Peele, S. (2015). Why neurobiological models can't contain mental disorder and addiction. In Deacon, B., and McKay, D. (Eds.), The Biomedical Model of Psychological Problems. the Behavior Therapist, October 2015, 38(7): 218-222.
Why Neurobiological Models Can’t Contain Mental Disorder and Addiction
Stanton Peele, Brooklyn, NY
The Contemporary Rush to Reductionism in Mental Disorders
In 1981, I wrote “Reductionism in the Psychology of the Eighties” for American Psychologist. Here are two quotes from that text worth considering 35 years later. First, from neuropsychiatrist Richard Restak (1977):
[I]t’s hard to leave out the exclamation points when you are talking about a veritable philosopher’s stone—a group of substances [the endorphins] that hold out the promise of alleviating, or even eliminating, such age-old medical bugaboos as pain, drug addiction, and, among other mental illnesses, schizophrenia. (emphasis added)
Restak is a physician. But one of the leading figures in psychology of that era, Norman Garmezy, wrote for the 1975 American Psychological Association Master Lecture series four decades ago:
We stand on the threshold of advances in the biological sciences so relevant to psychopathology that one can look forward in the decades ahead to an ultimate resolution of the major psychotic disorders that have plagued mankind for centuries. (emphasis added)
(Need I note that neither of these professionals has/had ever done neuroscientific research? Garmezy’s specialty, resilience, would seemingly resist reductionism.)
We might fairly ask at this point, “How are we doing?” In fact, as former New England Journal of Medicine editor Marcia Angell (2011) asserted (based primarily on Whitaker, 2010) in the New York Review of Books, we are experiencing an epidemic of mental disorder, one tracing back to exactly the period in which I was writing (when DSM-III [APA, 1980] was published). Not only have entirely new categories of mental disorders been identified (e.g., ADD) and then proliferated, but formerly rare diagnoses (e.g., bipolar disorder) have exploded in their incidence, along with virtually every other type of mental disorder (e.g., depression). And, per Restak, there is addiction, which I will discuss separately.
More than being misguided, Restak and Garmezy were completely wrongheaded; their predictions were diametrically opposite of what has actually occurred. But what’s most interesting is that they and others who have taken these positions— and continue to do so—feel no need to apologize for such miscalculations. Indeed, the same predictions have been made continuously in the period since then and are frequently today. They are welcomed as wholeheartedly by scientists, the public, the media—and, seemingly, psychology—as they were in the 1970s. As Deacon (2013b) observes in “The United States of the Biomedical Model,” “It is difficult to overstate the ubiquity and influence of the biomedical model that provides the foundation for psychiatric diagnosis and treatment in the United States.”
Objections and Alternatives to the Biopsychiatric Revolution
But this isn’t working. In fact, the only potential result of this headlong rush to reductionism is to exacerbate our emotional and addictive vulnerability, both culturally and individually. Here are six progressively more fundamental relationships between our reductive views and approaches and the epidemic of mental disorder (DSM, of course, refers to “mental disorders,” including substance use disorders, formerly addiction).
1. The view that we have erroneously departed from the true biological bases for mental disorders
In this view, we are casting the mental disorder net too broadly, and redefining normal behavior as diseased. Allen Frances (2013), who was the Chair of the DSM-IV Task Force, is perhaps the main proponent of this viewpoint and of the idea that Big Pharma is behind this expansion. But Frances is a true believer in biological causation, and simply feels we have departed from this gold standard in defining mental disorder. This is a variation on the view of the head of the National Institute of Mental Health, Thomas Insel, that DSM-5 fails because it is too behavioral, whereas we need “to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience” (Belluck & Carey, 2013; cf. Insel, 2010).
This view pervades contemporary thinking, with the result that “the biomedical model era has been characterized by a broad lack of clinical innovation and poor mental health outcomes” (Deacon, 2013a). As Belluck and Carey note: “Basic research into the biology of mental disorders and treatment has stalled, . . . confounded by the labyrinth of the brain. Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions.” This confusion follows the disintegration of optimism about finding the genetics of mental disorder through the massive, decade-long Human Genome Project, completed in 2003, which has led to no diagnoses, treatments, or certainly answers for mental disorders (Peele, 2013a). A coordinator for a multisite, bigdata analysis of the genetic basis of the principal mental disorders declared, “these [individual] genetic associations individually can account for only a small amount of risk for mental illness, making them insufficient for predictive or diagnostic usefulness by themselves” (NIMH, 2013).
So, we see, the failures to find reductive causes and cures for mental disorders lead to continuing speculation, further and further removed from human experience, about their biological sources. The focus is now on the brain impulses underlying behavior, thought, and mental disorder, as represented by the new massive successor to the Human Genome Project—the BRAIN Initiative (Peele, 2013c).
2. Drug treatments hurt our brains
The most severe critics of the bio-diagnosis and treatment of mental disorder— i.e., Angell and the principal book she reviews for the New York Review of Books, and from which the title of her article is derived, Robert Whitaker’s Anatomy of an Epidemic—argue persuasively that psychiatric medications damage the brain. Whitaker (2010) shows that the introduction of new psychiatric medications never reduces the incidence of the disorders being treated, but rather does the opposite, and that the benefits from these medications for individuals taper over time, and wash out entirely, even reverse, when the individual chooses or is forced to quit the medication. One reason for this, according to Angell, is that “the use of antipsychotic drugs is associated with shrinkage of the brain, and that effect is directly related to the dose and duration of treatment.” The drugs themselves, Angell and Whitaker argue, exacerbate mental disorder through their impact on the brain. While data support their position, this argument reinforces the idea that mental disorder can be described solely through physical manifestations of the brain (although both Angell and Whitaker would undoubtedly reject this idea).
3. Reductive thinking is stigmatizing and antitherapeutic
A less reductive, more experiential view of how biological psychiatry hurts mentally ill people is that this view reduces therapeutic empathy and increases stigma for the mentally ill. Lebowitz and Ahn (2014; p. 17786) empirically investigated this dynamic, finding that:
biological explanations evoked significantly less empathy. These results are consistent with other research and theory that has suggested that biological accounts of psychopathology can exacerbate perceptions of patients as abnormal, distinct from the rest of the population, meriting social exclusion, and even less than fully human. … This is alarming because clinicians’ empathy is important for the therapeutic alliance between mental health providers and patients and significantly predicts positive clinical outcomes.
4. How we think as a culture causes mental disorder and addiction
Arthur Kleinman’s (1991) work is the missing ingredient in global criticisms of biopsychiatry. Humans think about themselves in the categories provided by their cultures. We are incapable, for the most part, of questioning our social and cultural assumptions. These categories are for us simply realities, virtually as real as gravity and the daily appearance of the sun and the moon. As a result, people internalize cultural memes: we conform our behavior, even our emotions, to them (Kirsch, 1999). That is, we examine our behavior and feelings and put ourselves into the cognitive categories available to us. This is a subtle process that operates in addition to how our agency, or resilience, or hope for recovery, or ability to control our behavior exacerbates mental disorders (cf. Deacon & Baird, 2009). For instance, simply believing in the disease theory of addiction makes people more likely to relapse (Heather, Winton, & Rollnick, 1982; Miller et al., 1996).
5. Our cultural investment in reductive treatments lessens our ability to address the actual cultural, social, and human sources of mental disorder and addiction
Keith Humphreys, an influential community psychologist in the addiction field, strongly advocates for the curative impact of broad environmental factors (White, 2011): “what all three of those great thinkers (Rudolph Moos, et al.) make clear is that in the long-term, most people are made better by the broader world and not by short-term treatments.” In response, his interviewer, Bill White, notes: “In Philadelphia, we have introduced the concept of community recovery—the idea that whole communities can be wounded by a critical mass of alcohol and other drug problems and that a community-level healing and recovery process may be required to restore the health of individuals, families, neighborhoods, and the community as a whole” (see White & Evans, 2014).
Humphreys and White both correctly indicate that addictive (and mental health) problems are best addressed, societally and individually, by enhancing societal and community resources. And, yet, they are among the most forceful defenders of Alcoholics Anonymous, 12-step, and disease-based folk treatments. In order to maintain these contradictory positions, they must ignore that infusing our culture and individuals with the “addiction-as-disease” meme depletes the attention and money devoted to the very community resources (e.g., housing, education, individual case management) that support recovery from both mental disorder and addiction. Instead, the disease concept fuels investment in expensive but ultimately ineffectual medical treatments. Imagine, for instance, removing someone from a deprived environment to a residential treatment site for some period and then redepositing him or her in that same environment without assisting the person to find a way of making a living or a stable home. Humphreys and Rappaport (1993) illuminated how this process began during the Reagan and Bush administrations as the federal government rebudgeted basic funding from direct social services to funding for treatment. This is the American version of anti-community psychiatry; it is a path to mental health disaster from which we seemingly cannot depart.
6. Belief that one is infested with a disease depletes the resilience and self-efficacy that are the best guards against addiction and mental disorder, and the most effective therapeutic process for overcoming them
CBT is built on the concept of self-efficacy, that psychological amelioration is the result of belief in one’s control over oneself and one’s environment. Not only does inculcating the belief that mental disorder and addiction are diseases undercut the self-efficacy essential to recovery, the disease model saddles the person with the belief that they have a lifetime deficiency— their addiction becomes a core part of their self-concept, of their being. Nothing is more self-defeating than this idea, as Ilse Thompson and I argue in Recover! Stop Thinking Like an Addict (Peele & Thompson, 2014). Yet more societal energy and greater societal effort are put to this way of thinking all the time.
Addictive Brain Disease
Perhaps even more than in the case of mental disorder, the chronic brain disease model of addiction has been embraced by both scientists and—fed nothing else—the public. Following on the endorphin revolution Restak announced, beginning in the 1980s, schematic views of the brain with regions specified for causing addiction have regularly graced the covers and pages of Time, Newsweek, and Scientific American. This public relations effort in the area of addiction has been cheer-led by Nora Volkow, Director of the National Institute on Drug Abuse, who has achieved a unique international public status. NIH Medline Plus (2007), for instance, presented “The Science of Addiction: Drugs, Brains, and Behavior”:
Two NIH institutes that are already on the forefront of research into drug and alcohol addiction recently joined with cable TV network HBO to present an unprecedented multi–platform film, TV, and print campaign aimed at helping Americans understand addiction as a chronic but treatable brain disease. . . . Many Americans today do not yet understand why people become addicted to drugs or how remarkable scientific advances are literally redefining the arena of addiction, notes Nora D. Volkow. (From NIH Webpage.)
The prestigious international journal Nature (2014) declared addiction a brain disease with nothing more than a generic reference to Volkow’s claims.
Drug addiction is a disease. Images of the brains of addicts show alterations in regions crucial to learning and memory, judgment and decision-making, and behavioural control. . . .The brain’s central reward system is overstimulated and flooded with dopamine. The brain adapts to this flood by turning down its ability to respond to dopamine — so addicts take more and more of the drug to push dopamine levels higher. . . .
None of that is particularly controversial, at least among scientists.
Here are five objections to this model (Peele & Thompson, 2014):
1. Brain images represent the effects of drugs, and have never been related to compulsive drug-taking (or any other behavior).
There is no brain scan according to which a person can be said to be addicted, as opposed to showing the acute or chronic effects of cocaine or another drug or powerful experience. No one is diagnosed as “addicted” based on a brain scan. And no one ever will be. (Peele&Thompson, 2014, p. 21)
2. Rather than addiction comprising a chronic brain disease, recovery without treatment (i.e., natural recovery) is the typical course for addiction (Heyman, 2013; Lopez-Quintero et al., 2011; Peele, 2014a).
3. No brain images distinguish between compulsive and episodic users, and particularly those who cut back or quit (common paths taken by long-time users), versus those who do not.
4. Stimulation of these same areas of the brain and dopamine flooding occur with a wide variety of appetitive behaviors and emotional reactions (seeing a baby smile, sex, food, romantic love, gambling, ad infinitum), all of which can be measured in brain images.
5. Higher-SES addicts show far better remission rates than impoverished or socially deprived people who are addicted.
The Volkow dopamine model of addiction outlined by Nature is itself over a decade old (cf. Volkow, Fowler, & Wang, 2004). Yet, while Nature (2014) glorifies Volkow and her mission—”Europe should look to the United States and to inspirational figures such as Nora Volkow”—Volkow and her colleagues have not generated a single diagnostic or prognostic tool, nor any treatment for addiction. Nature remains optimistic: “Given the technical tools now available for looking deep inside the brain, there is realistic hope that such treatments will emerge from research in the coming decades.”
The note Nature sounds—”hope that such treatments will emerge from research in the coming decades”—is more restrained than Restak’s vision of “alleviating, or even eliminating, such age-old medical bugaboos as pain, drug addiction, and, among other mental disorders, schizophrenia” or Garmezy’s “ultimate resolution of the major psychotic disorders” made 40 years ago. This caution is necessary because no one believes that mental disorders, substance abuse and addiction, as well as DSM-5’s newly recognized category of behavioral addictions (cf. Peele, 2014b), have been declining and are likely to decline in some foreseeable time frame.
Worse, biomedical models in the form of drug treatments for addiction have demonstrated their counter-efficacy. A study conducted by investigators whose own Center for Global Tobacco Control had spent millions on nicotine replacement therapy (NRT) tracked over several years smokers who either relied on NRT or did not in order to quit. The odds of relapse for a heavily dependent NRT quitter who had quit less than 6 months were 3.5 times that for a heavily dependent quitter who quit without NRT or professional help (Alpert, Connolly, & Blener, 2012). Apparently, those who quit on their own were more confident in their ability to control their own destinies—that is, they had higher self-efficacy, which is a self-fulfilling belief (Peele & Thompson, 2014).
In another remarkable demonstration of the failure of the neuropsychiatric and pharmacogenetic approach to addiction, a group central to the promotion of these views, Oslin et al. (2015) found no differences between double-blinded alcoholdependent subjects receiving either naltrexone or placebo on percentage of days of heavy drinking, number of heavy drinking days per week, number of drinking days per week, number of days until first heavy drinking, and weekly cravings. The authors’ conclusion— “Despite the results of this trial, pharmacogenetics continues to hold promise as a way to improve the targeting of medications to improve treatment response” (p. E6)—is yet another demonstration that reductionism cannot be refuted by mere facts, research, and data.
Note: these results do not disprove that alcoholic subjects reacted to naltrexone, only that they were subjectively able to reproduce entirely the drug’s effects in therapy.
Conclusion—Addicted to Failure
In his tour-de-force satire referencing NIMHdirectives, Brett Deacon (2014) captures their vision,whichDeacon characterizes as “we’re about to solve all of mental disorder momentarily, but unfortunately we haven’t gotten to first base, and we don’t know in which direction first base is.” On this basis, I argued in favor of a nonreductive view of human behavior:
There is an idea—no longer very popular in America—that personality traits, human behavior, and psychopathology just don't exist at the level of biochemistry, that the effort to “reduce” them to this level falls prey to the philosophical fallacy of “reductionism.” Instead, these human manifestations entail all of our lived experience, our physical settings, and our social relationships. After all, even the most committed biological determinists recognize the impact on children of deprivation and abuse. (Peele, 2013b)
Meanwhile, our brain revolution has resulted in no diagnostic tools or effective treatment while the prevalence of the maladies of concern grows, in many cases exponentially. And, yet, the dominant public health and political forces in the U.S. and internationally push the brain disease approach ever harder. There is nothing— except an unlikely return to reason and empiricism—to stop these forces from continuing to expand their influence as a paradoxical reward for their failures. As one answer to the question of how we are doing, the latest version of the National Epidemiologic Survey on Alcohol and Related Conditions found a 50% increase in past-year alcohol-use disorders between 2001–2002 and 2012–2013 (Grant et al. 2015).
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I am indebted to Brett Deacon for suggestions and ideas for this article and to Archie Brodsky for his careful review.
Correspondence to Stanton Peele, Ph.D.; firstname.lastname@example.org