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Don't Confuse Mental Health With Addictions

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January 28th is the annual Let's talk campaign by Bell to raise awareness about and reduce the stigma of mental illness. And, through this campaign, Bell has committed over $60 million for mental health in Canada. This is a commendable program and an example of good corporate responsibility. However, what would also be a tremendous benefit in reducing the stigma of mental illness is for governments and the health industry to end the partnership between mental illness and addictions.

The two are intertwined and treated as equals when they are not. As examples, the Mental Health Commission of Canada combines mental health and addictions, there are institutions like the Centre for Addiction and Mental Health in Ontario and of course the Substance Abuse and Mental Health Services Administration in the U.S. It may seem like I am speaking against conventional wisdom in suggesting that addictions and mental illnesses are different but I'm not.

Consider this. No one makes a decision to suddenly develop psychotic delusions or the mania of bipolar disorder or the crushing darkness of depression. These are illnesses that just happen as do other illnesses like MS or Parkinson's or rheumatoid arthritis. They are not our choice and they are not welcome but they happen and we have to contend with them as best we can.

That is not the case with addictions. No one forces anyone to take that first drink or chemical and to continue in self destructive behaviour. There is an element of free will in addictions. Peg O'Connor, who teaches philosophy at Gustavus Adolphus College in St. Peter, Minnesota, explored the issue of addiction as a disease or as choice in The Fallacy of the Hijacked Brain in the New York Times.

The term the hijacked brain, she says, is used to suggest "the addict's lack of choice in the matter. Sometimes the pleasure-reward system has been 'commandeered'. Other times it 'goes rogue'. These expressions are often accompanied by the conclusion that there are 'addicted brains'".

"In the 'hijacked' view of addiction, the brain is the innocent victim of certain substances" and "The drugs or the neurochemicals produced by the behaviors overpower and redirect the brain's normal responses, and thus take control of (hijack) it."

As the hijacker in any situation is the villain and the hijacked is the victim, is it really possible to hijack yourself? If you believe that, she says, then you would believe that it is possible to give yourself a gift when you pass money from your right hand to your left hand and then to send yourself a thank you card. That is known as a nonsense or category mistake.

If you know that taking that chemical will result in negative consequences, then you should not do so. And when you do, it was your choice. As Ms O'Connor concludes "Addicts are neither hijackers nor victims. It is time to retire this analogy."

Psychiatrist Sally Satel and psychologist Scott O. Lilienfeld also make a similar argument in their excellent book Brainwashed, The Seductive Appeal of Mindless Neuroscience. Chapter three is called Addiction and the Brain-Disease Fallacy. The impact of choice is clearly demonstrated in their recounting of heroin and opium use in Vietnam in 1970. It was estimated that nearly half of enlisted troops in Vietnam had tried opium or heroin and that between 10 and 25 per cent were addicted.

Afraid that returning addicts would join the addicted in US inner cities, compulsory drug testing was introduced and no one was permitted to return until they had passed the test. Those who failed were put into a detox program. Almost all who went through the program passed the test and returned home and only 5% of those relapsed after 10 months. Just 12% relapsed briefly after three years.

By the mid 1990s, Satel and Lilienfeld argue, the lesson of Vietnam had been lost and the concept of "once an addict, always an addict" was a truism along with the concept that addiction is a chronic brain disease. That, the authors argue is "fundamentally bad science". They go on to say that "the disruptions in neural mechanisms associated with addiction do constrain a person's capacity for choice, but they do not destroy it."

And, they say, quitting is the rule not the exception. One study they cite done in the early 1980s with 19000 people found that of those who had become drug dependent by age 24, half later had no drug related symptoms. By age 37, 75 per cent reported no drug problems. Another study involving 43,000 people between 1990 and 1992 and again between 2001 and 2003 found that 77 and 86 per cent who had initially been addicted reported no problems during the year before the survey.

Their conclusion is that:

The brain-disease narrative misappropriates language better used to describe such conditions as multiple sclerosis or schizophrenia - afflictions of the brain that are neither brought on by the sufferer nor modifiable by the desire to be well. It offers false hope that an addict's condition is completely amenable to medical cure (much as pneumonia is to antibiotics).

How often have people with serious mental illnesses been told to get over it or to smarten up? That might be appropriate to say to an addict but it is not appropriate for someone with a blameless illness. And by continuing to lump addictions in with mental illnesses we perpetuate the opinion that there is an element of choice in mental illnesses.

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