I once wrote a commentary for Advances in Psychiatric Treatment on two review articles that appeared in the same edition – one on shopping addiction and the other on the possibility of online sex addiction. I called my commentary ‘Addicted to “Addiction”?’.^{Reference Smith1} In my mind was the idea that the concept of addiction has become too expansive in explaining repetitive behaviours, to the point where the term addiction becomes too indistinct to be useful. I am also distrustful of grand theories that try to explain addiction in a uniform way. For example, the idea of the ‘hijacked brain’ and an overly biological emphasis in explaining addiction have become predominant in the USA.

So, with this in mind, I approached Elias Dakwar’s book with some trepidation. The Captive Imagination: Addiction, Reality and Our Search for Meaning, from an associate Professor of Psychiatry at Columbia University, and for someone like myself who is a practising addiction psychiatrist, turns out not to be of the neurobiological school of explanation and, refreshingly, takes a more psychological approach to the subject. If there is a grand theory, it is that for each addicted person there will be underlying personal meaning to their addiction, and that understanding this meaning will be helpful in relation to a psychotherapeutic approach to the patient. The best parts of the book are the case studies.

An additional fear I had in approaching the book was that it might be another example that promotes psychedelic therapies for addiction – an area of research where the jury is still out on the efficacy of such therapies. Such therapies combine drugs that are mind altering with particular psychotherapeutic approaches. Although Dakwar has done research in this field, the book does not proselytise for such treatment and rather he sees it as a possible tool that might help in some cases. Dakwar’s knowledge of philosophy and literature is clearly extensive. In a strange and expansive concluding chapter, ‘Breaking Earth’, he gives us a long and poetic list of what addiction is and isn’t. Take for example: ‘Addiction is haunted by hell, haunted by heaven. Addiction is haunted by the promise of the marriage between the two.’ Dakwar clearly knows his Blake.

The book is problematic in my view, despite its de-emphasising of the ‘NIDA/hijacked brain’ paradigm and the empathetic approach to individuals with addiction, in that it does seem to romanticise addiction. Dakwar’s approach is very much in the frame for the criticism that the British psychiatrist Theodore Dalrymple brought to bear against addiction psychiatry in his book Romancing Opiates – Pharmacological Lies and the Addiction Bureaucracy (2006), with the idea addiction is often romanticised.

Dakwar has little to say on opiate substitution therapy and harm reduction approaches, other than the idea that harm reduction is for those not yet ready to make a change away from the addicted state. The high death rate from addiction in the USA is not mentioned. In the index I could find ‘morality’ listed but not mortality. Also I found myself wondering how applicable Dakwar’s ideas are for patients in the lower social strata, given the clear evidence that poverty and social deprivation correlate with both the rate of addiction and increased death and harm resulting from it. Although the US author Carl Hart is mentioned – he is a mentor to Dakwar – and given that Hart is known for his view of addiction as primarily socially determined, the social dimension to addiction is strangely lacking in this book.

Overall, I have mixed feelings about this book. It could have benefitted from a firmer editorial intervention; on the other hand, the breadth of scholarship may lead me back to it for its extensive bibliography. My main struggle with the book, and this may be more about my own style as a clinician, is in wondering whether Darwar’s approach can be applied to the patients I see day to day from poor areas of Scotland, who may not be as articulate or as psychologically minded as those who are seen by the author. I aim to explore the possibility that I am missing a trick and be more explicit in asking the ‘Why?’ question of my patients.