A Nuanced Portrait of Addiction

Carl Fisher knows addiction intimately, from his work as a psychiatrist and his own personal history. At 29, during his residency training at Columbia, he was admitted to the psychiatric ward at Bellevue Hospital following a drinking and Adderall binge.

No longer able to deny he had a problem, he began to take the first important steps toward recovery. He also embarked on the study of addiction medicine, in part to make sense of what had gone wrong him and his family—both his parents were alcoholics—and committed himself to helping patients find the pathway to recovery.

The result is The Urge: Our History of Addiction (Penguin Press 2022), a book that interweaves medicine, psychology, sociology, and philosophy with his own experience as a clinician, researcher, and alcoholic in recovery. 

“Aside from my own recovery, writing this book is the hardest thing I’ve ever done,” said Fisher, an assistant professor of clinical psychiatry at Columbia University who teaches law, ethics, and policy related to psychiatry and neuroscience.

Columbia Psychiatry News spoke with Fisher about The Urge, why calling addiction a disease is misleading, recovery approaches, and creatively melding art and science. (Fun fact: After graduating from college, he sung opera professionally in Seoul, South Korea, where he also studied neuroscience as a Henry Luce Foundation Scholar.)

What made you decide to share your personal story publicly and did you have any concerns?

I wanted to include my own story, first, because I hoped to illustrate the real human implications of this history and how it continues to wield influence today, including on me and my family. As I got into the research, I was also struck by how strongly ideas about addiction are intertwined with social, cultural, and personal beliefs and experiences, so I also wanted to tell my story as a way to disclose my biases and make it clear that this book is my own attempt to make sense of addiction, not the final word. I think this latter point helped in discussing the book with my patients and emphasizing that they might have entirely different understandings of addiction and recovery.

You say that calling addiction a disease is misleading. Why is that?

One thing that surprised me about the history is how many times, and in how many ways, the notion of “disease” has been used in reference to addiction. The result is the term is now loaded with so many, sometimes conflicting notions, making the term a double-edged sword. Over the years, the notion of disease has helped in many ways: arguing for expanded treatment, getting funding for crucial research, and in some ways enhancing compassion for people with addiction, for example. On the other hand, there have been definite harms. "Disease" has been used in pessimistic and dehumanizing ways, and it might enhance some forms of stigma. Addiction-as-disease has even been used as a weapon against people with addiction. In the end, I believe the term disease has become so overused and ideologically freighted that it has become misleading, if not entirely meaningless. Better, I think, to use the word as a cue to look more deeply into the phenomenon.

In several interviews you've said that the medical profession largely abandoned the treatment of people with addiction roughly 100 years ago. Could you say more about that?

A common trope is that addiction was treated as a “moral failing” prior to the 20th century, but this is simply not true. I was surprised to find

that there were movements within medicine to treat addiction with care and compassion in the 19th century and earlier. However, in the earlier part of the 20th century, and in no small part because of racist and xenophobic panics about drug use, much of the profession withdrew from the care of addiction—to the point that the American Medical Association opposed treatment for opioid addiction in 1920. Even some of the wealthy and well-connected early members of Alcoholics Anonymous in the 1930s that I profile had tremendous problems obtaining treatment for alcohol problems. While the field has come a long way in recent years, we are still living with the legacy of that retreat from the care of people with addiction—for example, the way that too many addiction treatment services remain fragmented from general health care and even psychiatric care. 

As someone in recovery who also treats individuals with substance abuse disorders, do you favor in most instances abstinence-only approaches? Have you seen success with moderation-management?

My chief goal is to support my patients in their own goals. Sometimes people with serious substance use disorders can moderate their use; sometimes the attempt at moderation, supported carefully, gives them data that helps them to summon up more motivation and work toward abstinence. Sometimes, abstinence seems to be the only reasonable approach to harmful use, and I certainly wouldn't shy away from telling a patient so, even if they didn't want to hear it. But I think it would be very dangerous if I assumed my own pathway or understanding of recovery applied to all patients. Both the history and my own experience has shown me that there are many pathways to recovery.

What is your vision for how we as a society address alcohol other drug problems? 

There are no easy answers, but one crucial step I’m trying to promote is for people to pause and look more deeply at the big picture of our responses to substance problems. Over the centuries, societies have tended to swing from different responses to substance problems and addiction. I think we would stop a tremendous amount of harm and open up much more space to help if we could take a step back, get some perspective on those pendular swings, and attempt to take in the full picture with a little more compassion and nuance.

Now for questions not related to addiction. You majored in music and biology in college and went on to perform opera and study neuroscience in South Korea before deciding on medical school. How do you reconcile your dual passions for science and art?

My creative side has always been an essential counterweight to more analytical and logical tendencies. It's not unrelated to the book, come to think of it. I was motivated to study the humanities related to addiction (such as history, philosophy, and arts and literature) because I felt that, for all that science and medicine has given us, we need those other human endeavors to fully make sense of this phenomenon.

According to your website, you are both a Zen practitioner and certified yoga instructor? Does meditation and mindfulness influence your recovery and clinical work?

Absolutely. My personal recovery is completely intertwined with Zen practice. I'm happy to use secular and evidence-based versions of those practices in work with patients who want them; for example, exercises and reflections from Mindfulness-Based Cognitive Therapy, Mindfulness-Based Relapse Prevention, and more generally Acceptance and Commitment Therapy.