Addiction: Disease or choice?

This blog post expands on the points raised in my article about effective treatment for alcoholism.

An addiction disorder can be very distressing for an individual as well as their partner and family. Active addiction involves loss of ability to choose freely whether to stop or continue the behaviour (loss of control) and leads to experience of behaviour-related adverse consequences (Schneider & Irons, 2001).

The disease model of addiction underpins the enormous rehab industry whereby addicts get treated at the hands of so-called ‘experts’ at very expensive units, and often within residential retreats. The treatment team at such places invariably consists of medical experts (including psychiatrists) but also the burgeoning band of treatment personnel who report to them (a lot of whom are low paid staff or trainees on placement). The most common interventions are group process dynamics as this represents the most cost effective treatment plan. The success rate for these places in effectively treating addiction is poor as the rate of relapse amongst patrons is quite high. So, you might ask what is the theoretical foundations of their addiction treatment?

Addiction treatment is largely based on three broad categories that underpin addiction recovery treatment programmes. They overlap to some degree, but each model has unique implications for research, funding, and care, from the level of government policy to that of treatment options for individual sufferers. The three categories are:

1. The Brain disease model

Advocates of the disease model maintain that there is ample scientific evidence from PET scans to believe that the brain changes as a result of substance abuse and that because it changes it must, therefore, be evidence of disease.

The disease model of addiction is essentially a biological explanation for the causes of addiction. Drinkers and drug users follow a pathological road to destruction and have lost control as a result of their using. Proponents of this outlook see addiction affecting the brain in similar ways that physical illnesses produce changes to vital organs. For example, diabetes changes the way the pancreas works and hepatitis changes the way the liver functions and this is the same for alcoholism, in that it changes the manner in which the brain functions.

Alcoholism was officially designated an illness by the American Medical Association (AMA) in 1967. Seeing addiction in this way, rather than as a weakness by self-indulgent moral degenerates, has brought benefits to the medical community for it has stimulated research as well inspiring the development of useful medications that have helped ease the symptoms of withdrawal.

The disease concept of addiction has formed the basis of the 12 steps of recovery from Alcoholics Anonymous (AA) and Hazelden’s ‘Minnesota Model’ and contain key concepts of powerlessness around alcohol (and drugs) and personal unmanageability in life. These concepts form the bedrock for an abstinence based approach to treatment, for life, albeit one day at a time. AA’s 12 steps are a combination of cognitive and behavioural tools and techniques and have a concept of a mental and spiritual malady at its heart. AA’s founders Bill Wilson and Dr Bob Smith were heavily influenced by Carl Jung in embracing the idea of a higher power to stimulate personal and spiritual ‘recovery’. The 12 steps state that the chronic alcoholic must undergo an entire psychic change in order to recover from a seemingly hopeless state of mind. People attending AA meetings see themselves in perpetual ‘recovery’ from an illness and observe total abstinence for life.

search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life

The Diagnostic Statistical Manual of mental Disorders (DSM), currently in its fifth iteration, is the psychiatric bible for clinicians and states the following: a “substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.” The present trend in psychiatry is to also classify gambling and even excessive internet use as disorders (as listed in DSM5), which others see as a vague term that overlaps with “disease”. Critics of the disease model ask where it will stop when defining symptoms of disease. They ask whether net surfing, hoarding, unrequited love and compulsive shopping might also be classed as diseases or disorders. Stanton Peele, a big critic of the 12 steps approach, argues in his book The Diseasing of America (1989) that addicts can recover without so called treatment, and that it is wrong to build into treatment the notion of character flaws (one of the steps in AA is to undertake a personal and moral inventory and to start with a form of confession in relation to the 7 deadly sins). Peele argues that numerous studies have demonstrated that people can drink socially again at a point in the future. He rejects the idea of personal powerlessness, opting instead for the concept of personal empowerment, as a more robust and positive approach to addiction treatment. For Peele addiction is the search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life. Peele explains that addicts tend to display susceptibility to diverse addictions, in sequence or at the same time. However, the gratification turns out to be temporary and illusory and the addictive behaviour results in more and more self-disgust, reduced psychological security and a poorer ability to cope with stress. In the attached clip (below) Peele expands on his ideas about addiction with particular reference to the neuroscience of addiction.

Marc Lewis agrees with Peele in rejecting the disease model by pointing out that whilst the brain does indeed change in response to addiction, so the brain changes in response to falling in love. The brain will change in response to learning activity and, therefore, brain change itself should not be used as evidence of disease. He points out that the hippocampus of London cab drivers expands by learning The Knowledge Test (see Maguire and Woolett). Indeed, Lewis argues that advocates of the disease model need to prove that brain change in addiction goes beyond what would occur in response to normal learning and development. Rather than the 12 steps of recovery Lewis prefers the notion of motivated self-direction for treating addicts, when the addict finds greater meaning and purpose in their life to sustain a healthier lifestyle. For Lewis addiction is motivated repetition that gives rise to deep learning as he explains in great detail in his recent book The Biology of Desire: Why Addiction is not a disease. Addiction can also be seen as recurrent desire towards a single goal. In the attached clip (below) Lewis expands on his ideas about addiction.

2. The Choice model

The choice model was the theoretical basis of the War on Drugs campaign and the popular slogan “Just Say No”. Users do not consider addiction a good choice, but they often consider it a rational choice, at least in the short term – as when the relief gained from the addiction outweighs other possible choices.

Gene Heyman, is his book Addiction – A disorder of Choice, argues against the conventional psychiatric view that addiction is a disease. For Heyman, addiction is entirely voluntary and he sets out to demonstrate that drug use, like all choices, is influenced by preferences and goals. In the attached clip (below) Heyman articulates his ideas on addiction.

The Choice Model explains why people suddenly stop being addicted in response to a change in environment. An example would be when Vietnam veterans suddenly stopped abusing heroin when they returned to their homes after the war. This idea builds on the Bruce Alexander “rat park” experiments which showed that rats did not consume drugs in controlled trials in response to an improved social environment. In the attached clip (below) Alexander expands on these ideas of the need for an improved social environment.

Proponents of this model point to economic and environmental factors beyond the addict’s control such as poverty and social isolation. However, when conditions change with time and circumstances, then so do choices. Users see a different outcome to their predicament and change their behaviour accordingly.

The choice model explains better than the disease model how addicts suddenly quit but advocates of this approach risk viewing addicts as selfish and self-indulgent moral degenerates.Rather than being victim of a biological condition they are personally responsible for bringing on their misfortune in life by bad choices.

Treatment in this model could involve reviewing one’s beliefs and changing one’s perspectives, using tools and techniques offered by cognitive behavioural therapy (CBT) and motivational interviewing. Treatment invariably proposes total abstinence.

3. Self-medication model (or drive-reduction)

The self-medication model (or what some term drive-reduction) suggests that drink and drugs usage is an attempt to regulate or alleviate negative affect, and thus may become negatively reinforcing. It is not a coherent approach as it is grounded in developmental thinking and conflicts with the notion that addiction results from an allergy. As children and adolescents develop, emotional problems can erode their sense of well-being. Trauma, either social, psychological, or sexual, is a buzzword for early adversity and post-traumatic stress disorder (PTSD) is often found to underlie anxiety and depression. Researchers have found that substance abuse among those with PTSD is as high as 60-80% and the rate of PTSD among substance abusers is 40-60% (K. T. Brady and R. Shina, 2005).

Taking drugs and alcohol make you feel better until they don’t. A nasty side effect of addictive drugs is that the addiction itself becomes a source of stress.

Treatment, according to this model, stresses the need to protect people who are vulnerable to psychosocial pressures and to diagnose and treat underlying developmental issues that have predisposed someone to addiction. For Christine English drug use in adulthood is a recycling of prior experiences of hurt and harm in childhood. Gabor Mate in his book In the Realm of Hungry Ghosts skillfully made a case that addicts seek relief from drink and drugs in response to early bonding experiences that were difficult and painful. In the attached clip (below) Mate expands on these ideas on the power of addiction.

Treatment options cover a range of holistic tools and techniques including CBT, attachment theory, object relations theory, creative imagination and mindfulness for addiction can be viewed as a loss of connection, or meaning in life. It could also mean loss of soul in transpersonal terms. Counsellors and therapists in this theoretical model might advocate total abstinence but not necessarily so as working therapeutically on past trauma can potentially see a transformation that entails social drinking at some point in the future.

The process of therapy could be viewed as a shift from pleasure seeking behaviour towards relationship seeking, where reality is embraced rather than avoided. Bion saw addiction as a hatred of reality. Perhaps the most useful aspect of therapy for the addicted client is to explore ‘here and now’ feelings in a safe and contained environment.

See also

Addiction is not just about drink and drugs
When financial trading becomes problem gambling
Now that you have stopped drinking
Afraid of your gambling habits
Sex addiction – why its so misunderstood
My son is addicted to computer games
What to do when your partner has an active addiction
How to know if you have a problem with porn
The most effective treatment for alcoholism
Why FOBTs are dubbed the ‘crack cocaine of gambling’
Porn, alternative sexual lifestyles and addiction