By now, most American’s have heard of the book, The Big Short by Michael Lewis, and the movie of the same name. (To short is to sell something you don’t own because you believe it will go down in price or value a great deal) Most people know that the book is about people who saw the collapse in the housing market before it happened and made money from it. That’s not really what the book’s about. The book is about how hubris and cluelessness of government officials and establishment organizations allowed imbalances to get so great that when they finally balanced (as imbalances always do) the entire financial system was at risk. The fact that individual traders saw the imbalances and acted on them should be no surprise. What is a surprise is that those very traders tried to tell people something was wrong. They went to the rating agencies and told them they were wrong; they went to the big banks and told them they were wrong; they went to the government and told them they were wrong. The reaction of all these people was that the traders didn’t know what they were talking about. “How could they know?” the establishment seemed to say. “The system had worked just fine all these years. Who are they to tell us that there are hidden costs that we don’t see?” Well history has decided who was right and who was wrong on that score, and it was an expensive lesson for all of us.
The problem behind the Big Short was the assumption that housing in America could never go down across the country at the same time. It hadn’t happened for over 70 years, so it couldn’t happen, right? As long as it didn’t happen, even the crappiest sub-prime mortgage bond would be good. Turns out the assumption wasn’t true, the bonds were worthless, and the pyramid of derivatives built on them were as well.
Is there a “big short” in addiction today? Is there a situation in which entrenched establishment groups or regulators are so sure they are right that they can’t see the hidden costs of their system? Is there a situation based on an assumption so old that no one today can question it? I think there is, and it’s also about 70 years old, but that’s long enough for generations of academics and clinicians to have been trained by people who were trained by people who were trained by people who assumed that this was the truth.
The Big Short was a best selling book with hundreds of thousands of copies in print. There’s another bestseller that is the core of the problem I’d like to point out, The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM).
I’m sitting here with a copy of the first DSM published in 1952. It didn’t have a number behind the name, and I can’t find evidence that they imagined there’d be a DSM II one day. The original DSM is essentially broken into two sections: disorders caused by impairment of brain function and disorders of psychogenic origin. Guess where they put what we call addiction today. Yes, they felt strongly on the basis of the best evidence they had gathered from 1945-1951 that addiction had no biological basis in the brain. In fact, they put it under the heading of “Sociopathic personality disturbance” along with Sexual Deviation. My how times have changed, at least they have for Sexual Deviation.
But no matter how many numbers we put behind DSM, the original assumption, that addiction isn’t caused by dysfunction of the brain, hasn’t changed. In DSM II, published in 1968, what we call addiction was again placed under the heading of Personality Disorders. DSM III, published in 1980, was a little bit better. Substance Use Disorders got its own section. Addiction, no longer had no biological cause. It was caused by drugs, and that cause was now real, biological, and external. Addiction to anything other than substances couldn’t be considered (the many manifestations were elsewhere in the book), and only substances caused addiction. DSM III and IV kept a division between Substance Abuse and Substance Dependence with most practitioners understanding Substance Dependence to mean addiction and abuse to mean a normal person doing stupid things with drugs and alcohol. But that changed again in DSM5(2013). Substance Use Disorders were now listed with Addictive Disorders (finally allowing that compulsive gambling might be addiction), and abuse and dependence were considered mild and moderate forms of the same thing. Well, if you’re focused on the substance, I can see how it would make sense that way. But all the DSMs agree on this one point, addiction is not a primary biological brain illness, and that assumption is killing us.
The assumption is actually older than the DSM, but that book is a good place to start. After 65 years of modern scientific research into addiction, including the Decade of the Brain and the Human Genome Project, America and American Medicine still sees addiction as a disorder of “psychogenic origin” leading to substance use that causes damage. We still think this is a problem of our cortex and choice, even if we imagine that it’s due to damage of drugs or other substances. There’s a power to that assumption that is hidden from most of us. It limits our thinking; it limits our choices.
Follow my logic here. If addiction is of psychogenic origin then it cannot occur before our thinking reaches a point at which we can create it. Further, since our thinking created it, changing our thinking can make it go away. These two premises have led to most of our thinking about addiction treatment today. Alternately, if addiction is caused by drugs, the best thing to do is to get rid of drugs. This logic leads to most of our public policy about drugs today. So it is pointless to look at children so small that they can’t think deep thoughts about drug use or so short they can’t reach the beer off the counter. We miss the genetics entirely. We cannot conceive of someone having the disease of addiction because they were born that way. Yet, the single most common thing I hear from people with addiction is, “I was never normal.”
It is the common experience of people with addiction that something was wrong with them from the very beginning, yet it is the assumption of the organizations directing how research and treatment are done in this country that this cannot be. Generations of addiction researchers and clinicians have been taught that the most common experience of people with the illness isn’t real. Good luck with that.
Is it any wonder that addiction treatment doesn’t seem to work very well? Is it any wonder that addiction treatments aren’t welcomed with open arms by those whom the illness makes most miserable?
So our current state is that we are bound by an assumption that no one practicing today can remember a time before, an assumption so old that it seems handed down on stone tablets. A few years ago ASAM published a new definition of addiction that suggested that the underlying assumption of the last 70 years was wrong. Few, even in ASAM, fully understand the power of this new definition. It was applauded when published and then promptly forgotten. No one in government or academia has started to do research based on it. No one has asked, “What if they’re right?” No one has even thought enough about it to understand that if they are right, that it undermines most of what we think is true today.
There are billions of dollars spent on treatment and research based on assumptions that aren’t true. There is a mainstream addiction organization that has said the assumptions aren’t true. No one’s listening yet, but when they do it will be a dislocation in our industry like the one in housing in 2008. Now if only I could figure out who to short.
copyright 2016 Howard Wetsman MD