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The Gay Men's Health Summit By Walt Odets
I would like to talk today about models for substance use and abuse and start by saying that our theoretical models are not
the world. An architect's model of the Empire State Building is not only not the Empire State Building, it is not a building at all. While many models clearly have utility,
the utility does not offer itself because the model is, or describes, the truth.
Over the past thirty years, substance use and abuse have usually been described by one or a combination of three models: the epidemiological model, the social model, and the medical
model. All three models, in some contexts and for some purposes, can provide useful insight. Epidemiology can give us indications of the who, what, where, and when and in what
kinds of probable numbers. Social models can, as one example, describe peer group dynamics that influence patterns of substance use. The medical model - which is largely a disease, addiction, or pathology
model - can describe some of the physiological or neurophysiological mechanisms of some kinds of substance use.
In my experience as a clinical psychologist all three models have only limited utility in helping people understand the human purposes and meanings of their substance use, and only limited utility in helping people change
in important ways. The epidemiological model may identify "high risk" groups, but people don't actually do things because they are members of an
epidemiologically-conceived group. Epidemiology can talk only of associations, not causes and we do not know, as one
example, if gay men have unprotected sex because they use crystal; if gay men use crystal to allow themselves otherwise
forbidden unprotected sex; or if certain gay men both use crystal and have unprotected sex for other, unknown reasons -
depression being one obvious example. Social models suffer from some of the methodological limitations of epidemiology and are usually disciplinarily limited to a description of interpersonal, as opposed to intrapsychic
issues. The third of these models - the medical, disease, or addiction model - is the one I will focus on for the remainder of my talk. Over the past thirty or so years, the medical model has become the
premier model used to think about and address substance use and abuse.
Whether alcoholism is a disease in the conventional medical sense of the idea is questionable to me, but a discussion beyond the scope of this talk. In any case, the utility
of the model for specific purposes should probably decide that question. The matter of addiction is somewhat clearer. Addiction is a verifiable physiological process in which there is cellular
adaptation to the ongoing presence of a substance; increased tolerance due to the cellular adaptation; the need for increased dosing to offset tolerance and maintain a given clinical effect; and cellular re
adaptation - the withdrawal syndrome - on discontinuation of the substance. The alcoholic or opiate user who maintains a fairly consistent substance blood level is addicted. The binge drinker is not
addicted. And neither are the weekend crystal user, the E or K user, the sexual compulsive or the compulsive shopper.
The medical model has accomplished some important things: It has detached moral stigma from substance use - particularly
the stigma of "weak character" - and it has given rise to some effective interventions that pragmatically curb or stop the
abuse itself. What the model has not done well - what it has often obstructed - is to help clarify why people use substances.
Disease in the true medical sense does not need reasons and does not have meaning in itself. It is a physical pathology. We do not or should not speak of the purposes of a virus in the sense of human
purposes. But substance use is not only a biological process, it is something that people do and something that they subjectively experience. Because that is the case, I would like to talk about why
people might do that, what their purposes and motivations - conscious and unconscious - might be in doing that, about what the human meanings of substance use might be.
As a psychologist who daily listens to gay men explicate their feelings, I am uncomfortable with the medical model's removal
of human meanings from substance use. When people do things - particularly impairing, destructive things like "careers" in crystal - it is obvious to me that there is meaning
in the behavior. An exclusive medical model to explain such behavior is a scientific reductionism that is increasingly common in our explanations of human life. One scientific reductionism tells us
that human life - including our subjective experience of consciousness - is truly nothing more than a series of biochemical
events. While true in the description of one model - that of the microbiologist - this description cannot mean that we are simply to dismiss the significance of subjective human consciousness. Our mental lives
- our thoughts, joy, and pain, or our thrill at the smell and touch of another human body - are not to be simply dismissed in the face of a microbiologist's explanation.
As painful as it is to acknowledge the situation of this man and thousands like him, are not some of the meanings of crystal in our lives obvious
? Do we really not understand the substantial benefits John got from crystal? Does the idea of addiction,
disease, or simple pathology adequately describe what was going on here? In therapy, it became clear that crystal allowed
John a much more positive experience of himself and thus a connection with other men that was both essential and, without crystal, impossible for him. In this understanding, his use of crystal was an adaptive
response to emotional conflicts and limitations that he did not otherwise know how to address or resolve. With crystal, he could emerge from an excruciating isolation and make desperately needed sexual and emotional
connections with other men. Before I continue with what may now appear an unbridled enthusiasm for the benefits of crystal, let me acknowledge the
other side of the obvious: The abuse of many substances - crystal not least among them - can, itself, grow into a substantial
and crippling problem, and one that creates extremely destructive - so-called "secondary" - consequences. It can also
become the means to avoiding any insight about anything. It is not only the medical-model people who recognize these
serious problems. John, and most serious users, are well aware in moments of relaxed denial that they suffer negative
consequences of use. As with a majority of users, one of the most difficult problems working with John was having him acknowledge the benefits
he derived from crystal. Because of his own negative experiences with the drug - and particularly because of his assumptions about other's expectations - he was very inclined to talk about crystal as if it were nothing more
than an involuntary, addictive phenomenon that he would sooner be rid of. How do we understand this man - having arrived
at an adaptive, if deeply flawed, solution to his haunting loneliness - insisting upon the idea that the whole thing was meaningless?
If crystal provided John occasional, brief - and often unsatisfactory - respite from his depression and loneliness, it was not
because he had developed insight about his self-esteem issues and interpersonal isolation and prescribed himself an antidepressant. It was the very point of his crystal use to not
experience such feelings, feelings most powerfully conscious during attempted - often aborted - connections to others. Thus - and this is the crux of what I want to say - to
acknowledge the meanings of his crystal use meant looking at the very feelings John used crystal to try and bury below
conscious awareness. Acknowledging that crystal helped him feel desirable and able to connect with others meant acknowledging his more usual feelings of being fundamentally un
desirable and his feelings of almost unbearable isolation. Here is the real danger of reductionistic models for substance use: They too easily collude with the very process they purport to interrupt and "cure."
If the medical model has rightly extricated substance abuse from destructive moral stigma about things like "weak character,"
the idea that the "disease" might express emotional needs often feels as if it pushes the substance issue right back into the
province of moral issues. Physical distress is still much more acceptable than emotional distress. Disease is still much more
acceptable than feelings, and among gay men with HIV and AIDS, we have seen an acceptance by family, society, and Elizabeth Taylor that was never extended when we were merely homosexual - and often suffering quite badly in
psychological ways for that. If substance abuse is about feelings, then human complexities are reintroduced into a discussion that we hoped could be as "simple" which is also to say as
meaningless as a broken leg. Well, human life is about feelings. Those of us working with problematic substance use must help clarify the meanings in human life rather than
dismiss them with a scientific reductionism that pursues often relatively empty behavioral change and easy social approbation.
There is a popular idea that a meaning-based, interpretive approach does not work. This is expressed in the
detox-first-and-I'll-talk-to-you-in-six-months model. In fact, the approach works all the time, and there are good reasons to
let it work. Our ultimate purpose in attempting to help others is not simply to stop a particular behavior. Our purpose is not
to transform compulsive substance use into compulsive abstinence. Our purpose is, or should be, to clarify the experience motivating
the abuse, to understand the compulsivity, and by doing that to have the abuse over time become superfluous. It is only by understanding the meanings of our substance use that we can understand the possibility of life
without it. This is the clarification that brings about real change and that helps a person find his or her sober authenticity. It is
in finding that authenticity that we find lives that feel like our own and feel reasonably fulfilling.
I would like to close with one additional thought about the medical model and its invocation in LGBT lives. We have not
only used the model to demonstrate that our substance use is without meaning. We now invoke the model - in the form of
genetic or inutero explanations - to explain why we are who we are. I would like to offer the possibility of keeping the
meaning in being lesbian, gay, bisexual, or transgendered by asserting that we have every right to be who we are - not because it's not a choice and we can't help it - but because we want
to be who we are. That's the beginning of an understanding that will assist authentic self-respect and help make substance use - and especially abuse - much less a part of our lives. TOP OF PAGE |
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