Think. Discuss. Act. Addiction

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Review: Clean

David Sheff (2013). Clean: Overcoming Addiction and Ending America’s Greatest Tragedy. Boston: Houghton Mifflin Harcourt, 374PP.


What would America be like if drug addiction did not exist? As David Sheff points out, the majority of crime in America is drug related. In addition to the millions of lives ruined by addiction, the US government has spent trillions of dollars fighting a futile “war on drugs.” Hundreds of thousands of people are in jail for drug crimes.

Why has America been so thoroughly ineffective at solving our drug problem? David Sheff, who first gained fame for his book Beautiful Boy, about his son’s battle with addiction, makes an interesting comparison. In 1971, the same year that President Richard Nixon first declared the war on drugs, Nixon also asked Congress for an “intensive campaign” to cure cancer. In the decades since, says Sheff, we have made phenomenal progress in our ability to treat, prevent and stop cancer, but the nation’s drug problem has gotten worse and worse. The difference, he argues, is that we have treated cancer as a medical problem, whereas we approach drug addiction as a moral problem. Our favorite method of prevention is “just say no”, and addicts are sent to jail when they should be sent to hospitals.

Clean can be seen as a polemic against the way the U.S. has dealt with our drug-addiction problem. It fervently urges facing it as a real crisis, for treating it as a disease and a public health issue, for understanding what science suggests as the most effective treatment methods, and transferring monies spent on a failed “War on Drugs” and an overloaded criminal justice system to proper treatment. It presents facts from approved research and accepted principles. And it also presents stories: the author’s own addiction, a 12-year old’s, and more that pull us into this dramatic social crisis.

Almost everyone uses drugs at some point in their lives. Lots of people are prescribed painkillers, but most don’t get addicted. Alcohol is completely legal, but most people are not alcoholics. Many try marijuana and harder drugs without becoming addicted. Sheff argues that drugs don’t affect everyone the same way, so the moral decision to use drugs is not the same for everyone. It isn’t simply an issue of willpower or character. He says that addiction is essentially a disease: it’s something that happens to you, for one reason or another, rather than something you choose.

Most problematic drug use is related to stress, trauma, genetic predisposition, mild or serious mental illness, use at an early age, or some combination of those. Even in their relentless destruction and self-destruction, the addicted aren’t bad people. They’re gravely ill, afflicted with a chronic, progressive, and often terminal disease. (xi)

The external factors that lead to drug abuse have been well documented. Drugs give people a surge of good feelings, with the side effect that the normal means of acquiring good feelings are damaged. Understandably, drug abuse is more likely the more difficult a person’s life is. Poverty, domestic violence and mental illness are all strongly correlated with drug abuse. People use drugs in order to feel better, to allow them to forget the trauma they would otherwise be feeling.

Most drug addictions begin in a person’s teen years. The brain is not yet fully formed by a person’s teens, and its development can be permanently altered by early drug use. People who first use drugs in their twenties or later are unlikely to become addicted.

Sheff describes how teens often turn to drugs in order to assert their independence from their parents, learn to take risks, and fit in with their peers. These are all healthy motivations, he says. He argues that teens must have opportunities for controlled risk-taking. Adults need to recognize the importance of peer relationships if they want teens to actually say no when offered drugs. The most effective drug prevention programs talk with teens about the kinds of situations where people are likely to be using drugs, and offer them tactics to avoid drug use in a socially-acceptable way.

American culture is simply obsessed with drugs, Sheff says. No matter how often kids hear that drugs are bad, they can clearly see that lots of important people use drugs, and lots of people think drugs are good. Sheff says we cannot simply ignore this reality. Parents need to feel comfortable talking to their kids about drugs—not lecturing them, but talking to them, listening to their stories and concerns.

It’s normal for children growing up in a drug-obsessed culture to be curious about drugs. But since they’re told drugs are bad, having an interest in them, no matter how normal, is taboo. The drugs-are-bad view in a culture that promotes drugs is partly responsible for our failure to prevent use, because it alienates the very people—teenagers—who we want to influence….We tell our children to talk to us, but we often unwittingly motivate them to lie or keep silent….Their fantasies and fears go underground. They conduct their experiments in secret. (23)

Effective drug prevention and treatment needs to recognize and counteract the social and biological causes of addiction. The majority of Sheff’s book explains what a good treatment program looks like, so that families of addicts can recognize them. There are a lot of ineffective and even harmful programs, and it can be hard to tell a good program on sight.

A good treatment program begins by educating the recovering addict about how addiction works. The addict is taught what is going on in their brain when they want to use drugs, and they learn methods to guide their thoughts along more constructive channels. A good program is encouraging, rather than judgmental.

Because drug addiction is often a response to harmful life circumstances, effective treatment must take these circumstances into account. If an addict’s home life is unstable or unsupportive, a residential program can be more effective. On the other hand, addicts with a healthy home life often find that their everyday routines help them regulate their habits. Sheff emphasizes that there is no one-size-fits-all solution to addiction. In some cases, a wilderness program like Outward Bound can be very effective. But many people simply don’t enjoy camping, and such a program would simply be stressful. Twelve Step programs are often very effective, but they’re not for everyone.

Sheff describes the most common types of addiction therapy, and explains what makes them effective. Group therapy, for example, can be effective if it’s done right. It can often be very helpful to have a supportive peer group who can identify with a recovering addict’s struggles. But if a group of peers can be a positive influence, it can also be counterproductive. Sheff says, “I’ve sat in on group sessions where some participants listened passively while addict after addict told horror stories about drug use. Sometimes the descriptions of drug use seemed to do little more than trigger craving” (187). As one professional from Boston Children’s Hospital put it, “Take a group of kids who want to be in recovery and introduce a kid who doesn’t and is still using, talking about how great it is, and the other kids will flip” (187). Ultimately, what determines whether addiction treatment is effective is simply whether the therapists are good at their jobs.

Sheff sums up his argument with six key points: (1) “Most drug use isn’t about drugs; it’s about life.” (2) “Addiction is a disease.” (3) “This disease is preventable.” (4) “This disease is treatable.” (5) “As with any other illness, the prevention strategies and treatments most likely to work aren’t based on tradition, wishful thinking, or faith, but science.” (6) “Drug users and addicts can do more than get off drugs; they can achieve mental health” (xix-xxi). If we could begin to approach addiction like we approach cancer and other diseases, he argues, maybe we would actually begin to cure addiction.

Some critics feel that Sheff is overstating his case. An article in Psychology Today argued that Sheff’s rejection of the moral side of drug addiction would prevent us from understanding why some addicts succeed where others fail.

Grounded in evidence of genetic predispositions and the effect of drugs on the brain, Sheff’s main theme—that addiction is a disease, not a character flaw—does counter a pervasive and pernicious tendency to “blame the victim” (or the parents of the victim). But it leaves us struggling to comprehend the role of “free will” in resisting the disease….Hard put to explain “why some people do stop using on their own,” he speculates that members of this small group “aren’t as addicted in the first place.” His analogy, that “blaming an addict for relapse is like blaming a cancer patient when radiation and chemotherapy don’t work,” doesn’t seem entirely appropriate. (Glenn C. Altschuler & Patrick M. Burns (2013, Apr. 2), “Free Will Hunting: A Review of David Sheff’s Clean“, Psychology Today)

Another way of looking at Sheff’s argument is to say he doesn’t so much reject the moral side of addiction as take it for granted. Sheff assumes that addicts generally want to beat their addiction, and obviously an addict with unlimited willpower will succeed. But human beings don’t have unlimited willpower: we do the best we can and if that’s not enough, we fail. This is true of all of us, whether we are drug addicts or not. In that sense, anything that makes an addict’s task easier—encouragement, skills training, peer support, counseling, or even a residential treatment program—will make them more likely to succeed. Even if we recognize that willpower is necessary to overcome addiction, a judgmental “tough love” approach is unlikely to be very successful even at stimulating willpower. If we want people to beat addiction, then we should give them what they need.

Questions for Reflection and Discussion

  1. Do you have any personal experience with addiction treatment, whether for yourself or for a loved one?
  2. To what extent do you think drug abuse and addiction ever represent bad choices and moral failures? What is Sheff’s answer to this question?
  3. Have you seen firsthand the sort of programs Sheff describes as ineffective? If so, what did you think of them, their weaknesses or partial successes? Do you think Sheff’s criticisms or reservations about AA go too far? Can we accept AA and Sheff’s recommended solutions?
  4. Sheff admits that for most addicts, even the best treatment is not sufficient for them to beat their addiction. Have you ever seen someone successfully overcome an addiction? What kinds of things did they find helpful?
  5. Do you agree with Sheff’s assertion that if we treated addiction as we treat cancer our country would be better at stopping addiction? Why or why not?
  6. What are Sheff’s criticisms of many existing programs for addicts?
  7. Do you see faith-based programs as detrimental or complementary to “secular” treatment programs?


  1. The morality of addiction is often overemphasized, which can lead to treatment that’s judgmental and ineffective.
  2. Most people use drugs at some point in their lives (even if it’s just alcohol or painkillers), but only a few get addicted. Addiction is strongly conditioned by factors outside of a person’s control. Some people are biologically more susceptible to drugs. Traumatic circumstances, such as domestic abuse, poverty and mental illness also make addiction more likely.
  3. If these external circumstances are left unchanged, an addict is very unlikely to recover, no matter how strong their will is. Effective medical treatment of addiction targets these external factors.
  4. If we want to reduce drug addiction in America, then we need to make sure that effective medical care is available to everyone.
  5. To the extent that Sheff’s polemic presents us with an “either…or,” as to diagnosis and treatment, it may be possible to construct some “both…and” positions.

Peter Bass with Dean Borgman

© 2018 CYS

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