Nowadays, as in 1951, the very mention of the disease concept of addiction arouses passionate reactions, both positive and negative. While proponents of this concept are fervent in their belief, they often do not have a clear articulation of what this phrase means, or the actual mechanisms and dimensions of this disorder. Critics often argue that this is merely an excuse for addicts to avoid responsibility for their behavior. Rarely is there a middle ground sought or found.
We’ve heard various definitions of the disease concept: it is “brain disease;” it is “a family disease;” it is a state of “dis-ease,” it is “an allergy and a compulsion.” The lack of consensus in this area hampers an honest and insightful discussion. Disease proponents often tell clients,”that’s your addiction talking” when he or she challenges a therapeutic suggestion. Such simplistic formulations undermine this same discussion.
On the other hand, critics often are responding to a caricature of addiction as a disease. G. Alan Marlatt’s early research, demonstrating that one drink may not trigger a full-blown relapse, is powerful and noteworthy, but not realistic or representative. A further insight from this work is that a relapse may not be an “all-or-nothing” scenario’ this leads to the valuable distinction between a “lapse” and a “relapse.”
One familiar criticism is that calling addiction a disease allows the addicts to avoid responsibility for their actions. However, this does not reflect the actual practice of recovery, in which personal responsibility for addressing one’s illness is stressed. There is no parallel argument that diabetes is not a disease; the management of this disorder is a separate matter from the nature of its existence.
One of the problems in this debate is the black/white thinking that permeates the field. Addiction is often seen as a box” either you’re in or you’re out. Gradations of severity are simply seen as stages on a certain progression. It is increasingly obvious, from both research and clinical experience, that this is not the whole story. The recent conceptualization of severity in DSM-5 is a recognition that this ailment exists along a spectrum of severity.
E. M. Jellinek’s classic book on the disease concept of alcoholism (“the most quoted and least read book in the field” according to William White) has been cited by endorsers as academic support for their position. However, Jellinek provides a far more subtle analysis than can be translated into the simple statement that alcoholism is a disease. He identifies subtypes of addiction; some are considered diseases, while others are not. His distinctions remain valid today, and there is increasing support from our neuroscience colleagues for the existence of different “strains” of addiction.
Data indicate that a majority of those who meet criteria for a substance use disorder will resolve these problems naturally; they “mature out” of it. The Disease Concept is a valuable and valid way of understanding the more virulent forms of addiction, which are more likely to lead a person to seek professional help. These are the folks we see in our offices, those for whom natural recovery has not worked, for whom there is likely a more sinister process operating.
An integrative model of the disease of addiction (which I have articulated elsewhere) holds that addiction is a multi-layered phenomenon. The core of the addiction is rooted in brain dysfunction, which manifests as a vulnerability, a potential. This is largely genetically transmitted, but that is not the whole picture. This loss of control, dependence and tolerance is fed by psychological factors, which allow the disorder to flourish and develop, through the processes of “denial,” defenses, identity formation, expectation, and learned behaviors (or habits). This is, in turn, reinforced by social factors, including family dynamics, peer influences, and cultural factors. The cumulative effect of all these layers serves to preserve the fundamental physiological dysfunction; all layers will need to be addressed for recovery.
There is a semantic problem in this formulation. Does “disease” refer to the brain dysfunction, or to the whole phenomenon? If addiction is a dysfunction of the reward system and executive functioning, then the term “disease” clearly applies. In contrast, a clinician deals with the entire structure of addiction as a “bio-psycho-social” disorder, which is less purely a “disease” in the strictest sense. However, it is this entire phenomenon which requires attention by the clinician.
In a recent online debate, a clinician argued that loss of control was a fiction. If you had an alcoholic in your office, he said, and presented him with a bottle of his favorite liquor, and then pointed a gun at his head, he would not drink.
Apart from the difficulty of getting IRB approval, there is no need to conduct such an experiment. It happens every day in the real world. A doctor tells a patient that he will die if he drinks again; an employer warns an employee that another binge will end her job; a spouse warns of the end of their relationship if there is another bender. Sometimes, the person drinks anyway and dies, loses her job, or his wife.
When a person has such a form of disorder, I don’t think it can be reasonably seen as a moral defect, a personality failing or a choice. For such a person, I feel that the Disease Concept is a valid and accurate depiction of their condition.