We must change the way we talk about addiction

Why today’s loudest voices are flawed and dangerous

Addiction is complex. There is a vast sea of dense and at times conflicting information about it in relation to causation, outcome prediction and lived experience. Still, as is the case with most communication in the field of health, our understanding of addiction is matted with innumerable ‘experts’ and polarising viewpoints. But the loudest voices in this discourse, those that have come to frame the way mainstream culture currently conceives of addiction, are seriously flawed and therefore dangerous. We need to change the way we talk about addiction, and we need to do it soon.


Understanding the term ‘addiction’: the disease model

While the adoption of a disease model for conceptualising addiction has been a step in the right direction, it is not technically a sound definition, and further, has potentially harmful implications in practice.

First, some back story. With regard to etymology, the term ‘addiction’ itself is rooted in the latin term addictus, meaning to devote or surrender. While this definition remains a relevant component of our use of addiction terminology today, in practice it is also accompanied by centuries of additional accumulative meaning. So how do we talk about addiction today? Mostly by defining it as a disease and by embedding it lexically in the world of institutionalised medical care. From politicians to researchers to individuals experiencing addiction themselves, contemporary rhetoric has us all loudly proclaiming that ‘addiction is a disease’. In the US, for example, one of the most reputable resources in the space of addiction, the National Center on Addiction and Substance Abuse (CASA) repeatedly and explicitly refer to addiction as a disease. Plus, let’s not forget outgoing US Vice President Joe Biden’s Recognizing Addiction as a Disease Act in 2007. Meanwhile in Australia, a recent social survey found that most Australians conceive of addiction to certain substances such as alcohol and heroin, as a disease. So it appears that the voices in the spotlight have proclaimed addiction to be a disease and we, the public, have listened to their proclamations. However, medically speaking, addiction is referred to as dependence, or “a maladaptive pattern of substance use leading to clinically significant impairment or distress,” a categorical and medicalised definition if I ever saw one. In truth it is far more complicated than that.

There does exist a seriously robust biological argument against the claim that addiction is not a disease that we need to take into account. But in order to emphasise the implications of the way we use language, let’s remain for now in the space of semantics without delving into details of the science of addiction. While the adoption of a disease model for conceptualising addiction has been a step in the right direction, it is not technically a sound definition, and further, has potentially harmful implications in practice.


A step in the right direction

It seems there have been two key hypotheses for how to view disease, as either a criminal social deviation as it was seen in Greece, or as a psychological and moral event that people can cure themselves of. Despite the differences between them, Sontag suggests that these hypotheses converge by both reinstating blame for the disease on the ill themselves.

When compared to previous conventions of thought, the disease model of addiction is a step in the right direction. Until the late 19th century, popular conceptions of addiction were informed by what is referred to as the moral model of disease. This meant that disease was attributed to failings in moral character, which was obviously unhelpful. What transpired was a situation where the rare individual who acknowledged their struggles and reached out for (near non-existent) help would be met with punishment rather than support.

In her essay about sociocultural perceptions of illness, writer Susan Sontag points out that in the pre-modern view of disease, and in fact for the greater portion of human history, it was considered a punishment for wickedness. The Greeks thought of disease as punishment for anything, from personal and collective transgressions to a retribution for the actions of one’s ancestors. Then during the reign of Christianity in the modern Western world, disease became ‘moralised’ and began to be seen as an expression of the inner self, which, Sontag argues, is just as chastising as perceiving disease to be fated punishment. Later, as temperance movements began to emerge in the 20th century, voices advocating for the ban of drugs and alcohol became louder, incriminating the substances themselves as the causal agents of the ‘disease’ of addiction. In this way it seems there have been two key hypotheses for how to view disease, as either a criminal social deviation as it was seen in Greece, or as a psychological and moral event that people can cure themselves of. Despite the differences between them, Sontag suggests that these hypotheses converge by both reinstating blame for the disease on the ill themselves.

Labelling people constitutionally as addicts, because of the way they are as people, restrains them from developing self-control strategies. Which ultimately puts them at greater risk of harm.

Then, importantly, came the rise of Alcoholics Anonymous (AA) in the first half of the 1900s. AA’s assertions that individuals struggling with alcohol and drug use are, in fact, inflicted by a disease, have been subsumed into contemporary thought. As the AA movement gained momentum, its tenants were fleshed out and established in the US as the Minnesota Model of addiction, which was then adopted by treatment centres across the States and internationally. And AA did bring to the surface some helpful notions, such as the idea that people experiencing addiction need support, but also a couple that can hinder improvement for some people, such as the idea that individuals are powerless in the face of drugs and alcohol. As proponents of harm reduction — another, different, model of addiction — point out, this reasserts that the conceptualisation of addiction as a disease can be harmful. The harm reduction paradigm of addiction emphasises self-accountability, and unlike the Minnesota model, does not preach abstinence. Andrew Tatarsky, one such specialist in the field of harm reduction points out that by labelling people constitutionally as addicts, because of the way they are as people, restrains them from developing self-control strategies. Which ultimately can put them at greater risk of harm. Still, AA programs across the globe circle around this idea that the individual must accept and declare that they are powerless to the influence of these substances and to the unflinching grasp of addiction. And for some people, this paradigm for conceptualising addiction is fine. It works. But research in this area (which has been remarkably difficult to conduct due to their emphasis on anonymity) has estimated that only about 5–10 per cent of people who go through the AA program experience successful outcomes. This means that there remain a startling 90–95 per cent of people who would like help changing their relationship with alcohol but do not have access to support that works for them.

AA’s assertions that individuals struggling with alcohol and drug use are inflicted by a disease, have been subsumed into contemporary thought.

Dr Marc Lewis, neuroscientist and author of The Biology of Desire: Why Addiction is Not a Disease agrees, stating that “yes, conceptualising addiction as a disease is a step in the right direction, but that’s just what it is, a step or a stage. It is a stage in understanding addiction, a stage that arose through the integration of AA with treatment programs. It is better than throwing people in jail, it is better than a lot of alternatives. However, like everything else, it is a stage. We keep going. We need to continue to understand ourselves better and move away from this mid 20th century ideology.”

Part of the problem then, is perhaps the erroneous conceptual equivalence between physical and psychological disorder. While we are progressively expanding our understanding of the connection between mind and body, when it comes to concerns as complex in causation and outcome as addiction, there seems to be a long way to go.

Dr Lewis goes on to describe fibromyalgia, a similarly perplexing disorder to illustrate this point of view. Fibromyalgia is described as a chronic neurological condition that is characterised by a range of both physiological and psychological symptoms. As is the case for addiction, there exists an active and ongoing debate about its causes and its features. Voices in this debate, too, stand conflicted, with proponents on both sides of the “is fibromyalgia a disease?” discourse. Lewis points out there is a body of scientific literature suggesting that for blurry disorders like fibromyalgia or addiction, a diagnosis alone can cause more harm than good. “Just by diagnosing we are creating fatalist assumptions,” says Dr. Lewis.

“What this leads to is the patient internalising the idea that this thing lives with me and is a problem intrinsic to who I am. Which, for many people, actually acts as a barrier to improvement.”


Mental health ‘problems’

The problem with using the word ‘problem’ for these issues, is that it creates a conceptual binary, leaving an individual thinking I either have an issue or I don’t.

Even moving away from disease terminology, the vernacular of addiction is consistently negative and, I would argue, unreasonably medicalised. Currently I work at an Australian non-profit in the alcohol space where, by default, I regularly interact with the ways in which we socially perceive addiction. I first came across Hello Sunday Morning while undertaking a Masters of Health Communication, surprised that they managed to talk about alcohol use without explicitly employing the word ‘problem’. From my tertiary studies in psychology I am conscious of the personal and social ramifications of referring to a lived-experience as a ‘problem’. Perhaps it is for this reason that I was stunned by the antiquated language used by most health communicators regarding health in a carelessly binary way, using negative and generally fear based arguments to encourage people to change their behaviour; none of which seemed to adequately communicate the complexities of health and wellbeing. Health is a unique field of communication which, to a greater degree than standard consumer communications, has significant real-world implications for individual people. Hello Sunday Morning’s framing of alcohol use is unique in practice; theoretically, it is supported by many from Dr. Lewis to medical anthropologist Helen Fisher.

The problem with using the word ‘problem’ for these issues, is that it creates a conceptual binary, leaving an individual thinking I either have an issue or I don’t. And for many people this is not helpful. Through interacting with Hello Sunday Morning’s community for alcohol support, I have learnt that, yes, for some people, alcohol certainly becomes a problem which fits within the medical category of addiction, but there are also many others who want to change their relationships with alcohol well before they have a categorical and medical ‘problem’ with it. Hello Sunday Morning is an example of a health service that is there to support everyone: people who have experienced face-to-face support through medical systems; people who do not drink within medically recommended limits but for whom ‘treatment’ is not appropriate; and everyone in between. All these people really just want support to drink less, outside of labels and categories. And there is no reason this conceptual schema cannot be expanded to other forms of addiction.


On the importance of language

Now more than ever, we are conscious to avoid using terms like the word ‘crazy’ to refer to persons suffering from mental illness. But within certain domains of mental health, including addiction, as of yet we aren’t so concerned with the way we use language.

Wittgenstein once famously declared that ”the limits of my language mean the limits of our world.” In doing so, the Austrian philosopher asserted the importance of the way we use language by suggesting it is a process that informs how we perceive reality itself, rather than something that simply reflects it. Language, and the way it allows us to extract meaning and create a mind-reservoir of symbolic thought, is a remarkable (perhaps the most remarkable) feature of the human experience. Cognitive scientists agree, suggesting that by influencing what we pay attention to, how we categorise our experiences and how we consider our own place in the world, language shapes the way we understand our reality.

In the realm of health this is significant. In recent years, this idea has slowly absorbed into contemporary discourse, particularly in the space of mental health. Now more than ever, we are conscious to avoid using terms like the word ‘crazy’ to refer to persons suffering from mental illness. There even exist media guidelines for talking about mental health with sensitivity, which emphasise for example that media should avoid referring to individuals as ‘victims’ and resist succumbing to cultural myths and stereotypes.

All of which is good. A step in the right direction. But within certain domains of mental health, including addiction, as of yet we aren’t so concerned with the way we use language.


Resisting language is resisting culture: not an easy task

When addiction came to be regarded as a disease, its symptoms and causes were communicated as a disorder in culture. These metaphors are both powerful and powerfully flawed, and so resisting them is not only difficult, but our utmost imperative.

The flip-side of this idea that language represents our reality is that by considering the language we use, we can better understand the way we perceive complex constructs and the schemas they are embedded in. The concept of a culturally informed mental frame or cognitive model is represented in language. That is, the way we have collectively come to understand concepts is embedded in language. It has been suggested that mental frames are distributed and maintained at a sociocultural level and therefore are difficult to resist at an individual level because of the social pressure to conform. So changing language is a difficult task; it is, by default, the process of changing the way we think about things.

Referring again to Sontag’s meditations on how we historically and culturally understand disease, she suggests that illness and disease concepts are capable of communicating powerful metaphors about how we regard and therefore treat the ill. She points out that these ideas about disease “have been used as metaphors to enliven charges that a society was corrupt or unjust.” In this way, disease terms are used as a metaphor for disorder in the “body politic” of culture. When addiction came to be regarded as a disease, for example, its symptoms (people who are suffering from addiction) and causes (alcohol and drugs) were communicated as a disorder in culture. These metaphors are both powerful and powerfully flawed, and so resisting them is not only difficult, but our utmost imperative.


In practice: moving away from categorical disease definitions works

Encouraging people to view their experience of drugs or alcohol within the context of their lives, as they see it, is empowering and inherently supportive.

To me, it appears clearer than ever that we need to reexamine the way that we talk about addiction. Over time I have grown to understand that this practice of using positively framed and dimensional language around alcohol use at Hello Sunday Morning is intentional, because it works. Encouraging people to view their experience of drugs or alcohol within the context of their lives, as they see it, is empowering and inherently supportive. Talking about alcohol use without stigmatising the individual is possible and effective. Encouraging people to change their relationship with alcohol, without succumbing to categorical definitions of alcoholism or ‘problem’ alcohol use allows people to improve their well-being before the medical institution tells them they need to (which is generally after physical and psychological harm has already been done). But we need to move forward. We need to agree that the disease model of addiction is a stage, but that in order to maximise outcomes and provide the best support possible for everyone, must continue growing and developing our understanding of addiction. And part of that process is acknowledging that our language, as it exists today around addiction, is limiting.


Hello Sunday Morning is a movement towards a better drinking culture. Our vision is a world where drinking is an individual choice, not a cultural expectation. How do you feel about your relationship with alcohol?
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