Good grief. What a fine entry into the social construction of disease! Like one author, I am "long interested in the philosophical meaning of disease." I'll take a run at analyzing this..

While I'm not sure what the objective criteria of "knee-jerk reaction" are, here's what I notice in the editorial:

The senior author (Satel) is at a noted right-wing think tank, the AEI, most famous recently for their Exxon-funded denials of climate change. Other scholars and fellows include Charles "Bell Curve" Murray, Paul Wolfowitz, Ben Wattenberg, Lynn Cheney, Christian Hoff Sommers, and Fred Dalton Thompson.  Let's see .... spreading freedom through racism, imperialist war, demographic fear-mongering, hostility toward free speech and the arts, unreconstructed sexism, and --um, Republican party rule. Birds of a feather, the AEI scholars have flocked to leave no field undenied in their efforts to "cure" the moral sinfulness of not being just like them.

Satel's books are P.C. M.D.: How Political Correctness is Corrupting Medicine (2001) and Drug Treatment: The Case for Coercion (1999). But anyone can get published; more worrisome is her advisory seat at the Substance Abuse and Mental Health Services Administration. They made the news recently for refusing to allow the term "gay." I'm so relieved to see the AIE hasn't left anyone off their list of targets for intolerance.

Co-author Scott Lilienfeld appears to have done some good work critiquing "pop" therapies for mental and behavior disorders.   It's a far cry, however, from debunking (or scientifically assessing) an ineffective treatment to questioning the existence of the illness. I think the authors have confused the two. Here's one way to find out.

If I reword the essay to replace the word "addiction" with, say, high blood pressure, or epilepsy, or overweight - or being female or poor, for that matter - it remains remarkably and equally persuasive. For example:

"Self-governance, in fact, is key to the most promising treatments for
[epilepsy]. For example, relapse prevention therapy helps patients identify cues—often people, places, and things—that reliably trigger a [seizure]."

That paragraph reads equally true if you insert the word "high blood pressure."  Or asthma, or tension headaches, or the sudden nausea and acid stomach cramps that may come on when you are suddenly confronted by an irrational bigot in full cry. Of course, many illnesses (or most) have behavioral and social components. Even infectious diseases fit the authors' picture of illness as a personal failing:

Yet [people with malaria] rarely spend all of their time in the throes of an intense [fever] siege. In the days between [bouts], [malaria sufferers] make many decisions that have nothing to do with [the illness]. Should they try to find a different job? Kick that freeloading cousin off their couch for good? Register for food stamps? Most of the patients one of us treats hold jobs while [still suffering from untreated malaria].

Good heavens, one could even substitute the words "grief over the loss of one's child" or "spouting Republican rhetoric" for "being addicted" and the whole thing would read perfectly!  Except, I don't think the intensity of right-wing bigotry has yet been mapped through brain scans. There's an interesting research idea there...

Satel & Lilienfeld do discuss brain scans, in their only nod to actual science. However, it looks to me not only like a simplistic reduction of science fact and medical findings to social and subjective morality, it even points to the logical error in their own argument:

"It's easy to be misled into believing that these colorful images prove that the addict is helpless to change his behavior. In a powerful experiment, Deena Weisberg, a doctoral candidate at Yale University, and her colleagues presented nonexperts with flawed explanations for psychological phenomena. They were adept at spotting the errors—until, that is, these explanations were accompanied by "Brain scans indicate … " With those three words, Weisberg's participants suddenly found the flawed explanations compelling."

Ah yes, the mistaken attribution of authority to science rhetoric or credentials, instead of science fact. Interesting that their article uses the same strategy of making claims: that their scientific credentials "as a psychiatrist who treats heroin addicts and a psychologist long interested in the philosophical meaning of disease" bolster their arguments that public shame, legal punishment, and a turn to God would be much more effective than medicine in the treatment of addictive conditions.

I would have liked to see some science data rather than a single People Magazine-style anecdote about actress Jamie Lee Curtis getting sober by turning to God.  They could at least run their own highly publicized experiment to prove the efficacy of their three-pronged therapy (stigmatization, legal coercion, and intense religious reprogramming).  My modest proposal would involve asking, say, Larry Summers to see if this would change his beliefs about women, e.g., that:
"Telling the public that [being underrepresented in science] is a "[result of women's brains]" suggests that [a woman]'s disembodied brain holds the secrets to understanding" why they end up in the social roles they do. "It implies that medication is necessary and that interventions must be applied directly at the level of the brain."

Indeed. That does sound ridiculous. As an alternative, if Summers turned to God and 12-step groups like Jamie Lee Curtis (I believe the public stigmatization has already been applied), he too might quickly find that:

"[Sexism] is not as hopeless or uncontrollable as the brain disease metaphor suggests. Yes, like other bad habits, it is in our brains—but like other bad habits, it can be broken."

For a control, the experiment could use one of the actual women scholars Summers addressed. Oh, wait ... US women are already subject to the effects of stigmatization, legal coercion, and intense religious rhetoric.  Like people who are poor, immigrant, obese, gay, atheist, agnostic, middle eastern, environmentally concerned, politically radical, non-white, unmarried, or Dennis Kucinich supporters.  I guess this effort to separate the "natural" from the cultural components of socially stigmatized positions is already confounded.

Satel & Lilienfeld's arguments seem like a strange use of science.  By defining a biological condition that includes behavior as being only voluntary and social, they seem to empty out meaning from medicine. At the end, I can't figure out whether they even have a definition of "illness" or "disease." They appear to be extreme constructivists. I'm sure that the last thing an AEI scholar would want to be is a post-modernist.  Either they are actually trying to "use the enemy's tools against him," or they've just proved social constructivism's point. 

(Or they just managed to get me completely confused :-)

Michael, curiosity: Do you read Slate for fascinating examples of propaganda like this, or do they also do any real journalism?  I appreciate this weird editorial and will tuck a copy in my Canguilhem or Latour .... and keep hoping most addiction researchers -- and federal legislators -- rely on good science instead of bad self-help advocacy.


On 7/27/07, Michael Balter <[log in to unmask]> wrote:
Careful and thoughtful reading of this Slate article, no knee-jerk reactions please!


Michael Balter
Contributing Correspondent, Science
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