that serve the salt or water instincts (31) 19. For familiar reasons, this move opens the geneticists’ account to a further reduction into the language of bosons and fermions or whatever is the language of fundamental physics. With each reduction we move further and further from the phenomenon we started and are providing a less ecologically valid account of that phenomenon. If we are speaking of addiction among humans and addiction constitutes any sort of well-behaved or unified kind, every bit of evidence indicates that it is a psychological or behavioral kind that is also a double-normed social kind. This is perfectly compatible with this kind also having certain common features at the level of the brain and genes since kinds defined at the higher level have all the properties that the lower levels have but the reserve is not true, and this matters.

The Intervention Objection

The key to curing addiction is to arrest it, to stop the addict from using. Your view says that addicts fail to be able to exert normal self-control capacities and are ashamed of both this fact and the fact that they are failing to live a good human life. But you also acknowledge that knowing or experiencing this and also desiring to stop is normally not enough to stop. For this we are working toward pharmacological interventions that help addicts stop using, which is a necessary condition for any and all further healing. There are drugs that make the alcoholic sick if she uses, and others that mitigate the effects of cocaine and opiates. Eventually, work in genetics will yield simple interventions that adjust genes for those predisposed, and so on. If you think these interventions are already working, or might work, to arrest addiction, then you acknowledge that brain or genes cause of addiction.

Reply

The first part of the objection is not an objection to the view. I have said exactly nothing about opposing any and all therapeutic techniques that are helpful to the addict. If various kinds of psychopharmacological interventions can help without comparable costs, then, good, use them. But do not make the mistake of thinking that in locating an intervention site that one has identified the cause. Also beware the related mistake (sometimes made by psychoanalysis) that the root cause must be treated to arrest an ailment. First, many things are fixed without fixing what caused the breakdown. The weather caused the bicycle chain to rust. I clean the chain and oil it. I fix the bike but have done nothing to the weather. On the other side, we need to beware mono-causal thinking. The pragmatics of causal talk makes it sensible to say such things as the rock broke the window. But really the rock only broke the window because it, the window, had a certain density and brittleness (if it had been shatterproof, no breakage). And the window broke only because the boy threw the rock, and he threw it only because he was angry, and so on. No rock, no broken window; no angry boy, no broken window. The best analysis of causation in the philosophy of science says that the total cause of Θ is the set of events and processes (α, β, γ, δ … ω) such that if (counterfactually) anyone of them were different Θ would not have occurred as it is (32). And so it is with addiction. Take away the family that thinks adult drunkenness or drug use is amusing and some “addicts” never become one, take away the hopelessness of some urban environments and the rate of addiction will go down, and so on for genetic predispositions, etc. The first point is that many interventions do treat or require treating causes, and in so far as it is wise to treat a cause (or constituent or effect) of some disorder, and such intervention is effective, this should be applauded. But it is not at the same time any evidence at all that the cause has been found. It is rare for any phenomena that there is any such thing as the cause. Genes are causal factors in addiction, brains are causal factors, and families are causal factors. But invariably using a fair amount of some substance is a causal contributor to addiction, and this social practice – drinking, snorting, and mainlining – is not in the genes or the head.

Objection: Re-Moralizing Addiction

Fourth and finally, it will be objected that the appeal to the shame of addiction reintroduces the idea that addiction is a moral failing.

Reply

This is a simplistic and mistaken objection. Addiction is a normative disorder, a twin normative disorder that involves shame at one’s own survey, first because one is not an effective agent in relation to the Substance and cannot reliably do what one judges best, and second, because one is messing up one’s life because of one’s relation to the Substance. These are normal responses by the addict to his own realistic assessment of his plight. It is an interesting and important question whether an addict can take or adopt an “objective attitude” toward himself. It seems often to occur to some imperfect extent, and insofar as it does happen it may well prepare the person for self-forgiveness, and for reclamation of self-esteem and self-respect. There can be shame without blame. We acknowledge this when we say of the addict or the way he lives that “it” is “a shame.” Or to put the matter another way: guilt is anger turned inward and normally involves blame. Shame involves disappointment at self, but need not involve anger at self. Anger can immobilize; but shame can and often does motivate a change in direction, a search for a way to overcome his extraordinarily destructive relation to the Substance. As for others, knowledge is power, and the more that is know about the nature, causes, and multifarious trajectories of addiction, the more reasons others have to treat addicts as special cases, not as suffering an ordinary physical disease, but also not as fully effective agents, as worthy of sympathy and compassion because they suffer the shame of addiction. My recommendation is to accept that addiction just is a normative disorder, while at the same time not moralizing it.

Conflict of Interest Statement

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

George Graham was helpful at every stage of writing this paper. George’s thinking and writings on the nature of mental illness, and his suggestions, comments, and criticisms of this paper have contributed immeasurably to my thinking and writing about addiction. I am also grateful to Hanna Pickard, Serife Tekin, and Colin Klein, as well as Neil Levy and Serge Ahmed served initially anonymous referees and made extremely helpful critical comments on an earlier version.

Footnotes

^I mean the view to apply in the first instance to alcohol, cocaine, and opiate addiction.

^According to Dennett’s pragmatic taxonomy, the “intentional stance” is person-level psychology; the “design stance” is computational cognitive psychology, and the “physical stance” is neuroscience. One could, for pragmatic reasons and perfectly in the spirit of his taxonomy go higher than the intentional stance – to sociology and then anthropology – and lower that his physical stance, to biochemistry and eventually to basic physics. One my view, but possibly not on Dennett’s (he is well-known for his instrumentalist or eliminativist tendencies), the higher-level entities truly have properties that the lower levels don’t have. There really are such things as beliefs and desires. People have beliefs and desires; people contain brains and brains contain neurons; but neurons don’t have brains and brains aren’t people, and probably brains do not have beliefs and desire, although people with brains do, and so on.

^I don’t mean to overstate the degree to which people do or ought to examine and evaluate their lives from an articulate reflective pose (see Flanagan (33), for a critique of Charles Taylor for this intellectualist mistake). The point is that people have ideals, ends, goals, and purposes – many of which are socially scripted – and we are consciously or semi-consciously aware of how we are doing in relation to these ideals, ends, goals, and purposes. There are rational evaluations and adjustments of both ends and means along the way, as well as all the familiar kinds of rationalization and defensive denial that one really wanted to do such and so, or be such and so in the first place.

^“Self-represented identity” is the story from the first-person point of view; “actual full identity” is the true story of who one is, what one is like, the story that would be told by an ideal observer with the right theory of the human mind and action and knowledge of all the facts.

^I need to emphasize the idea that evaluation occurs “in broadly moral terms.” Later, following Williams (34), I distinguish between “morality, the peculiar institution,” which is roughly the kind picked out as “moral” inside the Abrahamic traditions and “the ethical,” which is much broader and includes the aspirations to live well by achieving maximal intersection of the goods that comprise what is true, beautiful, and good. I intend what I am calling “moral” and what constitutes “the moral failing” of the addict to align with “the ethical” and not with “morality, the peculiar institution.”

^The Big Book of AA describes the relevant first-person phenomenology as “incomprehensible demoralization (p. 30).”

^I am collaborating on a project with geneticists (31) who find that in mice, cocaine and opioid use activates genes associated with the salt and water instincts. The instincts to maximize salt and water intake when these are present and the organism needs them, are clearly adaptations, perhaps in exactly the form that leads some, but by no means all mice (29, 30) to become addicted mice. The addiction that piggybacks on these instincts is not an adaptation; it was not selected for in the original evolutionary environment or in recent ones to serve a fitness-enhancing effect. Liedtke thinks that this gene-level activity may be what at the genetic level subserves what some neuroscientists call the “midbrain mutiny” that involves the “hijacking” of normal reasons-responsiveness and control capacities by unusual schedules of reinforcement (35), or by an unwelcomed disassociation of the normally coordinated brain based “liking-wanting” systems (36), or by exhaustion of the brain’s mental muscle, aka, “willpower” (37), or by stress hypersensitivity (38). This gene-level explanation of higher order brain level processes that subserve addiction, which itself rests on an evolutionary explanation of selection of genes that code for salt and water instinct, and (45) one of these higher order brain explanations can both be true as far as what happens at the gene level and the brain level without even the combined resources of both levels remotely describing or explaining addiction at the person level.

^“The reactive attitudes” according to Strawson (18) are the set of familiar sentiments, emotions, or attitudes such as anger, guilt, shame, forgiveness, resentment, happiness, and gratitude that regulate human interaction.

^Insell (39) the head of NIMH is impatient about filling in the details, and wants to push on to the neuro-specifications of all bona fide mental disorders quickly. And he is willing to put the money he controls as head of NIMH where his mouth is Meanwhile, Frances (40) former head of the DSM IV taskforce laments the rush to neuroscientific reduction because neuroscience is immature, and because, like me, he is skeptical that all mental disorders are brain disorders, and third because he worries about the dominance of money in seeking neuro-pharmacological “cures” for problems that either are not in the brain at all or, even if they have a brain dysfunction component, are mostly psychosocial problems.

^Ahmed (29, 30) has done very important work inside the animal modeling tradition emphasizing that most rats offered cocaine do not get addicted and, more importantly for treating addiction, that compulsive cocaine use is lower in environments where there are multiple pleasure-producing and choice-worthy options besides the cocaine. My concern with animal models is not based on denial, not even skepticism, that there are genetic and/or neurobiological components of addiction, or on doubt that the brain might be the best place for interventionist strategies to short circuit the desire to use, the compulsion to use, the effects of use, and so on. It might be. The point is that even if the brain is an effective, even the most effective, site of intervention, this is not evidence that addiction is a brain disorder or that it is sensible or good to model it as such. Removing the battery of a car is an excellent way to immobilize it, but a running car is not a battery phenomenon and is not well modeled by the battery, what the battery is, does, and the ways it can malfunction. See below on Woodward’s (32) model of causation for why this is so.

^Contrast DSM 5 (12) with Graham’s (9) – what I call “the ignoble eightfold path of addiction,” especially, (iii), (iv), and (vii) which emphasize the self-directed reactive attitudes in addiction. DSM 5’s 1–11 speak about ways the addict fails to exert various kinds of control despite his best efforts and it speaks about feelings toward alcohol (craving, tolerance). I am emphasizing the addict’s feelings toward his SELF, possibly as a result of these failures and the harm he does to himself and others. And these reactive attitudes I claim, are part of what addiction is, and what needs treatment. TWO CAVEATS: first, in (vi–viii) Graham places I think too much stock in the belief that relapse is more or less inevitable. Second, I read (vi) as descriptive not prescriptive. It is true that relapse powerfully engages recognition of the twin normative failures including shame and its suite. Increased knowledge about addiction, of course, teaches that despite the shame, the addict may not in any robust sense be to blame or deserve blame.

(i) A person commences a behavior that is potentially harmful or deleterious. They consume a deleterious drug or other chemical substance or gamble.
(ii) The behavior eventually becomes an object of focal attention and periodically repeated or habitual activity. The focus is such that at times or in some cases it may be “the only tune or story in the addict’s head, and nothing else drives it out”.
(iii) The behavior produces consequences that are not just harmful or that seriously risk harm to self (and/or to others) but are perceived as harmful or destructive by the agent.
(iv) The perception or self-conscious experience of harmful consequences leads the person on certain lucid, critical or self-reflective occasions to negatively self-evaluate the behavior and attempt to refrain or quit. This does not mean the addict knows how to quit or how difficult it may be to quit or whether they can quit for any consistent period of time. But an attempt to refrain is made.
(v) The addict refrains, quits or inhibits the behavior during certain periods (perhaps without assistance, perhaps only with assistance – individual cases and occasions vary).
(vi) Quitting or cessation ultimately (timing and intervals vary) proves unsuccessful, however. The addict relapses. They “fall back” into the detrimental behavior after a period of temporary stoppage. The behavior returns together with its negative consequences or risks.
(vii) Relapse is interpreted by the agent as a form of personal disappointment or failure, not just as something destructive or risky, but as a source of shame, regret, self-blame, and embarrassment or as grounds for diminished self-confidence or self-esteem.
(viii) The steps or phases of harmful behavior, temporary abstention, and relapse cycle repeatedly. The recycling, in some cases, may cease permanently, perhaps without harmful long-term residue. And the person just plain quits. (Thousands of addicts just plain quit for good at some point. They “age out” of their addiction.) Or the addictive pattern may lead to an addict.s enduring exposure to harm or personal demise.

^One can, of course, make a rodent a psychological mess, extremely anxious, fearful, and so on, by mixing reinforcement schedules that both encourage and inhibit addiction.

^Psychopaths or people with schizoid personality disorder might be exceptions to Aristotle’s surmise.

^The straight rule is crude and says this: if I observe that A’s are B’s to m/n, then I do/should infer that unobserved A’s are B’s to m/n.

^The 12-step community speaks of addiction as a medical, psychological, and spiritual disease. Amazingly, the medical aspect was once thought to be or to involve an allergy to alcohol. The psychological and spiritual aspects refer to a host of problems in the self-esteem, self-respect, shame, and self-degradation arena.

^Pickard (25) argues that for individuals with both addictions and personality disorders, we can and should decouple (1) Holding a person responsible for what she did; (2) Holding her responsible for her future actions; (3) Blaming a person for failures on 1 or 2.

^Kennett (41) helpfully distinguishes four possible kinds of addicts: willing; unwilling; wanton; and resigned. She is skeptical about willing addicts. Wanton addicts, if there are any, are not reflective in ways that would allow noticing the twin normative failures or perhaps if they did, caring about them. Mice addicts are wanton addicts. I doubt that there are any person addicts who fit the bill since even wantons will need to schedule desires and trying to do so will result in recognition of their inability to successfully schedule substance-related desires (unless supply is unlimited), and thus in recognition and bewilderment over their control capacities. This much will lead, even the amoralist, to frustration and anger at his failure to live as he wishes, to coordinate demand/need to supply, and to gain the satisfactions he seeks. There probably are resigned or hopeless addicts, but even they will normally experience themselves, and will be seen by others as suffering the twin normative failures of loss of effective agency and life standard failure, although the space of live options for such resigned individuals will have pretty much closed off. Resignation is normally a sad emotion constituted in part by the sense that things could have gone better. When an environment is really objectively hopeless, offering no decent options for a good human life, then there just may be no norms against which the addicts life is better or worse than any other. I accept that in such environments, the twin normative failure model starts to lose its grip; perhaps, it is irrelevant.

^These sad cases are “resigned addicts” (41). It needn’t be that a whole social world has no choice-worthy options; it can be that certain social groups are trapped by racism or sexism or terrible poverty to have no or very limited choice-worthy options in a world where there are abundant options for others.

^To be fair, since full blown reduction never occurs, the geneticist should not claim reduction, but something like the further specification of mechanisms at the lower level (genes) that explain partly why the brain is doing what it is doing. Similar humility on the part of those who work on the neuroscience of addiction would claim to provide insight into some of the mechanisms involved in addiction.

References available at the Frontiers site.