Straight Talk from One of America's Top Addiction Specialists
This December, iconoclastic addiction specialist Dr. Stanton Peele joined the Drug Policy Alliance's Asha Bandele in the third of an ongoing series of telephone town halls organized by the as part of the groups movement-building effort. Previous calls coordinated by the Drug Policy Alliance included topics such as considering the role of black and other oppressed communities in emerging legal marijuan markets and what are the next steps needed in the effort to reform the drug laws.
In this third tele-town hall, the topic was addiction, and, as Bandele explained in her introduction, who better than Stanton Peele to provide a provocative take and go after some sacred cows?
Asha Bandele: This afternoon we turn to the topic of addiction. It’s a subject regularly debated by both those who’ve studied it and those who struggled with drug use or witnessed their loved one struggled with drug use.
This year what we felt was very important because this year beginning with the death of actor Philip Seymour Hoffman and the increased attention paid to opioid use. At DPA we take no singular position on approaches to addiction treatment beyond our general and very clear support for harm reduction methodologies and of course non-coercive treatment. They are part of the criminal justice system.
We do agree that addiction treatment is a topic live for discussion. To that extent, we are so excited to be joined by a man, a pioneer really who’s been working in the field for nearly 50 years, Dr. Stanton Peele. I’m certain that there’re hundreds of you joining us today are familiar with Dr. Peele.
But just by way of introduction, I will share that he’s both a psychologist and a psychotherapist. He’s also an attorney. But in 1970, Dr. Peele began a five-year process that would produce the groundbreaking book ‘Love and Addiction’ which was published in 1975 and thought to focus on natural recovery. The notion that addiction doesn’t stem from drugs themselves, but from the ways in which people live their lives.
Moreover, he was the first to assert that addiction was not restricted to drug use but to also include behaviors in gambling as well as the first to identify non-abstinence based harm reduction oriented treatment recovery as an option. Dr. Peele is the author of some 11 books since ‘Love and Addiction’. Most recently ‘Recover! Stop Thinking Like an Addict’ done with Ilsa Thompson. He’s published numerous scholarly articles. We are pleased to welcome him here today.
Dr. Peele: It’s so great to be here Asha. There’s no person or group I’d rather talk to than DPA and you.
Asha: Well, I’m really glad that you’re here and we’ve had just a wonderful three weeks of preparing for this and thinking through what we wanted to talk about. I’m going to go ahead and just jump right into it. Is there a way to understand the problematic drug use beyond the lens of addiction? In other words, can one use drugs problematically without being addicted to them? How do we both acknowledge that difference and address that. I realized that’s a few questions. Let me know if I need to come back.
Dr. Peele: To start, it’s not a matter that you jump into addiction or you jump out of addiction. That claim that some people make to be an alcoholic or to be an addict just like being pregnant--you’re either or you’re not--it’s just not true to the kinds of lives that human beings live. Instead I’ve always seen addiction as one end of an extreme. It’s a little bit of an image more than it is some kind of biological reality.
One reason it’s important to think about in that way is to recognize that we’re all capable of moving back and forth on that scale. For example, when soldiers were in Vietnam and became addicted they were in extremely gruesome situation. It took a toll on them. The same men when they returned to the United States slipped down scale away from addiction.
The way we’ve been taught to think about addiction, that’s not possible. As I said you’re either in or you’re out. But really looking at addiction is involving the situation you’re in, the individual, who’s involved with the addiction. Whatever your addicted experience is, it's not simply a matter of drugs. That allows us greater freedom, not only to think about addiction more broadly, but to approach it more realistic sensible in humane way.
Asha: When we think about the language of addiction within the parameters of a recurring brain disease, how do you respond to that?
Dr. Peele: I hate it. I hope I’m being pretty direct about that. First of all, calling it a brain disease takes it out of your own control. I think you mentioned our book by Ilse Thompson’s ‘Recover’, what we’re trying to do is to bring … One way of putting it, is our own brain is back into our control? But more accurately I’m talking about bringing it our lives into our control. Imagining you have a brain disease as a way of detaching yourself from your own experience, but in particular to lose control of that experience.
I have reviewed the film ‘Wild’ and I described how the Reese Witherspoon character takes a totally different approach from the normal recovery one. She refuses to label herself an addict. She rejects going to rehab or to the recovery room. Instead she embarks on a journey in her life. That’s such a good way of thinking about addiction and how you overcome addiction.
It’s one part of your journey if you are encapsulated in a drug experience, a bad drug experience, but it’s only part of what who you are and where you’re going. To the extent that you’re able to detach yourself from that sense of being addicted, to the extent that you’re able, like Witherspoon in the film, to plow ahead, getting satisfaction, realizing you’re turning your own destiny. To that extent you have the greatest chance of recovery.
Asha: That’s very helpful. As we acknowledge the dominant paradigm in drug treatment is the 12-Step approach, which for many people has been a very successful and life-saving route to a place where they feel healed. Are there any other approaches to treatment that you have also seen be a successful. I thought we might talk a little bit about those whether they’re in this country or outside of it?
Dr. Peele: Well, let me just back up a little. You began our conversation by mentioning Philip Seymour Hoffman. Philip Seymour Hoffman had just been in an AA meeting. He’d been recently in rehab. It’s fine to talk about there are people for whom 12 steps works, but the overall success rate of the 12 steps is nothing to brag about and they can actually have negative effects. I didn’t see it as being insistent with harm reduction.
In Philip Seymour Hoffman’s case, like many people’s cases, what happens is you go whole hog when you don’t abstain. It works against telling people both about relapse prevention that if you had a slip, there’s no need to go whole hog and it also doesn’t allow you to imagine that somewhere in your life you can use substances again in a harmful way.
I mean harm reduction itself is a type of therapy. What is involved in harm reduction is to tell people your life determines how you use this substance. We don’t tell people to use or not to use, but should you use again? There’s a way to control that. There’s a way to eject yourself from the downward spiral that can result in the full blown addiction.
I’ve had a treatment center and I have an online program for the Life Process Program. In the treatment center, we were the abstinence oriented on campus but afterwards we taught people about relapse prevention, that the goal is not to go all the way back to the level that you were when you went treatment, but to take different steps that we teach them mindfulness, the kinds of things that allow you to see your purpose, to employ different types of skills that can allow you not to tumble back all the way down.
Let me review some of these concepts. Relapse prevention. It's techniques for not spiraling out of control, skills training, ways to learn how to deal with stressful situations, communicate with people in a way that allows you not let your life get out of control, and mindfulness. Mindfulness is a kind of a meditation style but it’s a way of recognizing yourself as being separate from your addiction and at the same time giving you tools to combat addiction with.
For example, one meditation that we teach in recovery is imagining a craving as a way that you’re surfing rather than thinking of it as something that’s going to engulf you and take control of you. You’re able to imagine operating the way you think you can and you know because you’ve seen it happen before that that way to achieve it was to calm down.
My approach to addiction, I just don’t think it’s useful to tell people they're powerless. Everything is about allowing them to recognize their power. To think of themselves as powerful and more powerful than their addiction and giving them specific techniques that allow them to exercise that power. We see that all the time in harm reduction work.
For example, one of the things that we learned when we did needle exchange was that people were on their way once they began to have some control over their addiction, often concluding their addiction entirely. People will say, “Well, once I started looking after my health, once I realized that there were better or worse ways to use the drug, it began me on a journey of seeing that really I was able to assert control over this habit, that I could be the dominant force in my own life once I began taking steps to help myself, to make progress in my life and in my health.”
Asha: What brought you to this way of thinking? What first made it make sense to you and why just sharing a little bit about your own look into this particular area of addiction treatment?
Dr. Peele: Well, that kind of a reversed journey for most people. When I wrote ‘Love and Addiction," I was in my 20s and I based it on standard kind of college and graduate and young professional experiences I was exposed to. Of course I’m so old, my 20s were in the ‘60s, so people were starting to take drugs. But I was not mainly involved with addicted drug users. Nonetheless, I thought that I could understand the core of addiction even looking around me. It was called "Love and Addiction," looking at love relationships.
As I often say, “Nobody, virtually nobody ever kills themselves when they were withdrawing from alcohol, heroin or cigarettes but a remarkable number of people get into a life threatening situation when they lose a key relationship.” What I focused on was how people turn their lives over to an experience, how they become completely caught up in the experience because it provides them some form of gratification and yet that relationship is disruptive to them up to and including that.
Therefore, I believe every human being has had some kind of experience with addiction. "Love and Addiction" was an effort to encompass all of that experience to say that addiction is not something far away and that it only meant addiction to heroin. That was the tiny microscopic group of people who were "addicts" that anybody knew, and they were the only ones. We didn’t even think at that time it sounds crazy to say smoking was addictive.
But I said, “Oh no, addiction is much closer to all of us and those other people are not that far different from us. We all understand what that kind of an internal feeling is.” I wrote a book that was mass marketed, anything that’s sold at supermarkets, and you know it’s actually sold around a million copies. But then I went from there to becoming more engaged in dealing directly with substance addictions because that’s what people thought being addicted meant and because that’s where I thought it could be most helpful.
I emerged from writing ‘Love and Addiction’ to give a keynote address at the National Conference for what used to be called the Addiction Research Foundation, is now called KMH and then I was drawn fully into the addiction debates. And my whole perspective it was so strange to people at the time. It says that other things can be addictive, that addiction doesn’t stem from one withdrawal over another. It’s not a chemical result. I said that people’s lives influence whether they become addicted in the first place or whether they were able to overcome addiction.
It says that the way people think about addiction and calling it overpowering and that they are powerless against it actually influences their ability to get out of an addiction. What I’d like to say now is all of those things are now recognized to be true. In 2013 the diagnostic manual for the first time recognized the non-substance addiction gambling. They said it can be fully addictive.
We now of course recognize non-abstinence outcomes all over the map from a fully controlled recovery to one where people occasionally slip, to one where people allow themselves periodic excesses, to one where people switch to a different substance, which wasn’t allowed and wasn’t allowed in formal treatment protocols.
Going down the steps, I created the treatment program I had. I was the clinical director and I revised the treatment module based on the book I wrote called the ‘The Truth About Addiction and Recovery’ in 1991. It was called the Life Process Program and I had to resonate it to rehab. The essence of the Life Process Program is that addiction is a part of your overall life. It’s one part of that process and to the extent that you’re able to get controlled and master the various parts of your relationships dealing with emotional problems like depression, learning how to cope with life’s stresses and challenges, learning how to deal with relapse, to that extent you’ll be able to gain control over your addiction.
I was just referring to the movie ‘Wild.' I really identify with that film. TheReese Witherspoon character doesn’t go to rehab. She doesn’t join the support group. She does the opposite of that. She embarks on the life’s journey that’s really challenging. She doesn’t really know much about hiking. She’s physically out of shape. I mean certainly for a thousand mile journey, she doesn’t really know how to deal with people who are other than those who were involved with drugs because she’d been using heroin.
That’s a really good way to embody what it means and what I’m trying to describe in the Life Process Program as the way out of in addiction. It’s not escaping addiction. It’s creating your best self in life so that addiction has no place in it.
Asha: Let me thank you for the authenticity of your answer. I don’t know how many people know that you’re also an attorney, having achieved that degree I guess in the ‘90s. So it makes me want to ask you at somebody who worked in the drug war, at least from my point of view and probably as yours, a question about just macro versus micro approaches to solving the problems that are born of the drug war, including how we treat people who struggle with drug user. Or who just don’t struggle, they just use drugs. I wonder, should our work be more centered around reforming drug laws? Should drug laws be rooted in fixing people or should they be rooted in fixing policy?
Dr. Peele: I always think of policy and individuals, society and individuals change together. I wrote a book after ‘Love and Addiction’ called ‘The Meaning of Addiction’ and like all of my books, I wrote a chapter on policy. All that I write has tremendous implications for policy. For example, really the reason we came down so hard on heroin is simple—it's addictive. Then you think about how alcohol and cigarettes are addictive, how does that make sense? If relationships are addictive, are we really going to arrest people because they’re involved in something that’s addictive? That makes no sense whatsoever.
I believe the policy and legal approaches to addiction are fundamentally baseless. But going beyond that, what I need to say is we can't only approach drugs from a policy standpoint without first addressing underlying attitudes towards drugs. Here’s what I’m afraid of: that we will allow ourselves to normalize marijuana and we’ll say, 'Well, it’s not really that addictive,' without really questioning our underlying assumptions about drugs and addiction. The underlying assumptions are that drugs are inherently addictive.
We as a society and as individuals hurt ourselves thinking that way. It makes it less possible for us to manage those things. Let me give you three examples. When we pass rules against smoking in bars and smoking in workplaces, we figured that smoking is addictive and that people won't be able to do that able to do that. They’re addicted to cigarettes. How can they manage to stay at the workplace and not continue to smoke?
In fact what we’ve seen is that addicted smokers have cut their smoking back from a pack to about 10 cigarettes a day because it’s impossible, difficult to impossible to smoke the way you used to. It turns out that all kinds of people who never imagined that they could work through a day and then have a cigarette at the end or that they could wait in their house and then only go outside and smoke are capable of doing that.
By allowing society to recognize that drugs are not overwhelming monsters that create addictions, that control us, we enabled individuals at the same time to have a better chance to overcome the addictive problems that they get involved with.
By the way, of course one of the people that I so greatly admire at DPA is Meghan Ralston. I just like to quote this one thing she wrote. It almost make me cry whenever I read it. She had a period of substance abuse and she never wanted then or now to be referred to as an addict. She said, 'I’m just a person who had a period of difficulty, pain and challenge. I battled. I failed. I tried again just like everybody does.'
Even people who were addicted to substances are just a part of the normal range of human behavior, and being able to think like that the way Meghan described ultimately made it more possible, allowed her to escape an addiction because she just didn’t think of herself as an addict. That permitted her to get beyond her chaotic drug use that she described.
Asha: I have another question along the lines of policy but I’m going to save that for later. Instead, let's turn to questions from the audience. I’m going to begin with Will Godfrey. Please go ahead and ask your question. How are you doing today?
Will: Hi Asha! Thanks. I’m doing very well indeed. Thank you. I’m privileged to work with him at Substance.com. Peele, I'd just like to ask you about your belief in your particular model of addiction and your belief in the cause of drug policy reform. Tell us about how you think that they’re naturally entwined and go together so well?
Dr. Peele: Well, there’s a million ways. What’s going to happen? What’s happening now when we legalize marijuana in Colorado, Washington, or other places? What happens is we normalize that behavior by not only telling people that we are allowing them to use that to do those things, but that we expect them to be able to control their use of those things. We have a wider range of people that use that drug, so then now we see pictures of people in marijuana shops in Colorado and they don’t have the image that we used to have of drug users.
They are people in the broad spectrum of society, people with jobs or people with families, and recognizing that and at the same time making people aware that it’s possible to use drugs and still to maintain an orderly and positive life, it makes easier for people to behave that way with drugs. That’s true of every drug that we know.
I just described how in a way we normalize smoking by implementing where it can be done. We know that with alcohol, many people want to allow their children to drink when they are teenagers so that they can learn how to manage that experience before they go way to college and they learn a style of drinking that’s being truly excessive.
I’s possible—and this is a hard thing to convey to people--to do that with every type of drug. Let me step out on the precipice and say it’s possible with narcotics. We don’t recognize the range of usage patterns, but we see now that deaths from narcotic painkillers exceed by many times the number of overdose deaths for heroin and cocaine. But most everybody has used a painkiller.
We need to allow people to understand the process of using painkiller while you use them for a purpose that has a specific place in your life. Perhaps you got an operation and you want to use it in the aftermath of that operation. That shows the generic process that’s involved in controlling all forms of drug use. A policy that isn’t hysterical, that doesn’t penalize people from simply using a substance, but only if they misuse it in a way that brings harm to other people, would allow us to rein in the kinds of undesirable substance behavior that is sometimes associated with drugs, but is actually caused by the very policies that we use supposedly to allow us to manage drugs in our society.
Pat Deming: I have a couple of comments Peele and I’d like to see you speak about this confluence of treatment and policy a little more. One of the things is that I really believe that treatment is policy on the ground. The way that we conduct treatment in this country is allowed to continue partly because of our drug policy and the methodologies that Americans have adopted about addiction, a lot of the things that you’ve spoken about.
For me one of the main things that I think needs to happen is that we really need to do a concerted effort to get AA, and other 12 set programs out of treatment because they’re not treatment. They’re meant to be spiritual development self-help programs. Even though the courts have agreed in a number of cases that judges should not be allowed to mandate somebody to AA because it violates the religious freedom, they still do so regularly.
I just had a patient a few weeks ago who was denied access to our treatment center and forced to go to AA despite the fact that the judge knew that that wasn’t good. What I’m wondering is that how do we go about that given that there’s this belief that AA is the only way? How do we go about moving 12-Step programs out of treatment and allowing them to take their rightful place as a spiritual support of community?
Dr. Peele: It’s clear every time it’s been decided that AA is religious. Turning yourself over the will of God is just a religious activity. Every court has considered that as religious activity, including the 9th Federal Circuit court which controls California, Hawaii, Oregon and Washington.
Government agencies are not allowed to force you into a religious practice when you resist that and it’s not natural to your own belief system. No case has been lost arguing that. Nonetheless, it’s remarkable the degree to which that still persists in our world. Of course, now we’re talking about drug courts as well, where we channel people through the legal system into these semi-religious kinds of organizations. It shouldn’t be done and it shouldn’t be allowed. And who are we sentencing to this kind of experience, one that can really just change your old way of thinking?
I mean a lot of people say, 'Well, I never really thought of my drug use is being out of control or a disease until I went to a disease-oriented kind of treatment.' We’re doing the reverse of changing water into wine. We’re changing wine into water where we take people who are possibly moderate, controlled or occasional users and siting them in our program. Of course we only know how to deal with them either legally or ultimately by this one form of treatment that tells them that they can’t possibly control their drug use. They must be out of control.
Ie always been four square about that. The law is clearly on our side. I’ll give you this. There’s one practical suggestion to you, Pat. Write the court and say, 'It’s my understanding that I can’t be compelled to attend the 12-Step Program when that’s against my own personal beliefs. Can you please put in writing that you’re declining to give me that right, that it’s your view legally that I should not have that right.' Given the legal decisions that have come down, I don't believ any court in the country is going to say that. Public officials have even been found liable for violating people's civil liberties when they've done that.
Let me switch to a whole other topic. AA is not a treatment and AA is also not self-help. I want to refer back to ‘Wild’ again, the large majority of people overcome addiction eventually in their lives on in their own. Now, obviously I’m encouraging people to make their own choices. God bless them if they want to go to a church. God bless them if they want to go AA. It’s a free country.
But to tell people, as we do tell them, you can’t overcome an addiction unless you go to AA or a support group or treatment is now insupportable. You have to tell them that people overcome addiction all the time. That’s one way to go. I think that’s a very empowering insight.
By the way, let me tell you one thing. Anyone who has seen me speak has seen me do this. I ask a group of counselors 'What’s the toughest addiction to quit?' These are people who’ve been through a lot of addictions, both treating them and experiencing them, and they always shout out in unison 'Smoking cigarettes, nicotin.' Then I say, 'Ah, that’s amazing. That’s remarkable.' Has anybody in this room quit smoking?'
I’m in a room where 600 people of a thousand would raise their hands. I hope you see where I’m going now. Then I say, 'Oh, did you join a support group, go to treatment, or use psychoactive drugs in order to overcome smoking?' That’s common now, but the point nobody in the room has raised their hand. I say, 'Well, that’s the most remarkable thing I’ve ever heard. You just told me that the hardest substance addiction to quit, a majority of people in this room have quit that addiction, and none of you has relied or an externally agency to do that.'
Of course, probably they’ve gotten help, and friends have helped. We can get into how they overcame that, but it happens all the time and all you have to do is be open to the people, to the life, to the human beings around you to recognize that reality.