Unmasking the Sociopolitical Dimensions of Mental Distress

It is clear that addiction was not just an issue of medical science but also one of identity, power, commerce, and fear—as well as one of devotion.

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Following excerpts adopted from the author’s latest book, The Urge: Our History of Addiction, published by Penguin.

I am lying in bed when I hear the commotion. I peer through the doorway of my room, and right outside, the new guy is getting in Ruiz’s face. There’s a phone right outside the door, one of those sturdy metal payphones—it looks like it’s been carried in from the street—and Ruiz, a gentle older man with shoulders stooped by the demoralization of his nth relapse and hospitalization, is just trying to talk to his family. But the new guy has been manic and pacing since he arrived a few hours ago, and he won’t take no for an answer.

I watch the new guy stalk the other way across the doorway, muttering to himself, menacing even in retreat. Then a warning shout echoes from much too far in the distance, and he appears once again—flying, near horizontal—to tackle Ruiz, dragging him off the phone.

The staff quickly take him down; thankfully, no one was seriously hurt. Shaken, I try to focus on my journal, but my mind races. My roommate—a burly middle-aged guy with a scar down the side of his head, attesting to the brain injury that’s brought him back here over and over again—turns to me laconically and says, “There goes dinner.”

I’m twenty-nine years old, writing in my journal in a sloppy felt-tip pen (no ballpoints are allowed), trying to understand how I went from being a newly minted physician in a psychiatry residency program at Columbia University to a psychiatric patient at Bellevue, the city’s notorious public hospital. Bellevue is synonymous with the most challenging, chronic mentally ill cases, and now I’m locked on the dual diagnosis ward on the twentieth floor, near the top of the building, where they put people who have both substance use problems and other mental disorders. I’ve already recognized some of the faculty from when I applied here for residency, and I know from the tour I took as an applicant that the special prison ward, protected by a guardhouse with bulletproof glass and thickly barred gates, is a floor below us.

I need that phone those two men were fighting over. It’s my only way to reach the outside world, that other plane of reality where I was once a psychiatry resident. I’m having trouble accepting that I belong here, not there. Day by day, it seems more likely that what the doctors have been telling me is correct—that, just like the new guy, I too have had a manic episode, in my case induced by weeks of stimulants and alcohol. But I’m still not sure what I should do.

The next day, I meet with the whole treatment team—half a dozen psychiatrists, therapists, and counselors facing me across a massive table in one of those windowless

hospital conference rooms. For the first time, I truly let my guard down and recount my whole drinking history. How I grew up with two alcoholic parents and swore to myself I’d never be like them. How, even as I finished medical school at Columbia, I had the creeping sense that my drinking was out of control. How the blackouts got more and more frequent, but I didn’t reach out for help, and I didn’t accept the help that friends, colleagues, and supervisors had all offered, then implored me to take.

I tell them everything, even the one time that I woke up on the floor of the hallway in my building, shirtless, my skin sticking to the tacky linoleum, locked out of my own apartment. It was only by getting up to the roof and climbing down the fire escape that I made it in to work that day at all. I was late again, and so ashamed and scared by what it said about me. It was obvious that something was wrong, but I never told anyone about it, because to do so would be to acknowledge what I had long suspected.

They ask me about my family, and I tell them about my father’s four rehabs and the bottles of wine my mother secreted around the house. I describe my parents as alcoholics, as I usually do, but I also finally give voice to that dangerous suspicion about myself: “. . . And I’m starting to realize that I’m an alcoholic, too,” and I break down crying.

Despite all this, later that weekend, I call my friend Ravi from that payphone, looking down the disorientingly long hallway that stretches the whole length of the ward. He’s helping me with all the logistics, setting up disability insurance, getting my rent paid, and generally making it possible for me to go to rehab: a place I don’t quite want to go to but I’m told that I need.

We talk about how it’ll be good for me, and how I’ve struggled for so long. His voice is strained. It’s clear he’s worried about me. So I hesitate for a moment—I have the clear sense of telling myself, this is a truly ridiculous question, don’t ask him this—but then ask him anyway, even as I keep one eye down the hallway for any potential assailants: “Do you really think I can never drink again?”

I’m supposed to be headed to some specialized rehab for doctors, but I know nothing about it. I want to go, but not really. I need help, but maybe I can do it on my own, or at least find a better way. Why is this so hard?


I did go to that rehab for doctors, and in time, I returned to the residency program at Columbia. For years afterward, I was in supervised treatment. At a moment’s notice, I had to be prepared to run across the medical center or across town to my “urine monitor,” a woman who would watch me urinate to make sure I didn’t try to pass off someone else’s bodily fluids as my own. As I slogged through half a decade of this, I got more curious. I knew that the addiction treatment system was broken, having experienced it firsthand, but the why was mystifying: Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder? If everyone seems to know that the system is broken, why isn’t anyone changing it?

I decided to become an addiction medicine specialist. In a surreal twist, as I studied psychotherapy and medications, I was also going to my own treatment and meetings and generally trying to work out what recovery meant to me. As I finished training and joined the psychiatry and bioethics faculty at Columbia, the worst seemed to be behind me. But as I emerged from those revitalizing yet profoundly disorienting years, the same questions lingered, insistently: How did I get here, and what exactly had gone wrong in me? Or, as patients often ask: What happened to me? Why am I like this? How do I get better?

In search of answers, I immersed myself in the field, studying the psychology and neuroscience of addiction. I wanted to find the right definition—the correct and tidy medical theory that would explain it—but I was soon overwhelmed. The field seemed to be in chaos. Scientists and other scholars seemed bitterly divided, always talking past one another. Some insisted that addiction was primarily a brain disease. Others claimed that this brain-centric view blinded us to the psychological, cultural, and social dimensions, including trauma and systems of oppression. Few other fields of medicine are so powerfully driven by cultural bias and ideology.

Everyone seemed to have their own take, as did every field of study. One summary of “theories of addiction” listed no fewer than thirty different models—from psychological concepts to neurobiological mechanisms to economic models of choice—and those are just the ones deemed respectable today. Each one of them had something useful to add, but more often than not their answers felt demoralizingly incomplete.

I began working in psychiatry, not incidentally, at a time of increasing disillusionment with the simplistic view that all of human suffering could be reduced to neurobiology. President George H. W. Bush had designated the 1990s the “Decade of the Brain,” but during the 2000s and into the early 2010s, as I finished my training, there were signs that neuroscience, while useful and even revolutionary in some ways, was not sufficient to explain the complex phenomena of mental suffering. Researchers were still trying to make sense of what it meant to call something a mental disorder, and the picture was yet more complicated in the case of treatment. Antidepressants were nowhere near as useful as the first generation of heady advertisements had promised. Biotech companies were slashing funding and even shuttering their neuroscience research divisions altogether after years of failed drug discovery. There was a growing awareness that the country had been misled by pharmaceutical companies—and not just the opioid manufacturers. These developments motivated my own turn from neuroscience research to bioethics, where I hoped to incorporate a more thorough understanding of the social and political realities of mental suffering, along with the best the science had to offer.

Then, as I continued my research into addiction, I noticed something interesting. The broadest-thinking and most creative scholars kept making odd and intriguing connections to fields beyond my usual horizons. They drew on ancient philosophy to clarify the problem. They looked to sociology to show how it is impossible to separate addiction from its cultural context, now and for generations back. They even delved into theology, to trace how legacies of thinking about morality have powerfully influenced the way we think about choice and responsibility. In a short time, I became absolutely convinced that medical science alone, while important, was insufficient for understanding addiction.

Understanding addiction in the present required looking to the past. Addiction seemed to be everywhere and at every time. Starting my investigations in the midst of an opioid overdose epidemic, I learned that human society has been wracked by drug epidemics with dismaying regularity for more than half a millennium. I saw how centuries of policy, stigma, and racism are all inseparable from how we currently understand and treat, or fail to treat, addiction. We have long wielded the concept of addiction as a weapon, using it to wage war—not just “on drugs” but also on people who use drugs. I was struck by how long societies have feared the corrupting forces of technology, from opioids and smartphones and porn-on-demand to syringes and telegraphs and sugar. It was clear that addiction was not just an issue of medical science but also one of identity, power, commerce, and fear—as well as one of devotion.

I got to leave Bellevue relatively quickly. By nothing more than an accident of birth—my status as a doctor, my Ivy League education, my ability to pay, my access to a program that happened to treat addiction somewhat adequately, my whiteness, and just dumb luck—I entered recovery, returned to a good job, and eventually got to write this book. If only everyone were treated the way I was, we’d all be better off. But make no mistake. I am not an “unlikely” case. I am not fundamentally different from Ruiz, or the new guy, or anyone else on that dual diagnosis floor. The most important lesson the history taught me is how divisions between us are just a story, one that has long fed injustice, and one that comes back to harm us all. It will continue to do so, unless we start to look deeper.

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Copyright © by Carl Erik Fisher

Carl Erik Fisher

Carl Erik Fisher, M.D., is an addiction psychiatrist, bioethics scholar, author, and person in recovery. He is an assistant professor of clinical psychiatry at Columbia University, where he studies and teaches law, ethics, and policy relating to psychiatry and neuroscience, especially issues related to substance use disorders and other addictive behaviors. He also maintains a private clinical practice focused on complementary and integrative approaches to addiction and recovery.

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