The Disease Concept of Addiction Revisited by Richard S. Sandor, MD

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The Disease Concept of Addiction Revisited by Richard S. Sandor, MD

Richard S. Sandor, MD, practices psychiatry and addiction medicine in Santa Monica, California. He is a past president of the California Society of Addiction Medicine and is the author of Thinking Simply About Addiction (March 2009, Tarcher/ Penguin).

Next year, The Disease Concept of Alcoholism, by E.M. Jellinek, will be fifty years old, and while the idea that alcoholism and drug addiction are diseases is now widely accepted, it remains poorly understood. The latest contribution to the continuing muddle is a book published this June called Addiction: A Disorder of Choice by Dr. Gene Heyman of Harvard. Actually, the publication of this book is an ironic recapitulation of history. Thirty years ago, Herbert Fingarette, of the University of California, advanced essentially the same argument in his book Heavy Drinking: The Myth of Alcoholism as a Disease. Both men based their conclusions on studies and surveys. Fingarette was a philosopher, arguing from his reading of the scientific literature. Heyman, an academic psychologist, reaches his conclusions from epidemiological studies and surveys. Neither man, as far as I been able to determine, has spent much time in the clinical trenches, actually listening to alcoholics and drugs addicts describe their lives.

So it seems a good moment to re-examine the disease concept of alcoholism and other addictions.

In the first place, scientific data can no more “prove” that addiction is a disease than it can “prove” that the sky is blue. Either we all agree that the color of the sky is sufficiently like everything else we call “blue” to warrant using that word, or we agree to call it something else. By analogy, asserting that addiction is a disease cannot be founded on scientific data. It requires a theory of what addiction is. In other words, we have to show how addiction like all the other things we generally accept as diseases.

In proposing that addiction is a disease, we do not mean that drinking (heavy or otherwise) is a disease. Obviously, behavior may signify the presence of a disease – the behavior we call a “seizure,” for example, may indicate an infection, a hemorrhage or a tumor in the brain. But to consider the seizure itself a disease is to confuse symptom and cause. The common sense inherent in our language reflects this same point: we don't speak of a someone “high blood pressure-ing” or “pneumonia-ing.”

We speak of a disease as something a person has, not something he’s doing. This explains why no external measure of drinking or drug use defines alcoholism consistently. But if drinking or using is only a symptom of addiction, then no one should be surprised that measuring symptoms brings no uniform picture of the disorder. In virtually all illnesses, especially early in their course, symptoms are remarkably variable. Just as fevers may be high or low, pain severe or mild, alcoholic drinking may be heavy or light, intermittent or continuous, boisterous or quiet – all depending on biological, social and psychological factors influencing that individual.

If by calling addiction a disease we mean that sometimes drinking or using is a sign of something else – a result of something a person has, then we need to be clear about what that something is. Without a simple conception of what an addiction is, on par, for example, with what an infection is (i.e., microorganisms eating human tissue), we have no strong argument for the disease concept of addiction.

Part of the difficulty in establishing that concept is the same as for other mental illnesses, namely, that the essence of the condition is in the experience of the person who has it. It is largely subjective and cannot be quantified “objectively.” That’s why it’s so important to listen to the stories or alcoholics and addicts themselves – to hear what they themselves say about what's going on inside them. When we do that, what we learn is that they feel “powerlessness.”

But the idea of powerlessness is paradoxical. After all, many alcoholics and addicts do quit drinking and using for good. How can they claim to be powerless and at the same time claim that recovery is based on choosing not to drink (or use) “one day at a time?”

The answer lies in conceiving of addictions as “automatisms” – as disorders of automaticity. But before explaining what I mean by that, I want to say that I came to this idea after listening to the histories of thousands of alcoholics and addicts over 30 years. Somewhere around 2500 [sic], I discovered that the great American psychologist, Mark Twain, had distilled the essence of addiction down to this famous phrase:

“To cease smoking is the easiest thing I ever did; I ought to know because I’ve done it a thousand times.”

At the risk of being one of those people who spoil a good joke by explaining it, the genius of Twain’s remark lies in his articulation of the “all or nothing” quality central to the experience of having an addiction. Although addictive behavior is remarkably varied, in the end, most addicts discover that abstinence is the only reliable foundation for recovery. “Quitting,” it turns out, is hard, but it isn’t the major problem. The bigger problem, brilliantly expressed in AA, is “staying quit” – not starting again.

Addiction begins with the struggle for control (“never before 5:00 pm,” “only on weekends,” and so on, but as it develops, control becomes increasingly difficult to achieve. At a certain point, control is attained only by “quitting.” Indeed, episodes of quitting are almost an infallible indication of the diagnosis of addiction (as opposed to mere abuse or misuse). At this stage, if people begin again, they invariably spend increasing amounts of time and effort to maintain “control.” In the end, control is utterly lost. This is what the founders of Alcoholics Anonymous described as having become “powerless” over alcohol – not just for an episode of drinking, but repeatedly and inevitably. In the end, they discover that there is just no such thing as “one.”

Now comes another paradox. I call it the “control conundrum” because non-alcoholics never experience this difficulty controlling their drinking. Whether they are stronger or better people (as they sometimes like to think) is a matter of opinion. The fact remains that normal drinking is unaccompanied by the struggle for control. So here’s the puzzle: how can an illness be characterized by the sense of losing control when the healthy state of affairs is experienced as not needing control? How can an alcoholic lose what a non-alcoholic doesn't have? The answer is that an addiction is the development of something rather that has a life of its own: that something is an “automatism” – something that does itself.

A simple example is swimming. Once you “get it,” you can’t get rid of it – once a swimmer, always a swimmer. Stay out of the water for fifty years, get in over your head at the beach, and watch what happens: automatically, whether you intend to or not, you’ll swim. Now, suppose for some reason it became extremely important for you never to swim again (dangerous currents, sharks, motor boats). What choice do you actually have? Since you cannot forget or “unlearn” being a swimmer, you literally cannot chose not to swim. Your only reliable choice is to stay out of the water – to become abstinent. True, a swimmer might try to enjoy the water, but avoid swimming by confining himself to the shallows. This would be analogous to the “setting limits” stage of an addiction. It just doesn’t work in the long run. Sooner or later, whether the swimmer intended to or not, if his feet leave the bottom, he’ll be swimming again, automatically. As long as he doesn’t drift out into the deep water, there may well be no problems, so it won’t matter. But that isn’t the point. The point is that despite having resolved to stay in the shallows, he is now swimming again. Whether or not you go into the water, yes, there you have choice, but once you’re in over your head, you'll swim. In order to succeed in controlling an automatism, one must become abstinent. For swimming, that means staying out of the water; for an alcoholic or drug addict, it means not drinking or using.

Please note, I am not saying that automatisms are necessarily harmful; on the contrary, our lives are filled with, and indeed, made possible by automaticity. Complex automatisms – bodily movement and speech, for example, free our attention for the experience of higher levels of responsiveness. Again, an example will be more instructive than description: DON'T READ THIS. In order to experience the meaning of the phrase (and the humor) you have sacrificed choice at the level of recognition – if you look at it, you cannot not read it.

Addictions are complex phenomena of the same type, involving the automatization of feelings (impulses), thoughts (obsessions), actions (behavior) and physiology (tolerance and withdrawal). This is the all-or-nothing experience of addiction: something inside has acquired a life of its own. When it threatens the well-being of the whole, it is rightly considered a disease.

If this conception of addictive disease fits the class of events called “illness,” it shouldn't have to be forced into place. It should fit the way other, well-accepted, conditions do (the "Is-the-sky-blue?" test). Does it?

In every disease, there is an agent of harm – a hostile germ, a defective protein, an abnormal growth that disrupts the harmonious balance of physiological and psychological functions. Alcohol, cocaine, heroin, nicotine, etc., certainly fit that definition. They are neurotoxins -- nerve poisons. But mere exposure to an agent of harm does not invariably lead to illness. Many of us are exposed to potentially harmful germs all the time. We don’t become sick, because we have resistance through the immune system. In the case of alcoholism and other addictions, a variety of factors combine to protect many of us from becoming addicted even though we are exposed to drugs and alcohol. But, as with other diseases, some people are more vulnerable. And just as the failure of resistance to a germ is a consequence of many factors – biological (hereditary and acquired), social, and psychological, so too, the development of an addiction is shaped by heredity, biochemical effects of the toxin, social conditions (availability, cultural expectations), and co-existing psychopathology. Clinical and scientific studies provide ample evidence of the different factors that contribute to the development of alcoholism and other addictions.

What about recovery and treatment? Is addiction an illness like other diseases? The argument has been made that because many people recover from addictions without professional help, these problems should not be called diseases. The word “disease,” it is said, should be reserved for conditions which require medical treatment. But this is an absurdly narrow view. First, we recover from all kinds of illnesses (mild and serious) without professional help. But second, and more importantly, an enormous proportion of modern health care is a result of the consequences of drug and alcohol use (cirrhosis, trauma, emphysema, AIDS, etc.). To treat only the results of addictions without attending to the underlying cause is short-sighted in the extreme.

Is there a danger in the disease model of alcoholism? Yes, and in this, valid criticism of the medical perspective must be acknowledged. Addictions are chronic conditions in which the capacity for and exercise of choice play the major role in recovery. Like other patients who have lost control of a part of themselves, alcoholics and addicts must not only want to recover, they must be willing and able to work for it. Treatment programs, professional and non-professional alike, can do no more than create conditions in which this work can be accomplished. If the disease model of addiction gives people the message that they are not responsible for the decisions they make, then it will have done them great harm. It can all be summed up fairly simply: No one is responsible for having developed an illness; nevertheless to some degree, everyone is responsible for doing what they can to recover from it.

Recovering from any illness takes time. It may or may not require the patient to make any effort or endure much suffering. From the clinical perspective, illnesses, in this respect are on a spectrum. At the near end (an infection, for example), how much you suffer and the degree to which you have to consciously work at recovery is usually minimal. The body more or less does it for you. But addictions are at the other end of the spectrum – the end where recovery will not take place by itself. Recovery from addiction requires the willingness to endure suffering. After a lifetime of changing his state of consciousness at the drop of a hat, the alcoholic must become willing to experience life on life's terms – not because it's morally better, but because it's the only alternative to a path which leads to relapse.

The danger of the disease model of addiction then, is in the negation, intended or otherwise, of the awakening of the human spirit that is a fundamental part of recovery. However one conceives a Higher Power (the group, Humanity, Nature, God, whatever), without a sense of something greater than myself to which I am responsible, there is simply no reason to endure the pain of recovery. For this reason, despite the intoxicating success of modern medical technology, addictions will never be “cured.” Through our capacity for choice, addictions can be made dormant; they cannot be eliminated. It would appear that the wisdom of the great French surgeon, Ambroise Paré, is as true today as it was 200 years ago – “I merely dress the wound. God heals it.” There’s something in that lesson for all of us.


Article re-printed by permission of author.

The following article originally appeared on what-does-it-mean/ and is re-printed by permission.