Drug abusers should just say sorry

Opinion Article

2007 December, 8

Retired AFL star Gary Ablett last week gave a long interview explaining the reasons for his use of psychoactive substances including cocaine and heroin over many years. Ablett’s drug use had disastrous consequences for him: a young admirer, Alisha Horan, died after having overdosed on drugs supplied by him. Ablett said in the interview that he now realises “how destructive [his behaviour] was, spiritually, emotionally, relationally, financially. It affects every area of your life.”

The two main schools of thought in substance abuse policy are harm prevention and harm minimisation. Proponents of harm prevention tend to assume that substance abuse unavoidably has severe effects on the individual and society; the harm minimisation camp believes, whilst not denying that some substances are physiologically and psychiatrically damaging, that a different policy and different social attitudes would remove much of the harm experienced by people like Ablett and prevent deaths like Horan’s.

The best way to move beyond the locked positions of the substance abuse debate is to discuss thoroughly why some people start using psychoactive substances (and addictive processes such as gambling) habitually. This question can properly be discussed without a priori committing to particular policies in relation to psychoactive substances (though many people would probably prefer to perform the analysis backwards and favour a theory of the reasons for drug use that supports their permissive or restrictive policies).

Ablett’s interview is interesting because he powerfully states in layman’s terms a politically and socially influential theory: that drug use involves self-medication.

“I have battled with bouts of depression right throughout my life and it got to a point where I was so desperate to relieve it I started to experiment with drugs”, Ablett said. “Most people have no idea just how debilitating and painful depression is. I started using cocaine thinking it was the answer, and for the first time in a long time I wasn’t depressed. So I continued to use cocaine and then ecstasy, not realising how destructive it was until later on. I began to use more cocaine and got caught up in the party scene over two or three years.

“It’s basically self-medicating, a coping mechanism. It’s time society realised people who have a drug problem are not necessarily bad people, they're hurting people. Most of our behaviour is…people just trying to meet their needs, because unmet needs produce emotional pain in our lives. That’s why it is foolish to try to correct behaviour without first seeking to understand the needs that motivate and drive that behaviour.

“People need our love and understanding, not our condemnation. Doctors talk about addictive personalities – there's no such thing. It’s how much emotional pain there is in a person's life. The more pain there is, the more vulnerable and prone they are to get hooked on something that relieves their pain. It’s time we realised that drugs are not the problem but a symptom of far deeper issues, both in people’s lives and in our society.

“As a society we are so blind and superficial, and only see secondary causes and symptoms, and fail to identify and recognise the real issues and deal with them, then wonder why we don’t see the change we so desperately need.”

Ablett is wrong. In the words of that lay movement which understands addiction more keenly than is appreciated by those who engage in public discourse about addiction, Alcoholics and Narcotics Anonymous, Ablett is in denial. Ablett’s ascription of his descent into addiction as self-medication against depression or any other personal or social problem is a post-facto rationalisation of the process which led him into drug use.

The problem with Ablett’s analysis is that there are many people who suffer from depression who are not and will not become addicted to drugs. There are also many, many people who do not suffer mental illness, and whose socio-economic and personal circumstances could not be better, who become addicts.

The late Swedish psychiatrist, Nils Bejerot, rejected the symptom theory of substance abuse. Bejerot separated those factors that are primary contributors to substance abuse and those factors that may make individuals susceptible to experimenting with substances and behaviours that trigger and eventually hijack the brain’s internal chemical reward system.

Certainly there is a strong correlation between depressed circumstances of individuals and communities and substance abuse: my home region of Cape York Peninsula is testament to that. Historical factors and contemporary dysfunction also make communities susceptible to outbreaks of substance abuse epidemics. But susceptibility factors are only indirectly causal factors of uncontrolled use of psychoactive substances.

We must make a clear distinction between susceptibility factors and primary contributing factors.

The primary contributing factors are:

• Availability of the addictive substance  

• Money to acquire the substance  

• Time to use the substance  

• Example of use of the substance in the immediate environment  

• A permissive ideology in relation to the use of the substance

These five factors can be summarised as opportunity to experiment with and then use the addictive substance.

Depression may well be a susceptibility factor but it is not a causal factor. The same goes for other forms of social and personal problems that individuals experience in society or within their own psychology: they may increase individual susceptibility to drug experimentation, but drug experimentation is not an inevitable outcome of these problems.

The symptom theory is debilitating because it tells us that the behaviour (of drug experimentation and use) is not the problem, it is merely a symptom of a whole range of personal, social and economic factors causing the behaviour.

The key sentence in Ablett’s account of his thinking is this: “[Use of psychoactive substances is] basically self-medicating, a coping mechanism.” The theory of self-medication is the most insidious form of symptom theory thinking because it uses the most compelling examples of addicts (those suffering acute depression and young people who have been abused) to make the case that their use of drugs was unavoidable and understandable: they were medicating against their pain.

Ablett is expressing an emerging popular, political and academic consensus that self-medication is a major cause of debilitating substance abuse. Conservatives (including socially conservative members of the Left) who continue to view substance and process abuse as problems in their own right are not successful in the debate, because the socially conservative catchphrase “tough on drugs” is easily dismissed by the harm minimisers as intellectually unsophisticated.

When Ablett seeks to explain the depression that allegedly caused his drug use, he says that “unmet needs produce emotional pain in our lives.” We as society fail to “identify and recognise the real issues and deal with them”, he says.

It’s unclear whether Ablett advocates the social constructivist idea that mental illnesses are not biological inevitabilities and that we could have a society free of depression.

This progressive utopianism is probably factually wrong; nothing suggests that humankind is living through a temporary deviation from a natural happier state of affairs, or a depressing transition from Marxian ur-communism to a class-less society. In any case, the notion that the answer to substance abuse lies in a heroic transformation of society is practically useless: we cannot even conceive of a credible alternative to the ascendant global system of liberal market-based societies tempered by social welfare, which determines our personal circumstances.

When Ablett urges us to deal with the real issues, he (and most adherents of the self-medication school of thought) probably do not advocate social revolution. They argue that severe and long-term substance abuse is a symptom of mental problems, which unfortunately will affect some people; that the mental pain predates the abuse, and that the correct response is to help the troubled individual to treatment.

AA have an aphorism aimed at tackling denial: is it the problems that caused your drinking or the drinking that has caused your problems? When it comes to alcohol, the drinking songs of country and western music contribute greatly to the popular form of denial: I am drinking because the wife used to nag me and has now left me and the dog died. When in truth the wife nagged me and left me because of my drinking and the dog died because I ran him over when driving drunk.

As well as this mundane (and widespread) form of denial, there is a more difficult explanation of addiction which recovered addicts often express. A spiritual epiphany is frequently an aspect of individual rehabilitation from addiction (indeed AA and NA’s 12 steps centre on this). I do not seek to refute that there is a spiritual dimension to addiction and rehabilitation, however my contention is that in reconstructing the trajectory of their personal descent into addiction, recovered addicts are prone to identifying subjective reasons for their behaviour which may not be objectively correct. We could all look back on a life of pain and “unmet needs” and reconstruct how and why we became addicts. My point is that there are understandable reasons for misinterpretation in this process.

The true history of Ablett’s descent into addiction is that the addictive substances were available in the social world that he occupied and he had the money and the time to indulge in them. He was recruited to this use by persons in his immediate environment, and large sectors of Australian society were and are permissive about the use of these substances.

Whether the initial susceptibility to experimentation on the part of an individual such as Ablett is explained in his need for relief from pain or whether it is explained by the pursuit of sheer hedonistic pleasure, can perhaps be debated endlessly. Although Ablett is entitled to his own explanation of his own story, he is wrong to offer his story as confirmation of the social theory of self-medication, which I believe is fundamentally mistaken.

Drug abusers should just say sorry