How AA and 12-step programs erect barriers while attempting to relieve suffering.
Defining addiction as a disease is marketing for the rehab industry — and an excuse when treatment doesn’t work
The idea that addiction is some kind of disease is unquestionably the dominant view in government, medical, and most scientific circles around the world. So dominant in the West, for example, that US vice president Joe Biden introduced the Recognizing Addiction as a Disease Act for debate in the US Senate on March 28, 2007.
S. 1011: Recognizing Addiction as a Disease Act of 2007
(1) Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs. The disease of addiction affects both brain and behavior, and scientists have identified many of the biological and environmental factors that contribute to the development and progression of the disease.
Yet the concept that addiction is a disease is certainly not new. In fact, it’s been promoted and rebutted since the time of Aristotle (and other Greek and Egyptian scholars), and it has grown exponentially in authority and popularity since the early 1900s. This quote from a hundred years ago captures the flavour of the disease concept when it began to proliferate in the West:
The author considers it very unfortunate that the terms “morphine habit” and “opium habit” have been, and are still, so universally employed when referring to narcotic addiction (disease). They are misleading and do not, in any wise, accurately describe the condition present. . . . Habit implies something that can be corrected by an exercise of the will. . . . This is not true of narcotic disease; therefore, it is not a mere habit and should not be spoken of as such. . . .
The man who is addicted to a narcotic drug is as truly a diseased man as one who has typhoid fever or pneumonia.
How did this definition arise, and how has it evolved in our own time?
Society’s conceptualization of addiction has always reflected its policies for dealing with it. While Shakespeare referred to addiction in”Henry V,” nobody at the time advocated treatment centres for debauched nobility. Public alarm began to rise over “demon rum” and other spirits early in the nineteenth century. By the end of that century, temperance movements vociferously demanded total abstinence. In the early twentieth century, alcoholics and addicts were seen as both doomed and damned if they could not or would not dry up. And when those warnings didn’t work, Prohibition was launched in the United States as the next-best solution. Temperance activists saw alcohol itself as the cause of alcoholism, much like contemporary disease theorists see drugs (rather than environments) as the cause of drug addiction. When Prohibition was repealed to allow for social drinking, hard-core alcoholics were nevertheless reviled as morally depraved and undeserving of help.
Public policy thus maintained its moralistic and puritanical slant well into the 1930s. But then the view of medical practitioners, that addiction was a malady rather than a personal failing, picked up support from an unexpected source. Bill Wilson and Robert Smith started Alcoholics Anonymous (AA) in 1935, launching a new era in society’s perception of addicts and their treatment. The premise of AA was that alcoholics were suffering human beings who had the right and the obligation to try to relieve their suffering. Through principles of mutual support, ongoing group attendance, self-honesty, and spiritual transformation, AA helped millions of alcoholics overcome their addictions, as it still does today. It also spearheaded society’s recognition that addicts need help, not rejection, and that they can get better.
The founders of AA did not see addiction as a disease, exactly, but as a mental and spiritual “malady.” Physical sensitivity to alcohol was initially conceived of as an “allergy,” while the spiritual malady expressed itself in perpetual discomfort with life on life’s terms, an inability to be at peace in the moment. Booze first seemed to soothe this discomfort but ultimately exacerbated the physical sensitivity. The result was a lifelong disorder that remained treatable, though never actually curable. AA counselled its members to stay vigilant about their vulnerability and to keep it firmly in mind by reciting metaphors, chanting slogans, and telling and retelling personal tales of failure and of success. A crucial springboard to sobriety was realizing that you were powerless over alcohol—you were not capable of moderate or occasional drinking. The twelve steps of AA begin, still today, with an admission of powerlessness and a commitment to trust in a higher authority. It turns out not to matter as much anymore whether that authority is God, the group itself, your sponsor, or the medical community. What does matter is the acknowledgement of a serious deficit, which is—not coincidentally—the state you find yourself in when the doctor says you have cancer or pneumonia. That’s when you know you need help.
While AA’s emphasis was on the mental and spiritual aspects of addiction, the idea of a biological sensitivity to alcohol opened the door to a more specific (and broadly accepted) definition of addiction as a disease. In the early 1950s, when Narcotics Anonymous (NA) and Hazelden’s “Minnesota Model” got off the ground, the disease nomenclature began to flourish. NA, an outgrowth of AA, was established to treat those addicted to heroin and other drugs, and it was considered self-evident that the drug was what caused the disease of addiction. The Minnesota Model, which blended twelve-step philosophy with principles of residential care and education, became the gold standard for treatment centres by the 1960s. The Minnesota Model specifically labelled alcoholism a disease that overcame people physically, mentally, and spiritually. At the same time, an influential book by E. M. Jellinek, “The Disease Concept of Alcoholism,” articulated a medical model that traced the progression of alcoholism through a series of phases leading to loss of control, insanity, and death. Now the “disease” terminology began to appear in the literature of twelve-step programs throughout North America. And the American Medical Association classified alcoholism as an “illness” in 1967, making it official. In retrospect, the concept of a biological deficit, reified by AA, helped pave the way for the disease concept of addiction, and a medical term became standard parlance in the world of addiction treatment.
Today the disease definition is used by twelve-step programs around the world, though its meaning continues to morph and vary from group to group. Moreover, twelve-step methods have become central in the world of institutional treatment, where the disease definition has been imported wholesale. There is a basic incompatibility between AA philosophy and the impersonal character of institutional care, and the disease label just reinforces the resulting fallout. Addicts seeking treatment, or those coerced into treatment by the justice system, are compelled to follow a recipe for recovery targeted to what is viewed as their disease, independent of their personal beliefs, which are often dismissed as irrelevant. If they do not follow the recipe, they may be denied any treatment at all, a policy that is fundamentally at odds with official twelve-step literature (though some twelve-step groups adopt the same punitive methods). For many addicts, this pressure tactic is a deal breaker, and that helps explain the acrimonious tone of the criticisms expressed by those who’ve quit or been excluded from twelve-step-based care.
There are other ways in which twelve-step practice has helped erect barriers while attempting to relieve suffering. First, the AA framework and the medical notion of disease share the core assumption that addiction is a lifelong disorder and total abstinence is necessary to arrest it. The graded (e.g., occasional, social) use of any substance is deemed self-destructive, inevitably leading to relapse. This position often strikes former addicts as exaggerated and untenable, and epidemiological research shows that many recovered alcoholics are capable of social drinking. (The debate about moderation versus total abstinence is contentious and volatile, and I won’t attempt to get into it here. Suffice it to say that many sources of evidence point to highly individualistic outcomes and resting points along the route to recovery. And whether or not total abstinence is necessary has little bearing on the disease concept, regardless.) Second, the collaboration between the twelve-step movement and institutional thinking asserts the need for treatment through recognized programs. This policy discourages addicts from finding their own way to recovery, and it blocks their access to benefits that might help pay for alternative resources. Moreover, it ignores compelling data, collected by a variety of independent organizations (most famously the National Epidemiologic Survey on Alcohol and Related Conditions, NESARC), showing that most addicts and alcoholics do recover, and that a majority of those—up to three-quarters, depending on where you get your statistics—recover without any treatment. Third, twelve-step literature maintains that the disease of addiction is built into one’s character. Experts including Stanton Peele have shown how destructive this attribution can be, especially for young people whose identities are still under construction.
Finally, and most troubling, is the confusion that surrounds AA’s emphasis on recognizing one’s “powerlessness” as a condition for overcoming addiction. For those helped by twelve-step methods, powerlessness is usually viewed as a hinge point for surrendering unworkable strategies and admitting that one has to start over and revamp one’s design for quitting. However, others interpret the emphasis on powerlessness as suggesting ongoing helplessness, perhaps because their thinking has been distorted by submission to a set of impersonal rules imposed by the courts, institutional policies, or overly severe group leaders. As I noted earlier, many experts highlight the value of empowerment for overcoming addiction. In fact, most former addicts claim that empowerment, not powerlessness, was essential to them, especially in the latter stages of their recovery. Sensitivity to the meaning of empowerment in recovery may be greatest for those who’ve been disempowered in their social world, including women, minorities, the poor, and those with devastating family histories.
It’s an open question whether the disease nomenclature, partially absorbed into the AA mainstream, has alienated more members than it’s helped. Here’s a comment I received about a year ago, following a blog post on the disease label:
I am a Registered Professional Counsellor and I have personally struggled with alcohol addiction in my life.
After the last three years of intense psycho-therapy and group work focused on healing personal wounds from our childhood and dealing with our traumas, I have managed to come out of my addiction on to the other side.
I have many friends who still rely heavily on the AA program, and with no disrespect to the program—I can see how it works for them, it just does not work for me.
I have had a long hard look inside about how I feel personally about addiction. I do not feel that I have or had a disease. I see my past drinking as a behavioral problem, a learned response to dealing (or not dealing) with emotional pain and stress. Once I achieved the excavating of my wounds I no longer lived with the same anxiety or sense of dread/guilt and shame. . . . I have completed the steps—however, I see them as steppingstones rather than a Solution.
The disease concept evolved from a description to a model in the 1990s—“the decade of the brain.” Neuroscientists began to show new synaptic growth in morphine-addicted lab rats and neural rewiring in human cocaine addicts: clear evidence of brain change. With other drugs the story was sometimes more complicated, but the fundamental message was the same: drug use messes up brain wiring, and the mess doesn’t disappear when you quit. Many of the reported structural changes were related to changes in the release and absorption of dopamine, a neurochemical associated with reward in subcortical systems but with cognitive control in the loftier reaches of the cortex. In study after study, dopamine levels went up and down with drug availability—and not much else. Dopamine was increasingly released by getting high, or by cues that predicted getting high, or by cues that predicted cues that predicted getting high, and decreased in relation to other formerly pleasurable activities like sex, food, and watching your kids grow up. The brain receptors that absorb and use dopamine were also found to change in structure or efficiency over months and years of use.
Because the action of dopamine enhances the formation of new synapses (and the corresponding loss of older ones), changes in the dopamine system bring about structural changes in synaptic networks—the basic wiring diagram of the brain. And they do so most significantly in a brain region called the striatum, the area responsible for pursuing rewards. These brain changes were seen as direct evidence that an insidious force—namely, drugs—had “hijacked the brain,” a phrase first uttered by Bill Moyers on a popular PBS television series but quick to catch on in addiction debates everywhere. I’ll delve more deeply into brain change in subsequent chapters. For now, what’s important to emphasize is the impact of such findings on the conceptualization of addiction, comfortably defined as a “chronic brain disease” from the late 1990s to the present.
It makes sense that medical practitioners (and their colleagues in related professions) readily jumped on the bandwagon. First, it jibed with psychiatrists’ long-standing efforts to “medicalize” psychological problems, to see mental illness through a biological lens, so that medical doctors (especially psychiatrists) remained the ruling experts on psychological matters. Second, by fitting addiction within a medical category, the disease model provided coherence and closure in a field customarily sown with discord. Doctors rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem is identified with a medical label, from borderline personality disorder to autism, depression, anxiety, and addiction. These conditions are described as tightly as possible and listed in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM) and the International Classification of Diseases (ICD). In fact, the DSM is famous for categorizing every nuance of personal disturbance as a type or subtype of disease, and the latest rewrite of the DSM—creatively labelled DSM-5—can be seen as leading to more medicalization because it includes more symptoms. It would be strange indeed if addiction were not invited to join the club.
Since our opinions and convictions are so firmly guided by the dictates of medicine, the disease concept has become a juggernaut, overtaking diverse arenas of public opinion and public health. Thousands of self-help books, websites, and YouTube videos spread the word: Addiction is nothing to be ashamed of. It’s a brain disease.
As argued earlier, the disease model probably does more harm than good for most addicts. Yet its benefits for other players are clear. The disease model is excellent news for the owners and managers of the more than fifteen thousand drug and alcohol rehab centres operating in the United States and Canada, because it means We know what your problem is, and we’re the ones to fix it. Drug and alcohol treatment and rehab represents a multibillion-dollar industry in the Western world. (Costs vary from country to country but are generally above $2,500 per week in the United States and Canada, slightly lower in Britain and Europe.) And while the size of the problem may justify the enormous size of this network, we must recognize the industry as a special interest with much to gain and much to lose.
The definition of addiction as a disease, endorsed by the medical and scientific communities and most Western governments, may be the most powerful marketing tool there is for the rehab industry. It’s not only a great way to get people in the door—clearly people with a disease need treatment, and judges in the United States have fully endorsed this logic—but also a way of explaining what goes wrong when treatment doesn’t work. Because no doctor, nurse, or shrink will ever tell you that they can fix you for sure. All they can say is that they’ll try. And if you end up not getting fixed, well, that’s the way it is with diseases. And probably you didn’t quite follow the regimen you were instructed to follow. The wagging finger isn’t hard to visualize. The disease concept is also a useful tool for the insurance industry, because it defines and delimits the kind of treatment that will and won’t be covered, for how long, and at what cost. Closer to home, most addicts’ families (76 percent in a recent Gallup poll) also see addiction as a disease, because it makes the disgraceful behavior of their loved ones comprehensible and even forgivable. So the disease model becomes a convincing framework for understanding addiction from the outside—even when that definition is ineffective, inaccurate, or harmful for addicts themselves.
Adapted from “The Biology of Desire: Why Addiction Is Not a Disease” by Marc Lewis. Reprinted with permission from PublicAffairs. All rights reserved.