Stereo Sue, or the Quale of Sobriety

The June 19 New Yorker has an essay titled “Stereo Sue” by the neurologist Oliver Sacks, author of The Man Who Mistook His Wife for a Hat and other books. Sacks shines at the classical art of extracting large general insights from the detailed clinical study of individual cases, much in the vein of Freud and Jung, but with the benefit of a huge library of other studies as reference points. The titular Sue is a real person, Sue Barry, a professor of neurobiology and a mother, who was born cross-eyed. Because her eyes could not simultaneously focus on the same object, she lacked true depth perception, commonly known as binocular vision, stereoscopic vision, or stereopsis. When the two eyes are able to focus on the same object, the distance between the eyes feeds the brain with two slightly different images, and the brain uses these differences to generate the remarkable three-dimensional composite image that most of us take for granted as a representation of reality. Even after a series of cosmetic operations in childhood which brought her eyes into apparent alignment from an observer’s viewpoint, Sue remained stereo-blind. She could function quite adequately in the three-dimensional world by deducing depth and distances from other clues such as size and motion. But she had no concept of what the world looked like to persons with binocular vision. Friends tried to explain the experience of stereo vision to her, but she could grasp it hardly better than a color-blind person could understand the spectrum. What Sacks called “the subjective quality, the quale of stereopsis” completely escaped her.

Sacks’ use of the word ‘quale’ sent me to Google, where I learned that it is pronounced KWAH-lay, and means the “raw feel”, the basic “what it is like-ness” of a particular sensation or state of mind. According to an academic author in the Wikipedia, ‘quale’ refers to the properties of sensory experiences which are, by definition, unknowable in the absence of direct experience of them. As a result, says this writer, they are incommunicable.

After almost half a century of monocular vision, Sue experienced mounting practical problems with her vision as she passed middle age. Sue found an eye therapist who fitted her with special glasses and taught her a series of eye exercises designed to train her eyes to focus simultaneously on the same object. After the first session, Sue went back to her car and happened to glance at the steering wheel. It had “popped out” of the dashboard. As she continued her exercises, she was delighted. “Ordinary things looked extraordinary. Light fixtures floated and water faucets stuck way out into space.” She also experienced feelings of confusion, as if she were in a fun house or high on drugs. “The world really does look different.” A grape poised at the edge of her fork fascinated her. The skull of the skeleton of a horse in the building where she works suddenly seemed to stick out so much that she actually jumped back and cried out. When she walked in the park, every leaf stood out in its own space. Every surface had more texture. “She was startled and disoriented at first, but for the most part she felt entirely, and increasingly, at home with stereoscopy. Though she continues to be conscious of the novelty of stereo vision, and indeed rejoices in it, she also feels now that it is ‘natural’ — that she is seeing the world as it really is, as it should be. Flowers, she says, seem ‘intensely real, inflated,’ wher they were ‘flat’ before.” The acquisition of stereoscopy, Sacks writes, has been a constant source of delight for her, and a great practical benefit. Sacks sums up that Sue “had discovered for herself that there is no substitute for experience, that there is an unbridgeable gulf between what Bertrand Russell called ‘knowledge by description’ and ‘knowledge by acquaintance’.”

The case for recovery from addiction to alcohol and drugs is often grounded in the avoidance of dramatic harms such as car crashes, crimes, suicides, and debilitating illness, to name just a few. Dr. Sacks’ essay about Stereo Sue suggests a far more important and more difficult challenge, namely that of conveying to those who are still actively drinking and/or using the “raw feel” or “what-it-is-likeness” of sobriety. It is a more important challenge, because the great majority of addicted persons do not personally experience the catastrophic harms that make headlines, nor the lurid agonies that make bestselling memoirs. The sociologist C. Wright Mills famously wrote in the 1950s that “most men lead lives of quiet desperation.” Most persons who are addicted to alcohol and/or drugs lead functional lives. If there is drama, it is tightly controlled and kept private. To the outsider, most addicted persons seem normal and their addiction is invisible. Addicted persons range up and down the social scale and occupy all points on the bell curve of achievements. In your local high school, both the dropout candidate and the valedictorian may be addicted. In your workplace, the lowest go-fer and the chairman of the board may have something unsuspected in common. Basing the case for recovery on a parade of horrors does not resonate with the personal experience of most addicts; it falls as flat as the scare tactics in the movie Reefer Madness.

However, trying to talk about sobriety to people who suffer from addiction, without resorting to scare tactics, can be as challenging as explaining stereoscopic vision to Dr. Sack’s friend Sue before she found her eye therapist. The problem is not merely “denial,” in the sense of actively rejecting a proposed diagnosis. If so, it would be a relatively simple matter of adopting a more skillful clinical approach — “rolling with resistance,” in the words of Motivational Interviewing, instead of the confrontational approach that seeks the patient’s surrender. The more difficult problem is perceptual. The mind under the chronic influence of intoxicating substances may have as much difficulty grasping the quale of sobriety as a color-blind person has in appreciating a rainbow. Frequently there is a crust of stereotypical beliefs to the effect that sobriety is gray, joyless, and somber, and this may be sustained by the anecdotal evidence of persons whose venture into sobriety unmasks a lingering clinical depression. But even when this is stripped away, and when the addicted person knows deep inside that there is nothing more desperately boring and anhedonic than addiction, there is still no insight into the “raw feel,” the “what-it-is-likeness” of sobriety. There is no way to know sobriety without going there. If you wish to know the taste of a pear, you must eat it yourself (Mao). Everything short of that is hypothesis, speculation, fantasy, illusion, self-deception — ignorance.

And so we seem to have come to a logical dead end. Using scare tactics to motivate actively addicted persons does not work. But trying to sell in words the positive experience of sobriety, its quale, does not work either. By definition, the inner experience of sobriety is unknowable in the absence of direct experience, and cannot be conveyed in words. We who stand in the three-dimensional world must communicate the positive feel of our sobriety by supplementing verbal description with our attitude and behavior. We can begin by correcting our perception of persons who are addicted. When we see such a person with both eyes open, we perceive both the manifestations of the addicted self, and also the positive inner pole within the person that clings to life and seeks freedom from the drug. To see only the addicted side, or only the healthy side, is to look at the addicted person with one eye shut. Binocular vision means to see these two different and mutually exclusive images and to combine them mentally into a three-dimensional composite that is realistic and lifelike precisely because it harbors opposites within it. When we demonstrate the advantages of our sober vision by treating the addicted person — despite perhaps their numerous and horrible negative qualities — with the respect and dignity that we would wish for ourselves, then we stand a chance of communicating that which cannot be communicated. Words are, after all, only one narrow channel on the broad spectrum of human communication. When we demonstrate in our own lives, but above all in our contacts with persons suffering from addiction, that the state of sobriety is worth inhabiting, then we have a chance of motivating the addicted to take the leap into our territory. Once here, they too will come to experience sobriety, like Sue experienced stereo vision, as a constant source of delight, a great practical benefit, and the ‘natural’ way of being in the world, of seeing the world as it really is.

Thank you, Rosa Parks!

Luck would have it that I was in Washington DC the weekend that Rosa Parks lay in state in the Capitol Rotunda, the first woman and only the second black person ever to be accorded this honor. The line to get in to see Ms. Parks' coffin on Sunday night Oct. 30 stretched for miles, and after waiting for more than two hours in a queue that barely moved, the cold D.C. night got to my temperate California constitution and I gave up. But I was back the next morning and this time I got in without delay. Her simple wooden closed coffin lay between two floral arrangements and a military honor guard in the center of the lofty Rotunda. As I walked around, the words "Thank you!" came to my lips. In a few seconds, it was over and I was back outside the Capitol in the bright morning sun.

I never met Ms. Parks, but the movement that her courageous act inspired touched my life. As a college student at Wesleyan in Connecticut, I answered an appeal from a group called the Northern Student Movement to come down to the D.C. area and help integrate lunch counters and other public facilities along the main Washington-New York highway. A handful of us assembled at the home of historian Howard Zinn in New Haven, and then drove to Howard University in D.C., where we learned freedom songs and received training in nonviolence. The next day we matched up with pairs of black students from Howard and set out for Glen Burnie, MD, a Baltimore suburb. At this time -- it was 1960 or 1961, I don't recall exactly -- the national chains like Woolworths still had separate counters for whites and blacks, and in the local movie theatre, blacks had to sit in the balcony. At the first lunch counter, when our integrated group of four sat in the white section, the place emptied within minutes and all the serving staff seemingly disappeared. We waited for what seemed like an hour. Eventually someone came and took our order: coffee. After a long time, it came. We tasted it carefully, wisely -- they had put salt in it. Still, we counted it a victory: we got served. We moved on to other restaurants, got served in some, got refused and told to leave in others. In the afternoon, about ten of us formed a picket line in front of the movie theatre. Under darkening skies, about 20 to 30 local rednecks gathered around and taunted us. Two sheriff's deputies came and watched. The rednecks took to throwing pennies at us and spitting. It looked like it was going to get ugly. Just then, the clouds opened up and a deluge defused the situation. We all scattered.

A few years later, in 1964, after the civil rights workers Chaney, Schwerner, and Goodman were murdered in Mississippi, there was an appeal for more volunteers to go south to replace them, to send a message that terror would not deter us. I was part of this second wave, arriving on election eve 1964. I stayed until the next spring. I've written something about this experience elsewhere. All the countless scores of us civil rights activists, locals and Northern volunteers alike, were in some measure the children of Rosa Parks.

Marx wrote somewhere that the philosophers have only interpreted the world; the point, however, is to change it. Social change does require people who merely interpret the world, because they help to prepare public opinion. It requires philosophers, preachers, pundits, and many others who act in words. But all these words are nothing, and may be sheer hypocrisy, worse than nothing, without the crystallizing power of a strategically chosen direct action. After all the ink is spilled and the sermons have stopped ringing, someone has to put their body on the line. That was Rosa Parks.

It was particularly delicious to think that here in the Rotunda, the highest place of honor that the capital city knows, the president, prominent senators, and many others from the ruling establishment came to pay homage to someone for breaking the law. In this post 9-11 era, when the Patriot Act and the president's "war on terror" zealots have whipped much of the American public into a sheeplike trance, it was like a breath of fresh air to celebrate someone who was an outlaw in her time and place. This feeling ran strong among many of the more than 30,000 people who waited in the cold and the dark outside the Capitol on Sunday night. Yes, there are laws and customs that are stupid, dishonest, and unconscionable. Yes, it is much easier to obey them and blend in than to stand up to them. But those who have the vision and the courage to challenge the cruel and stupid laws and customs of their time do sometimes receive respect and recognition -- even if it takes fifty years.

The example of Rosa Parks shines far beyond the civil rights movement and the race issue in America. The disability rights movement, for example, acknowledges her act as the inspiration for wheelchair activists fighting for access to buses and other public transportation. Thoughtful advocates of social change generally -- in a broad range of domestic and foreign policy arenas -- cite Rosa Parks as a model. It is a sad but important truth that progress in important matters only comes through acts of resistance and disobedience to entrenched authority. Thank you, Rosa Parks.

We who are in recovery from alcohol and drug abuse should also join in honoring Ms. Parks and in learning from her example. This is true in two senses. Addiction is a stupid and cruel authority entrenched within our own minds. It is surely no coincidence that the words addiction and dictatorship share the same root. To live in an addicted mind means to serve a ruthless despot that manages our lives. Addiction governs what we do with our time, how we choose our friends and associates, how we view and evaluate reality, how we feel and react, virtually everything about us. Addiction is a 1984 of the mind; it is a Big Brother whose self-propaganda turns white into black, lies into truth, down into up, pain into pleasure, death into living, and defeat into victory. Against addiction, sermons and lectures are powerless. Making promises to yourself, making good resolutions, massaging yourself with words of good intention has no effect, and can even delay your liberation. The only thing that begins to work against addiction is a planful act of disobedience. Put the drink down, pour it out; flush the drug down the toilet, take a hammer to the pipe and other paraphernalia and throw them into the trash. When you stop drinking and using, and only when you actually stop, then you begin to sit in the front of the bus of your own mind. Thank you, Rosa Parks.

Another brutal and stupid dictatorship that many people encounter in early recovery is the "my way or the highway" recovery authority. Whether a self-appointed guru or a paid professional, they think they have The Answer and they're going to push it down your throat, "for your own good." They may pose as helpers, gurus, and wise counselors, but they are psychological thugs and cutthroats who know next to nothing about recovery and care nothing about you. Inside their soul burns a big ego fire, and you are nothing but fuel. When a newly recovering person encounters this sort of bully, the easiest and most natural response is to go out and drink and use. "If this is recovery, I prefer addiction." Please, friend, don't go there. The best revenge against recovery gangsters is to stay sober. Ignore them, or tell them off if it makes you feel better, but by all means stay sober. If you relapse, they'll gloat: "I told you so!" If you stay sober without them and despite them, you challenge their world view in the most fundamental, irrevocable manner. If you stay sober, you deflate them and shrink their malignant flame. If you stay sober, you help others like yourself who come after you to recognize that recovery must sometimes begin with defiance of established authority. Thank you, Rosa Parks.

Real Medicine Means Honoring Patient Choice

“Here’s a range of treatment options. What do you want to do?” That, according to Bruce Fuchs, the director of the Office of Science Education at the National Institute of Health, is what physicians today are likely to tell the patient. (Newsweek, Jan. 31 2005, p. 9). Presenting patients with a choice of treatment paths and letting the patient choose reflects the growing sense of responsibility that people have for participating in planning their own medical care. “Medicine is less paternalistic than it used to be,” said Dr. Fuchs in another recent interview. A lot of people “recognize they need to be more active participants in their health care.”

For the contemporary physician, giving the patient a choice is nothing less than an ethical obligation. The American Medical Association’s ethics advisor put it this way:

Each individual has the right to determine what medical treatment he or she will receive, including what life-sustaining treatment will be provided for a terminal condition. It is the physician’s responsibility to advocate for the patient’s right to choose any therapy, including alternative or nontraditional treatments, that reasonably may be expected to improve the patient’s quality of life. Source.

Breach of the doctor’s obligation to give the patient a choice of treatment options may constitute actionable negligence. One current text on the law of medical malpractice puts it this way:

In order to obtain the patient’s informed consent, the doctor must tell the patient not only about the alternatives that the doctor recommends, but also about all medically reasonable alternatives that the doctor does not recommend. A doctor does not comply with the duty of informed consent by disclosing only the treatment alternatives that the doctor recommends. Accordingly, the doctor must discuss all medically reasonable courses of treatment, including non-treatment, and the probable risks and outcomes of each alternative. By not discussing these alternatives, the doctor breaches the patient’s right to make an informed choice and effectively makes the choice for the patient. Source.

Giving the patient a range of alternatives and letting the patient choose is not merely a formal legal exercise. It’s good medicine. Behavioral scientists have long known that treatment which the patient chooses tends to work better than the same treatment when the patient does not choose it. The key is that choice enhances motivation. Source. “A fascinating study found that blood donors perceived significantly less discomfort when they were allowed to select the arm from which the blood would be drawn. The lesson is clear: people are happier and more comfortable when they believe they have some control over a process, particularly an uncomfortable one. Often the control handed over is largely symbolic (as in the choice of arm). In other cases, it’s very real: the medical profession has long recognized the value of allowing the patient to make an informed choice about alternative treatments for cancer and heart disease. These are extremely important, high-stakes decisions, and great value is gained by including the patient in the decision. He or she feels less helpless, less hopeless, and more committed to making the process work.” Source.

What does all this have to do with recovery from addiction? About ninety per cent of the current providers of treatment for addiction in the U.S. subscribe to the teaching that addiction is a disease, on a par with diabetes, heart disease, and cancer. But most of those same addiction treatment providers appear unaware of the basic ethical and motivational approach that real physicians today use in the treatment of patients with real diseases.

Real physicians give patients a choice of treatment options, including options that the physician doesn’t personally recommend. Rare is the addiction treatment program where this principle is observed. In most of them, “range of options” means only the choice between the “Big Books” of AA or of NA. Many treatment providers do not know that there are secular treatment and support group options, and when presented with this information, they do not want to hear it. Such counselors are incapable of conducting the kind of informed discussion of pros and cons of different alternatives that is required today in the real treatment of real diseases.

The real medical model of disease treatment requires obtaining the patient’s informed consent. Few and far between are the addiction treatment programs where informed consent is part of the professional vocabulary. Much more common in the addiction treatment business is the view that the addicted patient does not have the capacity to give informed consent, so that the treatment provider not only may, but must make the choice of treatments for the patient. Therefore, when the addiction patient asks about options or declines to follow the provider’s recommendations, the patient is “in denial” and the provider is justified in applying pressure until the patient “surrenders.”

In real medicine, the authoritarian, nonconsensual approach used in many addiction treatment programs today would be considered unethical, unprofessional, and liable to be prosecuted as malpractice. It’s high time that the addiction treatment field caught up with modern medicine and recognized that patients have rights, including the right to a choice of treatments. Giving patients a choice and involving them as participants in their own treatment yields substantially better results in the treatment of diabetes, heart disease, and cancer. Honoring the addicted patient’s choice among treatment alternatives will yield similar improvement in treating the disease of addiction.

Bush Taking the Axe to Recovery

The Bush Administration is in power for another four years, and the “Christian” right, which claims credit for the electoral win, is pressing to impose its agenda. I put Christian in quotes because I was raised in that religion, but I can’t match up what I learned as a kid with what I see this administration doing. Whom would Jesus bomb?

One of the first patients I met in a local psychiatric hospital ward, where I was doing a LifeRing meeting, was a woman with a nasty bruise in one eye and a bandage over her head. When her husband found out she was using heroin, he bludgeoned her with the family Bible until she collapsed. I’m concerned that the faith-based recovery agenda that the administration is now pushing with renewed vigor is coming from this same kind of moralizing and punitive outlook.

“Drug addiction is not a disease, it’s a SIN” read the sign over the door of a church-based addiction treatment center in Houston, one of the pilot programs established when Pres. Bush was Gov. Bush. Under the 1997 legislation Bush sponsored, church-based treatment programs in the state are exempt from licensing and inspection requirements of traditional centers. Addiction treatment professionals vigorously opposed the program. See May 2000 coverage in Washington Post. Now the faith-based Texas pilot program — despite atrocity stories featuring physical abuse of patients — is going national, under the label “Access to Recovery.”

The American chemical dependency treatment industry — more or less the only place where a person hooked on addictive substances has a hope of getting clinical therapy — is already in disarray. The Journal of Substance Abuse Treatment reported last year that about 40 per cent of the nation’s substance abuse treatment facilities had either gone out of business or reorganized during the previous two years, and that the turnover among treatment staff at all levels had reached the level of “extreme instability.” More than half of program directors surveyed nationwide had served in their positions less than one year.

Now add to this unstable mix a legion of well-meaning churchmen and women unsullied by clinical experience with addiction, and fueled by $100 million in federal vouchers. That’s the initial price tag of the administration’s faith-based “Access to Recovery” program; the projected total is $600 million. Thousands of people looking for recovery will be getting “treatment” in church basements and parish halls instead of in licensed clinics and counseling centers. Chances are that much of that “treatment” will consist of getting bludgeoned with the Bible — metaphorically, at least. At taxpayer expense.

NAADAC, the National Association of Addiction Professionals, rightly lobbied the administration to require that the new legions of faith-based providers be held to “the same set of licensure and certification requirements that secular counselors have adhered to for decades.” Those are the words of Jonathan Westin, NAADAC’s Director of Government Relations, writing in Addiction Professional. At last report, that won’t happen nationwide, any more than it happened under Gov. Bush in Texas. There will be no comparable licensure and certification requirements. For addiction professionals who have been struggling to raise the level of the field, including the compensation and status of counselors, the administration’s “Access to Recovery” has to be a bitter pill. “Taking the Ax to Recovery” is a more fitting name.

The backstory is that most addiction treatment programs have done little to deserve the label “secular” or to elevate the professional level of the field. About 90 per cent of the programs in the U.S. dispense the faith-based 12-step model. Too many treatment programs are happy to hire staff whose main professional qualification is their own recent recovery, and whose only professional reference is a phone call from their sponsor. They work cheap, and it’s unclear why they should be paid at all. The other month a counselor was telling me about the wonderful step study meeting he and his patients attended, and how step study would be the focus of their recovery work in the weeks ahead. That may be fine, but in what sense is this a “secular counselor”? Why should people pay for step study in treatment programs, when they can get it for free in AA?

In trying to take a stand on secular professionalism, NAADAC’s lobbyists are on slippery ground. There’s just not that much secular professionalism in evidence. If the administration’s legions of subsidized vendors of faith-based addiction “treatment” end up laying waste to the already shaken industry, as seems possible, it will be because the industry’s unhealthy dependency on the faith-based 12-Step paradigm has left the door open to precisely this kind of invasion. Cynics would say that “Access to Recovery” is nothing more than a $600-million government subsidy for the most Bible-thumping wing of the 12-step movement, which has never seen much value in clinical treatment anyway, other than as a funnel to fill the rooms.

The core reason for the disarray in the treatment industry, in my opinion, is that its dominant paradigm doesn’t work well enough to earn solid, sustaining public trust. You don’t have to parse the outcome statistics — deplorably scarce as they are — to see the pall that hangs over the industry. Prof. George Vaillant of Harvard, who is a Trustee of Alcoholics Anonymous, reported in his book The Natural History of Alcoholism that the success rate of his 12-step based model treatment clinic in Boston was no better than the spontaneous recovery rate among the untreated. Prof. Alan Marlatt of Seattle found that the most common outcome of treatment — which 90 per cent of the time means 12-step treatment — is relapse. That’s not to say there aren’t treatment success stories. I’m one of them. There are laudable islands of quality treatment, and I was lucky enough to have access to one. But the Big Picture is not confidence-inspiring. Faith-based treatment and faith-based support groups have had a virtual lock on the American recovery scene for about fifty years, but they haven’t made a dent in the addiction problem. If anything, substance abuse is more widespread, more severe, more costly, and more notoriously out of control than when the 12-step movement started.

In a sense, every addict can relate to what the Bush administration is doing here. The faith-based approach isn’t getting us off, so what’s needed is a stronger dose of the same thing. The “God as you understand Him” of the 12 steps is too wishy-washy; what addicts need is the God of the Ten Commandments. Recovering addicts aren’t straightening other addicts out fast enough; what’s needed is staff who’ve never given in to sin and can provide stern moral examples. The experiment has led to the same negative result ten thousand times, so we need to repeat the experiment again, but harder. And if that leads to terrible consequences, too bad. We’ve all been there.

It’s too early to predict the shape of treatment in 2008. But one thing is certain: in the next four years the case for a caring, rational recovery path such as LifeRing will become more compelling than ever. Wherever there is an action, there is a reaction. The comparatively mild faith-based approach of the 12 steps has always driven thousands of people away in search of an alternative. The hard faith-based approach that may dominate the next four years under Bush will drive away many more. They will be looking for another road, and we need to be there for them. In the treatment profession, the progressive crumbling of the dominant paradigm will lead some individuals to put their heads into the sand, hoping that change won’t occur if they don’t see it. Many others will be jostled into awakening, rethinking old assumptions, and looking for new ideas. This may be a bumpy period, but it will also be a period of great opportunity for moving forward and reaching larger numbers.