FOLK NEUROLOGY and the REMAKING of IDENTITY

Introduction

The molecular revolution that has occurred within the neurosciences since the 1970s has had profound impacts on how scientists understand many aspects of human life. The ways that individuals think, act, and feel have increasingly come to be described in relation to receptors, synapses, and other structures of the brain, and in terms of the flows of neurotransmitters within those structures. More recently, the field of “social neuroscience” has begun to venture descriptions of the neurobiological bases of society and social interaction. These scientific developments are immensely significant not only as scientific developments, but also as cultural ones––for the advances that have occurred within the brain sciences have implications for knowledge beyond scientific journals, laboratories, and clinical medicine.

As a sociologist whose work focuses on the emerging specialization of “neuroscience and society,” I think it is important to reflect upon the ways that the theories, treatments, and explanations of the neurosciences are changing the understandings that lay individuals have of themselves and their worlds and are giving rise to what might usefully be thought of as a sort of “folk neurology.” Folk neurology––the views and beliefs that lay people have about their brains, which provide a basis for explaining, predicting, and managing themselves and others—may not be very interesting to think about as a contribution to scientific knowledge. Lay individuals are not neuroscientists, after all; they may not fully understand the complexity and tentativeness of brain science, and may interpret or use facts in ways that scientists would not consider justified. Folk neurology, however, is interesting to consider as an indication of the contribution neuroscience makes to today’s “neurological cultures” of the industrialized West. Just as concepts of psychoanalysis (e.g., sexual repression, the libido, subconsciousness, etc.) came to form part of our culture’s commonsense understandings in the mid-20th-century, today the ideas from the new brain sciences are increasingly called upon when interpreting and analyzing day-to-day life. To list just a few examples: We think of the pleasure we get from a vigorous run or the consumption of chocolate as related to the release of endorphins in our brains; we relate our experiences of sadness and depression to malfunctions within our serotonin systems; and we know that disruptive, hyperactive children can be managed with medications that target their prefrontal lobes. These new ways of understanding ourselves and others are significant, especially as they provide new ways for us to interpret and make sense of dilemmas we face; however, we should not expect that there is a single story to be told about the “neurologization” of every aspect of our lives. What is required, I think, is an examination of how ideas about neurology are taken up and used by lay individuals in a range of particular contexts and sites.

In what follows, I outline some aspects of an emerging folk neurology of alcoholism, examining the ways that brain-centered ideas about, and treatments for, problem drinking are providing new means for individuals to understand themselves and manage their thoughts and behaviors. Philosopher Ian Hacking’s concept of “human kinds” provides a useful starting point here, because it calls to our attention the ways that expert explanations and classifications can take on a life of their own, once adopted by the non-experts being described (1). Hacking distinguishes human kinds (i.e., types of people) from natural kinds (i.e., types of things) on the basis that whereas natural kinds––such as stones, horses, or fungi––do not change in response to the ways they are classified or described, human kinds do. When a category is applied to a group of particular individuals, those individuals may themselves adopt the category as a basis for self-identification and, in doing so, may incline others to think about that category in new ways.

To take a concrete example, Hacking points out that before the term “homosexual” had been coined by scientists to classify people who were attracted to their own gender, gay identities did not exist. Once invented, however, the category of homosexuality began to provide a means for individuals who experienced strong same-sex attraction to distinguish themselves from most other people. Over time, more individuals began to claim the identity of homosexual as their own, and gay activists and communities that subsequently emerged eventually forced medical experts to rethink their own concept. The result, of course, was that homosexuality was abandoned as a medical diagnosis. Today, although it is assumed by many that homosexuals may in some ways be biologically different from heterosexuals, this is not considered an indication of disease.

Hacking’s ideas are useful for thinking about how the understandings and categorizations of the neurosciences are making up new “kinds” of people who identify and describe themselves in terms of their brain chemistry––what we might call “neurobiological human kinds.” To highlight what is distinctive about the emergence of neurobiological human kinds in relation to problem drinking, I begin by contrasting the traditional approach of Alcoholics Anonymous (AA) with newer, “brain-based” treatment approaches.

From Treating the Soul to Targeting the Brain

Most of us are at least somewhat familiar with the twelve-step program of AA, whose steps were formulated (and are still followed) as a means of achieving lifelong abstinence from alcohol. They are informed by an understanding that alcoholism is a life-long condition, and that what is required in order for an alcoholic to stop drinking is nothing less than a spiritual transformation––and the development of a completely new approach to living one’s life. While “working the steps,” virtually everything in an alcoholic’s life must be examined and opened to the possibility of change: how one thinks about the world, relates to people, occupies one’s time, and so on. In essence, the program assumes that problem drinking originates from the depths of a flawed inner self: One must recognize that one is, and always will be, an alcoholic; and one must act accordingly for the rest of one’s life, working to establish new levels of introspection and self-discipline that enable one to quit drinking once and for all.

Something quite different occurs in the new treatment programs that have emerged over the last decade, which are based upon neuroscientific accounts of alcoholism, and which use anti-craving medications to manage problem drinking. These programs do not focus on the state of one’s psyche or the existence of a soul; rather, they focus on the state of one’s neurochemistry. They are based upon the understanding that in all individuals, drinking activates the brain’s pleasure circuitry––but that in some individuals, the brain may begin to reward drinking too powerfully, with the eventual result that such individuals experience intense cravings for alcohol. The problem, in essence, is an overstimulated endorphin system. The therapeutic approach correspondingly uses brain-targeting anti-craving medications such as the opiate-antagonist naltrexone, which occupies the brain’s endorphin receptors and thus prevents the reward system from getting too excited when an individual drinks alcohol.

Whereas AA insists that an alcoholic must fundamentally alter the way he lives his life, naltrexone-based programs are promoted on the basis that they involve a less complicated regime of simply taking medication to bring the brain’s reward system under control. One of the most successful of such programs, developed and used within the international series of ContrAl clinics, is in fact promoted on the basis that it “does not interfere with everyday life but allows people to live normally while undergoing the program” (2). For example, whereas in AA individuals are encouraged to tell their stories of alcohol-related humiliation and devastation to an audience of strangers, ContrAl clinics comfort prospective patients by asserting that: “Client dignity is assured; there is no need for self-effacement since the motivation for alcohol is reduced by extinction. Excessive drinking is simply a case of a behaviour having been learned too well––somewhat like fingernails that have grown too long. The ContrAl Method provides a means for trimming” (3).

Of course the growth of fingernails is not exactly analogous with the process of behavioral reinforcement; but the suggestion is that the control of problem drinking may be thought of within naltrexone-based programs as a routine matter of self-care, which requires simple decisions about taking medication rather than the complex confessional and self-revealing practices associated with AA. Although this may seem to suggest less of a focus on identity––unlike AA, naltrexone-based programs do not require one to adopt the identity of alcoholic as a prerequisite for treatment––if one looks closely, one finds that new forms of self description and classification nevertheless do appear in the accounts of naltrexone users.

“I’m not Alcoholic, I’m Endorphin Challenged!”

We can get a sense of how individuals begin to see themselves and conduct their lives as neurobiological human kinds by viewing the many addiction-recovery Web sites and list-serv archives on the internet––and especially on those in which individuals post their own stories of experiences with naltrexone. It can be striking to see how patient narratives incorporate expert neuroscience into their own folk neurology and how a patient formulates the relationship between herself, her neurochemistry, and her drinking behavior. For example, in one on-line forum for naltrexone users (4), a woman named Sophia reports having learned from her physician that her excessive desires for alcohol and her inability to control her drinking were a result of endorphin activity in her brain:

It appears that on occasions when I would take that first glass of wine, the surge in my endorphins was so swift and high that the effects of the wine would kick in and I would lose all control as I wanted to maintain that state...and of course ending up in a disaster.

With the information she received from her doctor, Sophia is able to develop new kinds of explanations that differs significantly from the sorts of explanations one hears in AA meetings––there is no mention of a lack of willpower, insufficient self-control, or moral weakness. As with other naltrexone users, the story of drinking to excess becomes, for Sophia, a story of molecular events within her brain.

Unsurprisingly perhaps, naltrexone also appears as an important element within these narratives of drinking and recovery. The anti-craving medication is frequently praised for its ability to bring intense urges and desires under control, as in the account offered by another woman in Sophia’s forum:

This prescription is really something…it controls the cravings, controls the urges, it blocks some receptors or something in the brain and blocks the high from the alcohol. It blocks the pleasurable effects of alcohol, and the desire to drink, and if I do drink one or two it controls the compelling urge for more, more, more.

Sandra does not explain the management of problematic drinking as a matter of summoning willpower, but rather as a matter of targeting and controlling specific elements of neurochemistry. The precise details of pharmacological action may be vague, but that does not matter too much: What is important is that naltrexone allows individuals who are plagued with compulsive drinking urges to develop practical methods of thinking about and acting upon themselves, their desires, and their conduct.

Often, the accounts offered by individuals on-line first describe the doubts they experience when told about the neurobiological basis of their behavior, and then how such doubts are eliminated after taking naltrexone. Such conversions are not just about developing beliefs in the efficacy of the medication but also developing new self-understandings. The story of Sophia, mentioned above, illustrates this process particularly well: Out of her experiences with naltrexone, her relationship with her physician, and her interaction with others on-line, she forges a new self-identity that can compete with, and potentially replace, the identity of “alcoholic.” Having read a posting made by Serena––another naltrexone user who had coined the neurocentric term “endorphin challenged” in order to avoid the moralistic connotations of the term “alcoholic”––Sophia adopts the neologism and explains: “I do love the phrase ‘endorphin challenged’ because that is exactly what I am.” Although the notion of an endorphin-challenged individual is based on scientific understandings of the brain, Serena’s and Sophia’s conceptions of themselves are obviously not strictly determined by expert neuroscientific descriptions of drinking problems. Rather, these patients have taken the descriptions and classifications applied to them and have run with them in unexpected ways, coming up with their own particular self-understandings: as their online comments make clear they do not take those two terms to relate to the same kind of person.

Conclusion

The point underlying the concept of human kinds is not that all forms of classification are purely fictional, with no basis in reality; rather, it is to highlight the ways that the slots into which individuals are sorted (by themselves and by others) change. Over time, different human kinds come into being, sometimes replacing older kinds, and sometimes subtly changing them. It would perhaps be premature to suggest that the “endorphin challenged” individual is a new human kind that is likely to supersede the older classification of alcoholic. Nevertheless, the newly created identities of Sophia and Serena exemplify, in extreme form, the ways that many other individuals have come to describe their conduct and experiences with alcohol in neurobiological terms. Just as the neurosciences have moved beyond mentalistic representations to provide neurological accounts of human action and experience, so too are lay individuals increasingly able to draw upon languages, concepts, and explanatory logics that set up the brain as the essential locus of personal agency and emotion. Thus, it does not seem premature to suggest that the notion of neurobiological human kinds may be useful as we think about the ways in which the molecular facts of contemporary neuroscience have ceased to be simply scientific facts––isolated in specialist journals and esoteric discussions––but have also come to provide the basis for forms of folk neurology that have, to an extent, a life of their own in everyday culture.