Addiction Is A Serious Condition But It Is Not A Disease (Part 2/2)
August 16, 2016: 27 year-old William Martin died of asphyxiation from a deadly combination of mixed sedatives, including heroin and benzodiazepines. Yesterday, exactly one year since his death, Will’s mother Deborah accepted my invitation to my home for an interview.
Deborah was gentle and soft-spoken, likely to shed tears at any moment, even during our pre-interview small-talk. She began cautiously. Any statement she made about her son’s involvement with heroin was quickly qualified with, “but he was a wonderful person” or “but he wasn’t mean-spirited. Will was a gentle soul.” But she became relaxed once I explained my own heroin addiction and near-death experience.
We left political correctness behind and spoke honestly about addiction, policy, and Will, her late son. I was pleased that Deborah’s every word seemed to coincide perfectly with my own theory of addiction (It is not a biological disease but a developmental process). Here are a few such statements:
People warn parents to stay ahead of genetic vulnerability… but nobody in our family was an alcoholic or used drugs. I feel lied to.
He was in and out of treatment for years. Rehab did nothing but make things harder for him.
Sometimes I think about what he would be like if he were still alive. I think he would have figured things out. I think he would have been just fine… he just needed to grow up a little.
Deb could no longer restrained her tears and I handed her a box of tissues as she let it all out. “I don’t know Zach,” she cried, “Everybody thinks they are experts. I feel like I was lied to. Sometimes I wish I would have just listened to my instincts.”
Impressed that her ideas about addiction aligned with my own, I asked if I might read to her a piece I wrote about addiction. (It was Part 1 of this very article — before being published — in which I offered this definition: “Addiction is an involvement that satisfies an immediate — and otherwise unmet — need while causing destruction in other areas of life.”)
I read aloud:
People develop addictions to a range of things, including drugs. However, drugs themselves contain no ineluctable chemical draw. Instead, addiction happens when a) a person becomes involved in a thing or an activity b) the involvement provides some form of pleasure or relief compensatory for lack of such sensations in other areas of life.
When people with addiction find healthy alternatives to compulsive (addictive) behavior, they can begin to develop new patterns and move away from addiction. Nothing about this process implies that addiction is forever or that it cannot be escaped. The disease model tells us the opposite is true. Yet we continue to follow the disease blueprint, despite compelling research to suggest the disease notion is often self-fulfilling. It is because…
She stopped me. “How could you say that?” She asked.
“Say what?” I asked, unsettled.
“After everything we talked about, how can you sit there and tell me it was Will’s fault he was an addict?”
A long uncomfortable silence… does she truly believe I said this?
I became painfully cognizant of my communication misstep. While proudly reading my own work, explaining the folly of the disease model of addiction, all she heard was, “He chose this lifestyle and you could have done something about it. You are to blame, as is he.”
Of course, I detest such flavors of moral finger-pointing, but it took some time for Deb to believe me. She admitted, “Even though you emphasized the ‘moral failure’ stuff is not worth your time, it’s all I could think about.” Then she offered sage advice, “For those of us suffering the loss of loved-ones… We need to feel empowered before we can think about addiction the way you want us to.”
I am happy to adhere to this request.
I hope that this story adequately demonstrates the level of care and concern I feel for all affected by the ills and fatalities of addiction. Here is part 2/2…
Addiction And Choice
There are major problems with the current “disease vs. choice” dichotomy in the addiction field. The disease model obfuscates the crucial role making choices plays in the addiction process and downplays the resilience of human beings; the moral model ignores a fundamental truth that people experience varying degrees of freedom to make choices for themselves (some much more free than others). Realistically, the nature of addiction and recovery is immensely richer than can considered by committing to one of these two arguments.
Addiction is not a choice. However, people with addiction have the capacity to make choices. Both statements are true:
Addiction is not a choice
I’ve yet to meet a person for whom negative consequences is an end-game. Imagine, “My New Year’s resolution is to eat so compulsively that I gain weight and become unhealthy. I also vow to exercise so little as to perpetuate the destruction of my body.” Indeed, virtually nobody prefers a life of addiction over one of prosperity and good health.
Addicted people still make choices
It is also true that people with addiction have the capacity to make choices. Granted, choices can be made with varying degrees of free-will, but the addicted person, not the addiction itself, is the agent of his/her recovery process.
Addiction can be powerful: it can make each day feel scary and unpredictable; it can make people feel hopeless; it can make long-term planning feel impossible. But addiction does not have a mind of its own; it can be controlled. People with addiction are not victims of their own hijacked brains, nor are they morally incapable. In fact, addiction is influenced, and fueled by, value choices. It is by utilizing — not ignoring — the ability of people to make constructive choices that we will save lives.
Is There An Addiction Paradox?
How do we reconcile these seemingly contradictory views?
We can start by following the trajectory of the facts:
- Addiction is a symptom of an inadequate balance of life experiences
- Recovery is the rule, not the exception
- People with addictions have the power to “rewrite” their life experiences (they are not “powerless”)
Let’s follow these statements to a logical conclusion.
Addiction Is A Symptom Of Inadequate Life Experiences
Or as my colleague Stanton Peele describes, “Addiction is not an equal opportunity despoiler.” Addiction starts with a behavior that brings pleasure or security. The behavior acts as a coping mechanism for internal feelings of psychological or social pressures and stress and yields predictable gratification.
If involvement with the behavior becomes compulsive, it may produce negative social and psychological consequences. A behavior becomes an addiction when a person chooses to continue (or refuses to cease) the behavior, despite net negative consequences in other areas of life. The most insidious part of the process is this: the more frequently a person engages in the pleasurable behavior, the greater deficit they begin to face in other life circumstances, including in areas already lacking.
But Addiction Is Not An Equal Opportunity Assassin
Someone lacking the passions, skills, and connections to feel reliably gratified will often opt for immediate pleasure rather than long-term rewards. A deficit in these areas largely determines one’s addiction vulnerability (remember, addiction occurs when life revolves around instant gratifications, and moves away from the pursuit of lifelong happiness). In fact, we know who is most likely to become involved in addictive behavior.
- People living in poverty — Those making $20,000/year or less are 3 times more likely to develop addiction than those making $50,000 or more.
- People with co-occurring mental illness and/or personality disorders — Among this group, instability, hopelessness, and despair are common.
- Adolescents — The frontal cortex — part of the brain responsible for complex conscious decision-making — does not fully develop until at least age 25. 90% of people with addictions began the destructive behavior during adolescence.
Needless to say, poverty, mental illness, and age, have little-to-nothing to do with choice. When such people develop addictions, they are making choices, but with a very-limited capacity to make sustainable ones. Again, addiction itself is not a choice, but we should ask: are these folks doomed to live joylessly — forever? Evidence says no.
Recovery Is The Rule (Not The Exception)
Residual from the disease theory is the notion that people who develop addictions stay addicted forever. But quite the opposite is true and that tuneful phrase “once an addict always an addict” is manifestly false. First, it’s worth noting that 80–90% of people who use drugs, including cocaine and heroin, do so responsibly and without ever becoming addicted. Second, of the people who do become addicted, about 80% of them discontinue harmful use over time.
The National Comorbidity Survey produced two sets of data (one set from 1992; another from 2003): 77% of people who reported once having drug or alcohol addictions no longer had problems. Similarly, 86% of people surveyed in the National Epidemiological Survey on Alcohol and Related Conditions — a representative survey of over 43,000 participants — reported discontinuing harmful use without the aid of treatment. Put somewhat differently: the majority of participants decided to use moderately or completely quit their once-addictive behaviors. None of them had to carry the label “drug addict” or “alcoholic” for the rest of their lives, nor did they have to proclaim powerlessness.
So what should we do with this information?
Proponents of the disease model favor generalizing from the minority of people who don’t seem to “kick” their addictions (a total of roughly 5–8 % of people who try drugs in general; about 15–20% of people with addictions). This means extracting what is true about the patterns of behavior among [the minority of] people with the worst addictions and extrapolating that all people with addictions share such characteristics (including an apparent inability to quit). This approach is pernicious to say the least.
To be sure, this 15–20% of people are of vast importance. We need figure out why some people become so severely addicted and we need to know how to offer help. But generalizing from an underprivileged minority skews the larger truth, perpetuates stigma, brutalizes young people, makes matters worse than they already are, and is a tacit prearrangement of failure for many people. Focusing solely on the ills of addiction deprives people of opportunities to make progress.
Instead of asking, “What can we generalize based on people with the worst addictions?” we should be asking, “How is it that a majority of addicted people find success? How will we apply this information in a constructive way and perhaps assist those unable to overcome addictions in the past?” It is at this point the disease model fails to make progress and something else comes to the rescue — the capacity to make choices.
Choosing To Leave Addiction Behind
People push back when I speak about addiction in terms of statistics. They think I am ignoring the importance of subjective experience. As a showing of good-faith, here is an anecdote from my own life:
I had a heroin addiction for nearly five years. During that time, I routinely behaved in direct opposition to my core values. Once, flat broke — and in an attempt to obtain drugs — I took advantage of my sister’s love and kindness. I wrote her a check I knew would bounce, and made up a BS story about why I wasn’t able to get money out of my account at the time. I assured her I was good for it. It was Sunday and banks were closed so she deposited the fraudulent check through her ATM and gave me the cash. I felt I was violating a sacred trust taking it from her, but never once did I intend to hand it back.
In the typical addictive cycle, I got comfortably high for two days, then became even more miserable than before. My sister, bless her soul, was patient with me, even though she was confused about why I deceived her. I lied and told her there was a clerical error, and paid her back at a later date.
It’s tempting to believe the person who stole money from my sister that day “wasn’t really me”. And the idea of removing myself from the equation makes the disease model seem very appealing. A disease theorist will agree I wasn’t the one stealing the money, it was addiction. In fact, addiction hijacked my brain, was steering the ship, and called the shots. But this metaphorical language complicates the truth. As much as I hate to admit it, I — not my brain systems — was fully to blame for the theft.
Stealing money fulfilled an immediate need, part of a cycle with which I had become familiar: money + phone-call to dealer = drugs :: drugs = immediate satisfaction). When something was missing from that cycle, it became an emergency to me. In this case, money was the missing part of the equation. So, acting within a framework of survival, I side-stepped some very important values (family/honesty) in an attempt to rewrite the formula for instant gratification, a choice I made on my own. But context is everything. I chose this because it had become increasingly difficult to feel gratification and to choose otherwise — long-term goals seemed further and further away, and immediate gratification seemed more and more important.
I assure you I am basically a pro-social person. I value family and honesty more than anything. Lying and stealing money from family wasn’t me. And when I wasn’t fighting to survive, I would reflect on how I was flouting my moral principles. Among many things that moved me away from addiction was the way I — very naturally — highlighted my value basis as a way to reference who I was and who I really wanted to be. This concept of being driven by values choices is crucial; it contradicts the disease model (i.e. you are stuck this way forever) and is a framework for positive progress.
The brain disease model dethrones the idea that an addicted person is an active agent in his/her own self-restoration process. It reinforces for a person that any attempt to make progress — or act according to principles — is futile, and it obscures for people their ability to legislate intentions in line with their values. This model talks about addiction as if it were a metaphysical — and inescapable — parasite and the person with addiction is nothing more than a passive vehicle being steered by the addiction itself. This is not only demoralizing, but it is incorrect. I know this based on my own experience, and the experiences of 80% of people with addictions who recover on their own without professional help.
The worst thing about believing “i’m a lifelong addict, my brain has been rewired… I can’t change” is that you immediately become your own worst enemy and can be easily convinced there is no way to move forward positively. Of all the dangerous things you can become, being your own enemy is the most destructive.
The Way Forward
When my theory of addiction comes into contact with a deeply-felt emotional experience, it’s a hard bit to sell. If I’m not careful, it may appear to be projecting blame and guilt onto the parent or the child. When I told Deb (The woman with whom I spoke in my home) “addition is not a disease”, she pushed back immediately. As far as she could discern, I was saying, “There was a dynamic about your son’s life that could have been reversed.” Who wouldn’t react the way she did (I’m lucky she didn’t cancel the interview)?
But this is not my message. Blame and guilt have no place in forward-thinking and I want to avoid them at all costs.
Per Deb’s advice, I’ve thought of another way to phrase the whole thing. My message is this:
Addiction, and the driving forces behind it, can turn life’s landscape into a difficult one to navigate. People with addictions chase immediate rewards while moving ever-further away from more sustainable, fulfilling lifestyles. People don’t choose this for themselves.
The single greatest intersection you can make with an addicted person is to tell them they can change. That single intervention — giving them a reading about being able to change — provides a vehicle in which to handle anxiety, depression, and improves performance in life. It turns out most progress is the result of changing life narratives. By seeing there is greater potential, and with encouragement to move that trajectory, you can reverse a life-story of failure into a reality that you can and will experience.
None of this means addiction is blameworthy; it is not.
What this does mean is that addiction does not have to be forever.
Never give up on yourself and don’t give up on the ones you love.