Two and a Half Men sitcom star Charlie Sheen

When asked recently on The Today Show how he cured himself of his addiction, Two and a Half Men sitcom star Charlie Sheen replied, "I closed my eyes and made it so with the power of my mind."
Until last month, he was the highest paid actor on TV, despite his well-known bad-boy lifestyle and persistent problems with alcohol and cocaine. After the rest of his season's shows were canceled by producers, Sheen has gone on an interview tear with many bizarre statements, including that he is on a "winning" streak. His claims of quitting a serious drug habit on his own, however, is perhaps one of his least eccentric statements.
A prevailing view of substance abuse, supported by both the National Institute on Drug Abuse and Alcoholics Anonymous, is the disease model of addiction. The model attributes addiction largely to changes in brain structure and function. Because these changes make it much harder for the addict to control substance use, health experts recommend professional treatment and complete abstinence.
But some in the field point out that many if not most addicts successfully recover without professional help. A survey by Gene Heyman, a research psychologist at McLean Hospital in Massachusetts, found that between 60 to 80 percent of people who were addicted in their teens and 20s were substance-free by their 30s, and they avoided addiction in subsequent decades. Other studies on Vietnam War veterans suggest that the majority of soldiers who became addicted to narcotics overseas later stopped using them without therapy.
Scientific American spoke with Sally Satel, a resident scholar at the American Enterprise Institute for Public Policy Research and lecturer in psychiatry at the Yale University School of Medicine, about quitting drugs without professional treatment. Satel was formerly a staff psychiatrist at the Oasis Clinic in Washington, D.C., where she worked with substance abuse patients.
[An edited transcript of the interview follows.]

Is it possible to cure yourself of addiction without professional help? How often does that happen?Of course it's possible. Most people recover and most people do it on their own. That's in no way saying that everyone should be expected to quit on their own and in no way denies that quitting is a hard thing to do. This is just an empirical fact. It is even possible that those who quit on their own could have quit earlier if they sought professional help. The implicit message isn't that treatment isn't important for many—in fact it should probably be made more accessible—but it is simply a fact that most people cure themselves.
How do addicts stop on their own?They have to be motivated. It takes the realization that their family, their future, their employment—all these—are becoming severely compromised. The subtext isn't that they just "walk away" from the addiction. But I've had a number of patients in the clinic whose six-year-old says, "Why don't you ever come to my ball games?" This can prompt a crisis of identity causing the addict to ask himself, "Is this the type of father I want to be?"
If not, there are lots of recovery strategies that users figure out themselves. For example, they change whom they associate with. They can make it harder to access drugs, perhaps by never carrying cash with them. People will put obstacles in front of themselves. True, some people decide they can't do it on their own and decide to go into treatment—that's taking matters into one's own hands, too.
What do professional drug addiction programs offer that is difficult to replicate on one's own?If you're already in treatment, you've made a big step. Even for court-ordered treatment, people often internalize the decision as their own. You get a lot of support. You get instruction in formal relapse prevention therapy. You might get methadone for withdrawal and medications for an underlying psychiatric problem.
Most experts regard drug addiction as a brain disease. Do you agree?I'm critical of the standard view promoted by the National Institute on Drug Abuse that addiction is a brain disease. Naturally, every behavior is mediated by the brain, but the language "brain disease" carries the connotation that the afflicted person is helpless before his own brain chemistry. That is too fatalistic.
It also overlooks the enormously important truth that addicts use drugs to help them cope in some manner. That, as destructive as they are, drugs also serve a purpose. This recognition is very important for designing personalized therapies.
Don't most studies show that addicts do better with professional help?People who come to treatment tend to have concurrent psychiatric illness, and they also tend to be less responsive to treatment. Most research is done on people in a treatment program, so by definition you've already got a skewed population. This is called the "clinical illusion," and it applies to all medical conditions. It refers to a tendency to think that the patients you see in a clinical setting fully represent all people with that condition. It's not true. You're not seeing the full universe of people.
Based on his public interviews, does it seem likely that Charlie Sheen cured himself?I doubt it. Of course, I haven't examined him, but based on what one sees, one would be concerned about ongoing drug use and underlying mental illness.
Is there brain damage from drug use? Is it possible to recover from such damage?The only drugs that are neurotoxic are alcohol, methadone, LSD and some inhalants. Cocaine can lead to micro strokes. That's brain damage. Yes, addiction changes the brain but this does not doom people to use drugs forever. The most permanent change is memories. Some people have stronger memories and they are more cue-reactive [more reactive to stimulus that triggers the reward pathway]. Nonaddicts won't show that level of cue-reactivity.
For some people the addiction and withdrawal will be more intense through genetically mediated problems. Those people have a harder time stopping.
What else might account for Charlie Sheen's strange behavior in those interviews?One would want to explore the possibility of underlying psychiatric problems. The grandiosity, the loose associations, the jumbled flow suggest a thought disorder. Heavy, heavy drug use could cause that. Stimulant use can cause temporary thought disorder or intensify an underlying thought disorder or hypomanic state. To try to make a good diagnosis, whatever ongoing drug use there is would have to stop. After the withdrawal phase is resolved clinicians would then need to see if an underlying thought or mood disorder persisted. That would aid in parsing how much of a confusing clinical picture is due to drug use and how much is due to a primary mental disorder.
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