Wankers and prankers on the suicide hotline

CC Licensed Photo by Flickr user kev-shine. Click for source.The New York Magazine‘s new Science of Us section has an interesting review of a new documentary on hotlines – whether they be for suicide support or phone sex.

I was initially annoyed at the fact that the documentary puts both of these in the same category but it’s based on the interesting premise that hotlines – whether for mental health, sex or supporting members of a particular marginalised community – often involve the common component of lonely people reaching out to connect with a stranger, briefly, through conversation.

I don’t know how good the documentary is, I haven’t seen it, but interestingly the review was by an writer who himself had worked on a mental health support lines.

As a result the piece has some wonderfully insightful points about the emotional experience of working as a telephone support counsellor. I was really struck by this section:

Hotline mentions the masturbators, at least — cretins who call up and simply breathe heavily into their phones as they do their thing (at Samaritans, I never had to deal with them because they’d hang up and call back until a female picked up the phone). But the film doesn’t delve into other common experiences volunteers go through, such as how it feels to listen to and empathize with a desperate-sounding 12-year-old girl for seven devastating minutes, only to hear her — and the friends who have apparently been in the room with her the whole time — crack up with laughter, revealing her whole soul-crushing story of sexual abuse to have been a prank.

The problem is, after you’ve hung up angrily on the masturbator or the slumber-party pranksters, your phone is inevitably going to ring in another minute or five, and you have to somehow return to that place of empathy and openness, because the next person who calls may really need your help. It’s a strange sort of emotional bombardment, and Hotline missed an opportunity to unpack it a bit.

In the support hotline world, these callers are known as ‘wankers and prankers’ and they are surprisingly common. You probably wouldn’t imagine that people phone up suicide hotlines to whack off or wind people up, but it is common enough that most services have specific procedures to deal with these nuisance callers.

Many of these lines have a policy where the hotline attender doesn’t hang up on the caller, because people with the most disordered ways of accessing the services might be the ones who need it most.

To deal with this, some services have a specific person each shift whose job it is to listen to persistent masturbators. When they call they can just ask for ‘Julie’, or some other code name, and be passed on to the designated nuisance call monitor, who listens out for any signs that the person has something relevant they want to discuss.

This reduces the number of times people in the front line have the emotionally jarring experience of going from distressed suicidal people to ‘wankers and prankers’, meaning they’re better able to be open and empathetic for people who need it, and are less emotionally drained themselves.

It’s a strange corner of the mental health support world which has to overcome the foibles and dysfunction of social behaviour for which it was never designed to address.
 

Link to review of Hotline documentary.

More on the enigma of blindness and psychosis

A long-standing enigma in psychiatry has been why no-one has been able to find someone who has both congenital blindness and a diagnosis of schizophrenia. The newest and most comprehensive archive study to date has just been published on exactly this issue although it raises more questions than it answers.

Evelina Leivada and Cedric Boeckx from the University of Barcelona in Spain conducted an extensive medical literature search and did come up with some cases of congenital blindness and schizophrenia – 13 in total, although only two case studies (outlining a total of four cases) were found which were convincing enough to be unaffected by other serious problems, like severe genetic disorders.

And these remaining four were hardly straightforward and as one report was from 1943 and the other from 1967 where standards of both vision and psychiatric assessment were significantly short of modern standards.

Notably, all cases of co-occurrence were from blindness due to eye problems or where blindness happened relatively late (after 6 years of age). No cases were found were people had a diagnosis of schizophrenia and were congenitally cortically blind – where blindness was caused by problems with the brain’s visual system.

What this new study provides is weak evidence for the possibility of certain sorts of blindness coexisting with a diagnosis of schizophrenia and more comprehensive support for the curious finding that blindness seems to reduce the risk of developing psychosis.

It’s worth noting that what is really needed is a prospective epidemiological study of psychosis in blind people. However, researchers have been searching for congenitally blind people with psychosis since the issue of non-co-occurrence was first seriously raised in the 1980s and none have been found. Based on the rates of occurrence for each condition, the combination should be fairly common. This suggests that hypothesis of protective effects of congenital blindness needs to taken seriously.

The Leivada and Boeckx paper goes on to speculate about neuropsychological reasons why congenital blindness might protect against schizophrenia (essentially, changes in the interaction between key visual system components and the language system) and, somewhat less convincingly, genetic reasons – as just extrapolating likely genes from case studies is very speculative and both the eye and brain develop from the same cells during embryo development so it’s not clear shared genes won’t just reflect generally impaired neurodevelopment.

I have to say, I find the concept of schizophrenia to be a fairly useless, but if the increasingly plausible hypothesis that congenital blindness protects against psychosis is confirmed, it has interesting implications for those that argue that psychosis is nothing but the result of marginalisation, stigma or difficult life circumstances where biological explanations are irrelevant.

Blindness, clearly would increase your chances of all of these, and so on this theory, we would expect an increased rate of psychosis, but this doesn’t seem to be the case.

It’s not that marginalisation, stigma or difficult life circumstances aren’t causal factors in developing psychosis, they clearly are, but ignoring neuro-level explanations outside these effects is equally as narrow as suggesting that they are the only relevant influences.
 

Link to ‘Schizophrenia and cortical blindness’ in Frontiers.

Buggin’ Out

Sociology journal Transition has a fascinating article giving a history of the surprisingly frequent appearance of schizophrenia in rap music.

In psychiatric circles, schizophrenia is considered a serious mental illness that causes delusions, hallucinations, and social withdrawal. But in rap, schizophrenia means something else: a mode of defiance, a boast, or a threat. The term appears frequently when describing competition between rappers. In “Speak Ya Clout,” the duo Gang Starr rhymes that they are “schizophrenic with rhyme plus we’re well organized” as a way of warning that they are “stepping rugged and tough.”

Schizophrenia also enhances claims of competitive violence—in “16 on Death Row,” 2Pac famously warned that, “I’m kind of schizophrenic, I’m in this shit to win it.” Schizophrenia also helps rappers describe collective responses to racism or injustice. In the multi-artist hit “Everything,” Busta Rhymes calls for action by rapping, “Panic and schizophrenic, sylvy-Atlantic / Wrap up your face in ceramic, goddamit we controllin the planet.”…

Yet something much larger than mere sampling is at play in rap’s use of the terms schizophrenia and schizophrenic. Rap lyrics are the latest installments in a political debate that has evolved over the past century (at least) regarding the contested relationships between race, madness, violence, and civil rights… At stake is a series of existential and material questions about the causes, actions, and implications of sanity itself.

The article is locked but a pdf has made its way online.

It’s a fantastic piece that traces how schizophrenia and psychosis have become deeply politicised, racially charged concepts.

They were used to pathologise black civil rights protesters, whose demand for equal rights were considered part of a ‘protest psychosis’, and have been used in civil rights discourse to symbolise the effects of a racist society.

And this is how it seems to have ended up as a borrowed badge of pride for generations of MCs.

The piece is by psychiatrist Jonathan Metzl who also wrote the definitive history of the so-called ‘protest psychosis’ and it serves as a great introduction to an important chapter in the bitter history of race, psychiatry and psychosis.
 

Link to locked Transition article in JSTOR.
pdf of full-text.

An earlier death

Journalism site The Toast has what I believe is the only first-person account of Cotard’s delusion – the belief that you’re dead – which can occur in psychosis.

The article is by writer Esmé Weijun Wang who describes her own episode of psychosis and how she came to believe, and later unbelieve, that she was dead.

It’s an incredibly evocative piece and historically, worth remembering.

Somatic details figure heavily in these recollections: what I wore, what I looked like. I told myself, through mirrors and dressing-up and Polaroids and weighing myself, You have a body. The body is alive.

But the more that I tried to remind myself of the various ways in which I did, in fact, seem to have a body that was moving, with a heart that pumped blood, the more agitated I became. Being dead butted up against the so-called evidence of being alive, and so I grew to avoid that evidence because proof was not a comfort; instead, it pointed to my insanity.

 

Link to ‘Perdition Days: On Experiencing Psychosis’

Mental health debates without the stress

If you work in mental health, you could do much worse than reading the editorial in today’s Lancet Psychiatry about unpleasant debates and how to avoid them.

Unfortunately, debates in mental health tend to get nasty quite quickly – but I’ve seen no part of the debate spectrum which has a monopoly on bigotry or a blessed surplus of consideration.

But instead of throwing up their hands in despair, the editorial team wrote some sensible guidance on bringing some respect to moving mental health forward.

The first is to assume the best of one’s opponent: that their argument proceeds not from self-interest, financial interest, or wilful ignorance, but from genuine curiosity and a desire to improve the lives of people with mental health problems. There is a view that so-called punching up to perceived figures of authority is justifiable and necessary, but punching up is still punching someone. There is always potential in the discussion of mental health issues to trigger distress, as everyone, patient or professional, has an unseen personal history and sensitivity.

Second, it is worth questioning whether one line of investigation or treatment necessarily diminishes the other. Although a holistic medical perspective on mental distress is useful, alternative types of assistance might also be of value. Such services need to be taken seriously, evaluated thoroughly, and, when appropriate, considered for public funding. Perhaps some arguments about which model of research or practice should be prioritised would be better resolved by a united campaign for better funding across the board.

Third, as Sun Tzu advised, know your enemy. Do not dismiss biological data as an irrelevant folly, nor philosophical and sociological analysis as a form of obscurantism. Take some time to consider your opponent’s intellectual discipline, and how his or her work might be criticized on its own terms. This might be a long, difficult, and tedious process, but it is what patients, and the public, deserve.

The final point is to ensure that those whose voices are not listened to enough are given the space and opportunity to be heard. Their numbers include individuals such as mental health nurses and social workers, who provide a large amount of care but who are given little time compared with psychologists and psychiatrists. Most important, the voices of patients must be “airtime” respected in all their diversity. If a new form of mental health care is to be built, all involved would do well to remember the three principles of James Madison, President of the USA and father of its constitution: compromise, compromise, compromise.

A tip of the hat to you.
 

Link to Lancet Editorial ‘Duel diagnosis’ (via @PsychiatrySHO)

A cultural view of agony

painNew Statesman has a fascinating article on the ‘cultural history of pain’ that tracks how our ideas about pain and suffering have radically changed through the years.

One of the most interesting, and worrying, themes is how there have been lots of cultural beliefs about whether certain groups are more or less sensitive to pain.

Needless to say, these beliefs tended to justify existing prejudices rather than stem from any sound evidence.

Some speculated whether the availability of anaesthetics and analgesics had an effect on people’s ability (as well as willingness) to cope with acute affliction. Writing in the 1930s, the distinguished pain surgeon René Leriche argued fervently that Europeans had become more sensitive to pain. Unlike earlier in the century, he claimed, modern patients “would not have allowed us to cut even a centimetre . . . without administering an anaesthetic”. This was not due to any decline of moral fibre, Leriche added: rather, it was a sign of a “nervous system differently developed, and more sensitive”.

Other physicians and scientists of the 19th and early 20th centuries wanted to complicate the picture by making a distinction between pain perception and pain reaction. But this distinction was used to denigrate “outsider” groups even further. Their alleged insensitivity to pain was proof of their humble status – yet when they did exhibit pain reactions, their sensitivity was called “exaggerated” or “hysterical” and therefore seen as more evidence of their inferiority.

 

Link to New Statesman article (via @SarahRoseCrook)

The normality trap

I remember taking a bus to London Bridge when, after a few stops, a woman got on who seemed to move with a subtle but twitchy disregard for her surroundings. She found herself a seat among the Saturday shoppers and divided her time between looking out the window and responding to invisible companions, occasionally shouting at her unseen persecutors.

By East Street, the bus was empty.

You’ve probably encountered fellow travellers who are strikingly out of the ordinary, sometimes quite distressed, scattered among the urban landscape where they seem to have a social forcefield around them that makes crowds part in their presence.

If you’ve ever worked in a hospital or support service for people with psychological or neurological difficulties, you’ve probably met lots of people who are markedly out of step with the mundane rules of social engagement.

They seem to talk too loud, or too fast, or too much. They can be full of fantastical things or fantasies. They may be afraid or angry, difficult or disengaged or intent on rewind-replay behaviours. Their dress can be notable for its eccentricity or decay.

So why don’t we see people like these in anti-stigma campaigns?

Don’t get me wrong, I’m a massive fan of the great work anti-stigma campaigns do. Everybody is susceptible to mental health problems and the reason these campaigns are necessary is that they often go unrecognised by other people and instead of help, too often people receive misunderstanding and ignorance.

But there’s more to mental health than normality.

That woman on the bus shouting at her voices, she deserves respect too. That guy who posts those leaflets about Masons and thought-stealing all over town, deserves your time. The guy that speaks in a clumsy monotone voice and doesn’t look you in the eye, is also worthy of compassion.

Disability charities don’t base their campaigns solely on ‘nice people in wheelchairs’. They’re happy to show people who represent the full range of appearance and presentation. So why not mental health?

Step up mental health organisations, you’ve got nothing to lose except your conformity.

The genetics of intelligent radio

BBC Radio 4 has just concluded an excellent three-part series on the controversies over the genetics of intelligence and it’s one of the best and most nuanced discussions you’ll hear about the topic for many years.

The series is called Intelligence: Born Smart, Born Equal, Born Different and it’s carefully put together, wide in scope and doesn’t shy away from either tough science or difficult issues.

The only point I’d make about is one of context: most of the discussions apply to Western populations. This is not a point about race but one about environment.

Calculating heritability for a particular trait, in this case for cognitive function, involves working out how much of the difference between people is accounted for by genetics and the environment. But the result only holds for similar populations in similar environments.

For example, malnutrition, disease and high levels of environmental neurotoxins (e.g mercury from illegal gold mining) have a massive impact on cognitive function in kids and are clearly all environmental, rather than genetic, contributors to cognitive function.

But when most of these studies are done, these serious environmental effects have been screened out either explicitly (for example, by not including people who have pre-existing damage through neurotoxins in the study) or implicitly (because, for example, malnutrition barely exists where most heritability of intelligence studies are done).

The qualified conclusion is that general cognitive function is largely heritable when the most significant environmental effects on cognitive function have already been removed. This would be true for many European kids, for example, but much less so for kids from, let’s say, South Sudan.

The programme doesn’t claim otherwise, and lucidly describes how heritability is population specific, but it’s worth bearing in mind how much of the subsequent discussion addresses issues more relevant to the developed world than the one fifth of the world’s population who live in extreme poverty.

Either way, if you want to get up to speed on the debate about intelligence, cognitive function and genetics, the BBC Radio series is an excellent place to start and you’ll come away much smarter as a result.
 

Link to ‘Intelligence: Born Smart, Born Equal, Born Different’
Link to podcast page for the series.

The poly themes of psychosis

The latest London Review of Books has an amazing first-person account of psychosis that illustrates the complex interlocking webs of ideas and perceptions that can occur in the more intense versions of the experience.

As a description of the lived-experience of psychosis, it is actually quite rare, because most are written about relatively (and I mean relatively) circumscribed or contained experiences which clearly do not reflect reality but have their own internal logic.

These are perhaps the most common forms that psychosis takes but some are bizarre, intense and complex, involving delusions that seem to encompass a huge number of themes (known as polythematic delusions).

I met a woman called Margaret in Fairmile hospital. I assumed she was my link to the politician with the same first name. She explained periods to me. I wondered if the PM was angry with me for writing a story saying she deserved to hang for sinking the Belgrano. I tried to manoeuvre Margaret around to the front of the hospital so that a Rolls could pull in off the main road and take me to Mrs Thatcher. She didn’t seem very willing to comply. The shrink had been watching me and asked why I looked up at the sky when helicopters flew over. They were sent by Francis Pym to rescue me. Despite the massive grounds around the Victorian building the choppers never seemed to land. I soon realised I would do six months unless I staged a recovery. I stopped looking at helicopters and after only three months I was free.

One of the difficulties with a lot of discussion about mental health and mental health treatment is that ‘psychosis’ is assumed to be a single thing or variations of a single thing, when in fact it can vary massively both in terms of how the person experiences it and how it impacts them.

I have met people who have delusions and hallucinations but continue high powered jobs (probably, so have you, without realising it) whereas other people are massively disabled and / or distressed by their experiences.

As with most difficulties in life, those who are most affected are the least able to advocate for themselves, so this article stands out as a sharply written piece that captures some of the ever-woven web of intense psychosis.
 

Link to first-person account of psychosis in The LRB.

Coma alarm dreams

Intensive Care Medicine has published a wonderfully written and vivid account from a teenager who spent time brain injured and hallucinating in an intensive care unit.

The writer describes how he was admitted to intensive care at the age of 15 after suffering a head injury and had intense and bizarre hallucinations which are, as we know now, surprisingly common in critical care patients.

My experience of the time under sedation can be split into two. There was what I could perceive of the real world around me, and then there was my dream world.

In the real world, the most constant feature was sound. I could hear the nurses talking, understanding everything they said. They always spoke their names. They were always kind, conscious I think that I might hear them. They helped me to relax. I could hear the noises of the ward, tones of voices and alarms. The alarms made me tense. I can remember Mum talking to me a lot and Dad reading me ‘The Hobbit’, although I still can’t remember the names of all the dwarves. Mum and Dad’s voices always came from the left.

My other senses were not wholly switched off either. Things were put in my mouth: tubes, sucky things, wet watery pads and a toothbrush. Someone moved my hair about. I felt furry and silky toys placed under my fingers. My brother and sisters had brought a knitted tortoise and a horse for me. My feet were moved about and stretched, which felt really good. I remember that the rolled-up bed sheets were uncomfortable.

Other sensations were less good. The constant, repetitive shining of a bright light in my remaining eye really annoyed me – I am sure I can remember every single time.

Then there was my dreaming. I lived in the dream world nearly all the time and it went on and on. The dreams were vivid, terrifying and very disturbing. There were some good ones but unfortunately for me a lot of really bad ones. I can still remember most of them even now, more than a year since.

At the sound of an alarm, a giant monster appeared with a meat cleaver and pursued me around the sports hall. I had to protect a girl and prevent an army from crossing a river. The whole river and hall were aflame. I was burning from the heat.

In another I had to stop an alarm-driven colossal centipede from crossing a bridge. I could see the shadow of monsters looming towards me behind a curtain. I knew the monsters were there and about to consume me, but I lay transfixed, unable to move, and I remember feeling myself sweating with excruciating fear. I was then on the bridge of a nuclear submarine with maniacs trying to blow up the world, there was a huge explosion. Then it ended.

I was aboard a flying craft. I was there to stop green-coated aliens from creating human missiles. The aliens were forcing people into missile tubes. They were going to drop the human bombs from the aircraft.

Then there was a shape-shifter leopard beast chasing me and my friends. We were working in a fast-food place on a ship. It cornered us, and the Kentucky Fried Chicken sign burst into red lightning.

But I knew when something really nasty was going to happen. I could always hear the same alarm going off. It was a signal for the monsters to appear, for the centipede to attack, for bombs to be dropped, I would be sacrificed…I was very afraid. Tension would build to some hideous climax. Looking back, I suspect the pressure in my brain was causing both the nightmares and the alarm to go off.

I have made a great recovery from my injuries due in large part to the excellent care that was taken of my brain in intensive care. I have been into see the team a few times but I never stay too long. Those alarms still make me feel nervous!

As I noted in a recent article, these sorts of hallucinations were thought to be a distressing but ultimately irrelevant part of recovery but more recent studies suggests that have longer-term psychological impact that can be problematic in its own right.
 

Link to locked article ‘Coma alarm dreams on paediatric intensive care’

This is how stigma works

Sussex Police issue a statement about ‘Concern for missing Chichester man’, ITN News report it as ‘Police warn public over missing mental health patient’.

Sussex police:

Police are appealing for information about missing 43-year old Jason Merriman, who left The Oaklands Centre for Acute Care in Chichester on unescorted leave at 12.45pm on Friday 11 April. He was due back the same afternoon but has so far failed to return.
There are concerns for Jason’s welfare as he has mental health problems, and police advise that he is not approached by members of the public.

ITN News:

A mental health patient who has been missing from a care unit in Chichester for more than a day should not be approached by the public, police have warned.

Amazing really – (via @Sectioned_)

Is there creative accounting in behavioural economics?

The Financial Times has an excellent article on the future of behavioural economics.

Despite the fact that it is an incisive piece on a form of applied psychology that won Daniel Kahneman the Nobel Prize and has revolutionised political thinking, the FT has entitled the article ‘Behavioural economics and public policy’, to ensure it doesn’t arouse any passions which could bias your understanding of the text.

Ignore the title though, and it’s a fascinating and astutely critical piece on how the promises of behavioural economics haven’t always delivered and where it needs to go next.

So popular is the field that behavioural economics is now often misapplied as a catch-all term to refer to almost anything that’s cool in popular social science, from the storycraft of Malcolm Gladwell, author of The Tipping Point (2000), to the empirical investigations of Steven Levitt, co-author of Freakonomics (2005).

Yet, as with any success story, the backlash has begun. Critics argue that the field is overhyped, trivial, unreliable, a smokescreen for bad policy, an intellectual dead-end – or possibly all of the above. Is behavioural economics doomed to reflect the limitations of its intellectual parents, psychology and economics? Or can it build on their strengths and offer a powerful set of tools for policy makers and academics alike?

It’s by economist Tim Harford who also does good things on the Twitter.
 

Link to FT article ‘Behavioural economics and public policy’.
Link to alternate copy on Tim Harford’s blog.

Respect is a medicine

Aeon magazine has an excellent article on how social interactions among medical team members affect clinical outcomes, patient well-being and the number of medical errors that occur.

It’s probably worth saying that the vast majority of doctors and warm and respectful people but it remains one of the last professions where teaching though humiliation is given a place to survive.

The article in Aeon looks at research on teamwork, communication style and respect and finds out that this ‘treat ’em mean, keep ’em keen’ attitude actually leads to higher rates of medical errors.

…many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence. That fear is good for doctors-in-training and, by extension, good for patients. That public shaming holds us to higher standards. Efforts to change the current climate are shot down as medicine going ‘soft’. A medical school friend told me about a chief resident who publicly yelled at a new intern for suggesting a surgical problem could be treated with drugs. The resident then justified his tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’

Arguments such as these run counter to all the data we have on patient outcomes. Brutality doesn’t make better doctors; it just makes crankier doctors. And shame doesn’t foster improvement; it fosters more mistakes and more near-misses. We know now that clinicians working in a culture of blame and punishment report their errors less often, pointing to fear of repercussion. Meanwhile, when blame is abolished, reporting of all types of errors increases.

This, incidentally, tends to impact on certain students and trainees more than others. I still meet medical students who want to train as psychiatrists but have to suffer being humiliated in front of their peers by senior doctors when the inevitable ‘what speciality are you interested in’ question comes up.

The Aeon article is a brilliant analysis of the dynamics and interactions in medical teams and why respectful communication and a supportive teaching style is actually better medicine in terms of medical outcomes.
 

Link to Aeon magazine on interactions in medicine.

A reality of dreams

The journal Sleep has an interesting study on how people with narcolepsy can experience sometimes striking confusions between what they’ve dreamed and what’s actually happened.

Narcolepsy is a disorder of the immune system where it inappropriately attacks parts of the brain involved in sleep regulation.

The result is that affected people are not able to properly regulate sleep cycles meaning they can fall asleep unexpectedly, sometimes multiple times, during the day.

One effect of this is that the boundary between dreaming and everyday life can become a little bit blurred and a new study by sleep psychologist Erin Wamsley aimed to see how often this occurs and what happens when it does.

Some of the reports of are quite spectacular:

One man, after dreaming that a young girl had drowned in a nearby lake, asked his wife to turn on the local news in full expectation that the event would be covered. Another patient experienced sexual dreams of being unfaithful to her husband. She believed this had actually happened and felt guilty about it until she chanced to meet the ‘lover’ from her dreams and realized they had not seen each other in years, and had not been romantically involved.

Several patients dreamed that their parents, children, or pets had died, believing that this was true (one patient even made a phone call about funeral arrangements) until shocked with evidence to the contrary, when the presumed deceased suddenly reappeared. Although not all examples were this dramatic, such extreme scenarios were not uncommon.

This sometimes happens in people without narcolepsy but the difference in how often it occurs is really quite striking: 83% of patients with narcolepsy reported they had confused dreams with reality, but this only happened in 15% of the healthy controls they interviewed.

In terms of how often it happened, 95% of narcolepsy patients said it happened at least once a month and two thirds said it happened once a week. For people without the disorder, only 5% reported it had happened more than once in their life.

Although a small study, it suggests that the lives of people with narcolepsy can be surprisingly interwoven with their dreams to the point where it can at times it can be difficult to distinguish which is which.

If you want to read the study in full, there’s a pdf at the link below.
 

Link to locked study at Sleep journal (via @Neuro_Skeptic)
pdf of full text.

Heroin, addiction and free will

The death of Phillip Seymour Hoffman has sparked some strong and seemingly contradictory responses. What these reactions show is that many people find it hard to think of addiction as being anything except either a choice or a loss of free will.

The fact that addiction could involve an active choice to take drugs but still be utterly irresistible seems difficult for most people to fathom.

Let’s take some reactions from the media. Over at Time, David Sheff wrote that “it wasn’t Hoffman’s fault that he relapsed. It was the fault of a disease”. On the other hand, at Deadspin, Tim Grierson wrote that the drug taking was “thoughtless and irresponsible, leaving behind three children and a partner”.

So does addiction trap people within its claws or do drug users die from their own actions? It’s worth noting that this is a politicised debate. Those who favour a focus on social factors prefer prefer the ‘trap’ idea, those who prefer to emphasise individual responsibility like the ‘your own actions’ approach.

Those who want to tread the middle ground or aim to be diplomatic suggest it’s ‘half and half’ – but actually it’s both at the same time, and these are not, as most people believe, contradictory explanations.

To start, it’s worth thinking about how heroin has its effect at all. Heroin is metabolised to morphine which then binds to opioid receptors in the brain. It seems to be the effects in the nucleus accumbens and limbic system which are associated with the pleasure and reward associated with the drug.

But in terms of motivating actions, it is a remarkably non-specific drug and it doesn’t directly cause specific behaviours.

In fact, there is no drug that makes you hassle people in Soho for a score. There’s no drug that manipulates the neural pathways to make you take the last 40 quid out of your account to buy a bag of gear. No chemical exists that compels your hands to prepare a needle and shoot up.

You are not forced to inject heroin by your brain or by the drug. You do not become an H-zombie or a mindless smack-taking robot. You remain in control of your actions.

But that does not mean that it’s a simple ‘choice’ to do something different, as if it was like choosing one brand of soft drink over another, or like deciding between going to the cinema or staying at home.

Addiction has a massive effect on people’s choices but not so much by altering the control of actions but by changing the value and consequences of those actions.

If that’s not clear, try thinking of it like this. You probably have full mechanical control over your speech: you can talk when you want and you can stay silent when you want. Most people would say you have free will to speak or to not speak.

But try not speaking for a month and see what the consequences are. Strained relationship? Lost job maybe? Friends who ditch you? You are free to choose your actions but you are not free to choose your outcomes.

For heroin addicts, the situation is similar. As well as the pleasurable effects of taking it, not taking heroin has strong, negative and painful effects.

This is usually thought of as the effects of physical withdrawal but these are not the whole story. These are certainly important, but withdrawing from junk is like suffering a bad case of flu. Hardly something that would prevent most people from saving their lives from falling apart.

For many addicts, the physical withdrawal is painful, but it’s the emotional effects of not taking drugs that are worse.

Most smack addicts have a frightening pre-drug history of trauma, anxiety and mood disorders. Drugs can be a way of coping with those emotional problems in the short-term.

Unfortunately, in the longer-term, persistent drug use maintains the conditions that keep the problems going. Even for those few that don’t have a difficult past or unstable emotions, life quickly become difficult after regular heroin use sets in.

If you can stay high, you’ll be less affected by the consequences of both long-standing problems and your chaotic lifestyle. If you stop, you feel the full massive force of that emotional distress.

It’s vicious circle that is often set in motion by past trauma but requires a meeting with a drug and the right social circumstances. Just taking the drug until you develop tolerance and withdrawal is unlikely to addict most people.

For example, a Vietnam War study found that just under half of soldiers reported trying heroin, 1 in 5 developed full blown dependency while in Vietnam but only about 5-10% of the dependent soldiers continued using when they arrived home. Most said they gave up without any help and only a small minority had ongoing addiction problems.

In fact, some of you reading this may have been addicted to heroin and not known it. Heroin, under its medical name diamorphine, is commonly used as a painkiller after major surgery. It’s not uncommon that patients develop tolerance and go into withdrawal after they leave hospital but just put it down to ‘feeling poorly’ or ‘recovering’.

But for persistent addicts, the ‘short-term solution that maintains the long-term problem’ cycle is not the whole story and it’s important to remember the neurological effects of the drug and how it interacts with, and changes, the brain.

Addiction is associated with difficulties in resisting cravings and making flexible decisions. This is likely to be caused by a combination of genetics, earlier experience and the ongoing impact of the drug and the drug-focused lifestyle – all of which affect brain function.

A recently popular approach is the ‘disease model’ of addiction which says that the brains of those who become addicted are more susceptible to compulsive drug use because of genetic susceptibility and / or brain changes due to early experience that ‘prime’ the brain for addiction.

It’s probably true to say that the extreme version of the ‘disease model’ – which says addiction is entirely explained by these changes and is best characterised as a ‘brain disease’ – is an exaggeration of what we know about the neuroscience of addiction, but this is not to say that neuroscience is not important.

But either way, there is no clear relationship between an aspect of behaviour being best explained in neurobiological terms and not having any control over that behaviour. For example, most genuine addicts usually give up, on their own, without any assistance and don’t relapse. They still have brains, of course.

Unfortunately though, the ‘disease model’ approach is often used precisely because some think it implies addicts have less control, possibly because they feel (probably wrongly) that it is less ‘stigmatising’ to think of heroin users in this way.

Instead, we know that self-efficacy is one of the best predictors of recovery, so denying people’s role in their own decisions just undermines one of their most important tools for recovery – alongside medication, social support and other forms of therapy.

So to say an addict has ‘no choice’ over their actions is just to misunderstand addiction but to pretend these choices are like any others just misses the fact that they can sometimes be impossibly hard decisions.

Unfortunately though, people find it hard to separate any admission of addicts being able to choose their actions from blame and moral accusation.

Blaming someone for their addiction is like shaming someone for being wounded by an abusive partner. Whatever the circumstances that caused the problem, they deserve respect and treatment, and working with them to help them regain control of their circumstances and promote their own autonomy is an important and valuable way forward.

Revenge is not sweet

An interesting paper in the snappily titled International Journal of Offender Therapy and Comparative Criminology examines what we know about the psychology of revenge.

It has a fascinating section where it discusses how often people take vengeful actions and whether they actually bring any relief.

It seems that taking revenge is rare, but when it happens, it is not only remarkably unsatisfying but counter-productive in terms of dispelling the desire for retribution.

Empirical research by Crombag, Rassin, and Horselenberg (2003) showed that most people do not actually take revenge but merely have thoughts, feelings, and fantasies about it (see also Crombag, 2003). Most people become reconciled with the offender and many people decide to let bygones be bygones. Some of the people who did take revenge could not explain their reason for doing so…

It should be noted that, in the study of Crombag et al., the group of people who took revenge even after a period of time still struggled with more vengeful feelings than the people who did not take revenge. Although 58% experienced satisfaction and 16% experienced triumph, only 19% reported their vengeful feelings to be completely gone, compared with 40% of the people who did not take revenge.

A 2008 study found that one reason that people who do take revenge find it hard to move on is that taking action keeps them ruminating about the events.
 

Link to locked paper on the psychology of revenge.