Adriaans was the point investigator and contact for Kaplan's access to and involvement in the Dutch addict Self-Help Ibogaine scene.
Nico had a way with words. "People expect I will introduce myself as a heroin addict. Would you introduce yourself and say, Hello I'm a coffee drinker?"
Multistage Explorations in Social Neuroscience
The United States Congress has declared the decade of the 1990s the "Decade of the Brain". As Cacioppo and Berntson (1992, p. 1019) point out, "this delcaration is important to all psychologists, not only neuroscientists, because with this declaration come expectations of the cognitive and behavioral sciences generally and because the brain does not exist in isolation but rather is a fundamental component of developing and aging individuals who themselves are mere actors in the larger theater of life." We might add that this declaration is also of critical importance to anthropologists and sociologists, as well as physicians. The recognition that people are actors in the larger theater of life provides social neuroscience with an important place in the matrix organization of science in the decade of the brain. And also, to this end, are practical issues of applying the resulting scientific knowledge to the betterment of the condition of people through, among other disciplines, the practice of medicine.
In the Netherlands, there has been an upstart of multi-disciplinary formations in several medical schools to recognize research in psychiatry and related medical specializations into a brain-and-behavioral program. This ambitious attempt has not been easy and involves reconciliation of often conflicting epistemologies and methadologies, not to mention conflicting interest around basic and applied research. Medicine is an extremely practical affair, and no matter how elegant the research question and design can be, it must be tightly bound to issues of the patient. Our group, over the years, has attempted to contribute to the development of this brain and behavior initiative by emphasizing the basic role of culture and society in shaping the context of the patient and of determining what is in fact "the case" for social neuroscience. We have been especially influenced by ethnomedical and cross-cultural psychiatry traditions, but we have also tried to find our own way out of the limitations of these two traditions. We are not, in fact, interested in the macrocultural systems that have been the traditional object of ethnomedicine. Rather, we have worked to bring ethnography and other fieldwork methods into the design of medical research. In this regard, we have conceived of the endogenous mechanisms of the brain to have correlates in the exogenous mechanisms of cultural and social interaction,
To get from behavior to the brain and back again is a multistage process. The design of this research involves a stage 1 which identified risks and problems in a specific population. Stage 2 moves to target groups through snowball sampling and to problem clarification through focus groups which aim to develop theoretical constructs that have "member" (i.e. patient) validity. Stage 3 consists of the acquisitions of intensive field samples of a relatively small size studied through experience-sampling methadology (ESM; see de Vries 1992) and ethnography. Only after this work is done are we ready to enter the laboratory for testing our hypotheses related to specific exogenous and cultural variables and brain function. This laboratory work represents Stage 4. In Stage 5 clinical and field trials can be conducted on interventions that are based on the findings.
Most of our work to this date has been limited to Stages 2 and 3. We have conducted extensive studies in Stage 3 using ESM on various psychiatric-patient groups. Study participants wear programmed wrist terminals that beep at random intervals during waking hours. At each beep, the participant fills our a short questionnaire. Thus, in a design calling for ten beeps per day, for seven days, the respondent is asked to fill out the same questionnaire seventy times. These studies have provided us with a thick description of the daily rhythms of psychiatric syndromes and the interplay of their specific symptoms with contextual, thought and mood variables. These studies are allowing us to reframe diagnoses with new behavioral and cognitive data drawn from daily life. For example, in an ESM study of twenty active heroin addicts we were able to idenitfy protective factors that are imporant determinants of health within the context of addiction (Kaplan et al. 1990). The in-depth analysis of these factors has allowed us to understand how addict daily life is naturally organized to protect health as well as to result in illness. The positive factors in addict daily life should provide the basis for health-promotion efforts in this hidden population.
We also have been making extensive use of focus groups prior to ESM analysis. The focus group has received attention for some time as a tool in applied research (Krueger 1988). The method involves the systematic formation of groups organized for the purpose of obtaining specific information. The group is organized to produce specific data of interest to the researcher and therefore differs from the other groups, such as delphic and brain-storming. Focus groups are principally data-collection procedures, producing qualitative information which can facilitate theoretical insights. The topics for discussion are carefully selected and sequenced and are designed to provide materials for building theoretical understandings of the context and experience of the group participants. The focus group has recently been introduced as a tool relevant for public health problems.
For illustrative purposes we can present in this short communication two focus group studies that are currently underway. One involves focus groups conducted at the Tibetan Medical Institute in India with pain patients who have been treated with traditional Tibetan medicine and also Western techniques. The second focus group was conducted in the Netherlands with heroin addicts who had been treated by "lay healers" with ibogaine, an alkaloid extracted from an African root with potent mind-altering properties 1. Both focus groups collected background medical data and solicited information clarifying social neuroscientific processes that might be involved in reaching the state of wellness by these patients.
In the Tebetan focus groups, medicine blessed by His Holiness, the Dalai Lama was used together with natural techniques, such as regimes of warm baths, were reported to result in the gradual reaching of wellness after years of pain and unsuccessful treatment. The role of this specially blessed medicine is crucial in the patients' accounts. A question of future research is what sociocultural mechanisms in conjunction with neurochemical processes are able to alter long-enduring periods of illness?
Some suggestions emerge in the consideration of the results of the focus groups with the Dutch heroin addicts. The focus groups of addicts revealed that ibogaine was able to induce the experience of collective consciousness and a clearing up of the mind for members of the focus group. J., one of the members, reported a common experience, namely, that ibogaine had made her aware that "All the information I ever got through reading or experience was registered in my brain." This demonstration of the brain's capacities, which formerly was only theoretically known, became a lived experience. Common to all members was the production of an intense state of wakefullness. For three to four weeks after taking the ibogaine, they slept for only three to four hours per day. After a month they gradually returned to eight hours of sleep per day. The ibogaine was not comfortable for the members; all had highly anxious episodes. The state of ibogaine was described by all as a dream with full consciousness. All felt themselves to be physically heavy, i.e. in a somnolent stage like a body in sleep. All reported an interruption of heroin-seeking behavior for relatively long periods of time, a state that they never thought they would reach given their former nihilistic, depressed view of life.
From these focus groups some intriguing hypotheses have been clarified, highlighting both exogenous and endogenous processes. The ibogaine experience succeeded in providing a common sense of belonging to a distinct community oriented to wellness - a European variety of the African iboga medicine society. Thus, even, the one member who used heroin again rather shortly after the treatment did so out of a clear decision and reported that he did not feel himself addicted anymore. The focus group undermined a preconceived notion that, because of its extraordinary psychopharmacological effects, ibogaine produces a singular, common experience. However, the members discovered in the group that each experienced the ibogaine in a unique and different way. Does ibogaine, like the Dalai Lama's medicine, work to create a sense of belonging to a medicine community that is dedicated towards reaching a state of wellness? Is this special consensus an important exogenous mechanism culturally reframing pathological endogenous processes?
Turning to the endogenous system it is known that ibogaine is a sorotonin agonist and has been pharmacologically classified as an antidepressant. Ibogaine's tricyclic chemical structure resembles the tricyclic antidepressants, such as imipramine, which have had successful clinical trials in managing drug-craving. Could this ibogaine have resulted in a "rechanneling" of serotonin in the brain, basically altering the fixated behavioral rhythms of the addict? All addicts presented a significant weight alteration from 3 to 10 kilograms. These alterations, together with the dramatic sleep changes, suggest a rechanneling of serotonin inside the brain. In this case, could serotonin rechanneling inside the brain be correlated with a rechanneling of the drug addict's community consensus? Is wellness the outcome, if only for a while, of this correlation?
These focus groups have indeed served their purpose of claifying hypotheses and future research problems for specific subgroups of a larger population of patients. They illustrate that the correlation of exogenous and endogenous social neuroscientifically relevant mechanisms can be made available for empiral analysis through a stepwise, multistage method. Indeed, this related to the reasoning why Cacioppo amd Berntson have subtitled their article the "Doctrine of Multilevel Analysis." The decade of the brain in the 1990s will probably be one of great surprises. Not the least of these may be that an essential field of neuroscience research lies far beyond the laboratories of bench science. Reaching a state of wellness must certainly involve exogenous factors in "the larger theater of life." Focus groups, snowball sampling, experience sampling, and ethnography promise to be useful tools in the 1990s to carify the theater's plays, stages and scripts.
Cacioppo, John T and Gary G. Berntson (1992) "Social Psychological Contributions to the Decade of the Brain." American Psychologist 47:1019-1028. return
Kaplan C.D., de Vries M.W., Grund J.P. and Adriaans N.F.P. (1990) "Protective Factors: Dutch Interventions, Health Determinants and the Reorganization of Addict Life." Pp. 165-176 in H.A. Ghodse, C.D. Kaplan and R.D. Mann, eds, Drug Misuse and Dependence, Park Ridge, New Jersey: Panthenon Publishing Group. return
Kreuger R.A. (1988) Focus Groups: A pratical Guide for Applied Reserach. Newbury Park: Sage Publications. return
Vries M.W. de. (1992) The Experience of Psychopathology: Investigating Mental Disorders in their Natural Settings. Cambridge: Cambridge University Press. return
Underscoring of sections by B. Sisko, International Coalition for Addict Self-Help. return
The Ibogaine Dossier