…by Bill Abbott, M.D….
Bill has been a long-standing member of this blog community and he has contributed his leadership and knowledge to the SMART Recovery movement. Thanks, Bill, for taking the time to share your thoughts here.
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I’ve recently completed two books. The first is Marc Lewis’s recent one and it is a winner. In this book Marc describes a “model” to explain addiction that is counter to the prevailing “disease model” and he does so in a very credible and lucid way that is based on neuroscience integrated with personal experiences of people he interviewed. A very effective approach indeed.
The second book, republished recently, is entitled Love and Addiction by Stanton Peele, which was first published in 1975 – 40 years ago. In this book (and other books of about the same vintage, such as Diseasing of America) Peele described the problem of addiction in very similar ways – obviously without the neuroscience available today — and showed the similarities between addiction and some forms of love, as Marc does also.
This has left me both frustrated and somewhat sad – that is, so much was clear forty years ago and yet we seem to have learned so little, and I can only come to conclude the following:
- The current way we approach the problem of addiction in the United States is abysmal; it isn’t working because it is wrong.
- We have failed to learn from our mistakes.
- Much of what we really need to know to understand addiction has been known for a long time, but we haven’t paid attention.
- We know enough about the problem to effectively deal with it.
- And finally, the disease model is not only wrong; it is harmful.
Marc suggests that the disease model is harmful to a certain extent, but my purpose here is to expand on that idea. I feel justified perhaps because I am a medical doctor — and in long term recovery from alcohol misuse.
As a disclaimer, what I describe pertains to the United States, where I live… but probably to some extent to other western countries as well.
The harm stems from two sources:
The first is a practical issue. If addiction is a disease, doctors will be expected to “treat” it. That may not be too bad in theory, but unfortunately the medical profession (in the United States at least) is ill-prepared by virtue of knowledge, training, and — most problematic — insufficient time.
What about psychiatrists, you say? They are doctors. This is true (although many seem to forget clinical medicine)… but because they are doctors they treat patients by managing their patient’s diseases by prescribing medication, hoping for cure.
The underscored words lead to the second and greater problem with the brain disease model; and that is that it shifts the focus away from people with a problem to an outside entity, thereby mitigating personal responsibility. This position in essence means looking for an outside solution for an inside problem…that only an inside solution can help.
Let me expand on that a little.
Marc brings up two very important concepts in his book: what he calls “now appeal” (officially delay discounting) and ego fatigue or depletion (the depletion of cognitive resources for applying self-control). A related idea is the concept of locus of control.
This concept has been around for a number of years and has been described a number of ways. In general terms what it refers to is whether an individual believes in or relies on self-management or tends to look to 
outside resources for problem solving. This is not a fixed or constant trait but rather a tendency that varies with the problems and stresses people face. It often tends to be more on the external side in those encountering hard times – not uncommon in the addicted person. Some incorrectly call it low self-esteem.
So if addiction is a formerly useful coping strategy, now gone amiss, then one needs to look for other coping strategies that work better and be motivated to put them to use. And these work better if they are self-empowered. They don’t work if you rely on someone or something else. They just can’t.
The neuroscience points to the same conclusion; it is the “desire” that Marc is talking about that makes recovery work.
What is needed is a shift toward an internal locus of control. Something which the disease model tends to undermine because it fosters dependence on another power.
Surely you can and ought to seek help, advice, support, or what have you, if that can help. But ultimately you have to do it—for yourself
This is why the disease model is so insidious and counterproductive to successful recovery in many people. Although your doctor will encourage your participation, basically he is telling you what to do. This is prescription — be it medication or behavior. “You must stop drinking or you will die,“ my doctor said to me. I went home and poured a drink to think about that.
The evidence supporting the self-management approach is all over the place.
Consider so-called natural or spontaneous recovery — statistics show that as many as 80% of those who meet criteria for substance use disorder in the DSM-5 recover with no intervention or support whatsoever.
This is the epitome of self-management and empowerment.
For those who do need some help, self-management can be learned or better relearned in any number of ways… but I am skeptical that it will ever be learned in a doctor’s office, where you wait next to people with medical illnesses like hypertension and hemorrhoids.
A disease like cancer needs the doctor to manage it; addiction does not.
What those of us who solved the problem of addiction share is self-empowerment and then learning the skills to manage life’s many stresses in a different and ultimately less destructive manner.
The whole disease model concept is based on some really bad science and that in itself is harmful. But the fallout is potentially more damaging.
I only hope people start paying attention, because the problem is getting worse and we gotta do better. The people who suffer deserve that much, and if we help them to see what they can do for themselves, they may in fact do it — and feel good about the fact that they did.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Hi Bill thanks for this wonderful insight. You have hit on the serious concerns I have right now for the way we treat, and I use that word very loosely, addiction. For many years it was seen as, mainly, an issue of moral failing and was subsequently criminalised. Policy makers misguidedly thought they could punish it away, we locked people up, designed courses to tell them all about their moral failings, using things like guilt and shame in vain attempts to restore the moral compass. Unfortunately, but very predictably, this didn’t work so it became a medical problem. We were shown all sorts of CAT scans of addicted people’s brains lighting up like Christmas trees as they were exposed to images of drugs and associated materials. Imminent psychiatrists, despite their dismal record in mental health treatment, told us that there was something missing or not working in the brain so it needed something really powerful like a drug substitute or higher power to replace it. Psychiatrists became, and in many ways still are, the authority on addiction. The role of consultant psychiatrist addiction specialist was created and with it came authority, pseudo credibility, major financial gain and influence. We could now, apparently, diagnose and prescribe it away. All of this has made very little global difference, we still have an entire human culture based on addictive behaviours. Instant gratification is the norm and we keep doing lots of things purely on the basis of it making us feel transiently good, despite all the negative consequences.
In my very humble opinion addiction treatment, like most other areas of psychiatry, is based on our (clinicians, workers and Joe public) intolerance of uncertainty. We just feel so uncomfortable when confronted with something like addiction, psychoses or suicide, that we need to do something, anything to make it certain. It doesn’t really come from a position of helping someone it comes really from a very selfish perspective. Diagnosing it and prescribing for it is the quickest and easiest thing we’ve got. Kind of, “if I tell you what’s wrong with you and make it alright, even temporarily, then I’m ok.”
Whole systems have been created on this basis, charities have been formed and grown out of all proportion, fortunes have been made but people continue to die in increasing numbers, more and more people succumb and more and more families are destroyed.
I don’t pretend to have any easy answers, I just know that what we’re doing right now is probably causing more harm than good. I do know that addiction isn’t a disease, nor is it a moral issue. It’s a cultural phenomena and needs a cultural solution.
Wow Peter and I thought I had used strong language
Much of the disease model is based on so called evidence from neuro- imaging. Id best be careful here with a real neuroscience guy in the room but
1. Imaging is still a pretty crude technology. It only gives indirect information about increased activity in various anatomic locations – implied by blood flow ( thereby oxygen consumption) or glucose metabolism
2. The increased activity could be either agonist or antagonist – no way to know which ;that is up or down
3. The changes seen are not specific to addiction, nor particularly characteristic
4. Hence they are not pathognomonic – the word used in medicine to identify disease – of any value
5. After there is raw data collected, there is data manipulation so much room for varying interpretation . Dial in your cocaine abuse center so to speak . Not that Im implying fraud here but its not entirely objective either .
We medical types are not immune from enthusiastic reporting of our findings or opinions. Early in my career I published early findings on a treatment trial that enthusiastically pointed to improve outcomes. After further data collection I felt obligated to publish another paper said that although it was not harmful . the earlier results were incorrect and there was little benefit.
What Im saying here is that the enthusiasts that claim categorically “ Addiction is a disease of the brain” are on pretty soft sand.
Theres more to the fiction of the disease model but that’s enough for now
Bill and Peter
Both of you have brought some excellent points to the table. I agree wholeheartedly. To add to the imaging debate, we are also not seeing the publication of negative results – I was chatting to PhD student the other day who is struggling to replicate findings with methamphetamine users showing decreases in White Matter – she is seeing increases, but because it contradicts Volkow’s findings, no one wants to publish. Similarly, a colleague is analyzing retrospectively data from many imaging studies, and while finding clusters towards one end of the bell-curve, these are still within norms and only find statistical significance in certain (artificial) conditions.
Of course, no one is talking about longitudinal data because those don’t really exist – and certainly the silos of research are not being combined to create an holistic picture.
In the meantime people are being stigmatised and the biomedicalisation of addiction, and non-problematic drug use, is distracting from the broader systemic and social issues that make drug use so attractive and add momentum to the accelerated learning that addiction is.
Hi. I work with aboriginal men in Australia in a Residential AOD facility. What I see with a 40 year observation of Drug & Alcohol addiction which includes my own journey through it is humans treating themselves with their drug and alcohol use. Humans attempt to manage their anxiety. Certain people have more anxiety, often caused by a dysfunctional, traumatic or marginalised upbringing. Society does not like people treating themselves and decides to medicalize any and all human conditions, often with little success. I see men with no hope who see some pleasure in drinking and drugging. and then society tries to take that away with its puritanical attitude to drug users and those who drink outside societies norms, and then we send them back to hopelessness because none of the underlying factors, marginalisation, poverty, unemployment, homelessness or overcrowding, racism and welfare dependency via unemployment are addressed in any real way, and we wonder why they don’t respond to our treatment. I agree with Hari – we need to go with the flow and that can only be achieved via drug law reform and a release of the notion of a disease or moral failing and treat addiction as a mental health and social issue. I do though question Lewis’s use of the term Recovery. if there is no disease there is no recovery, there is however habit change. Addiction is an industry with the winners being the crime gangs and those who write books and sell treatment, the losers are the users.This is my personal view.
I too do not like the term recovery for that reason and also gives the idea to turning to the past as if that was so wonderful
HOwever IM afraid we are stuck with it in practical terms and can maybe just work to change its meaning ??
If we change the practice, the name will change.
Good point!!
Now just how we going to do that one?? LOL
Remains to be seen, but pretty certain it’s gonna take a while…:)
Great discussion. I am one too who has had to learn coping and thriving skills to deal with my own natural tendency toward Addiction. Today I have developed daily disciplines of meditation, exercise and ongoing attention to my behaviours to strive for an ongoing way of living that is conscious and not unconscious. Like many of those who deal with addictions I am aware that the world and life is full of triggers.
I would like to add to this whole discussion some degree of “Light!” What I mean by that is a recognition that dealing with Addictions as Marc Lewis notes changes the brain and the person. I am not the same person that I was before I began this journey that never ends. I will meditate and pray and exercise and strive to live consciously the rest of my life. I have no choice. I call it a “Choiceless Choice”. The other way I know leads to misery and darkness and at the very least mediocrity.
But it is my addictive tendencies that exist as a powerful force for change. Here is what I am trying to say. Recovery is not just a grim business. It is about Light and becoming conscious amongst all the forces that call us to be unconscious. Some in society will speak disparagingly about “addicts” – but look at what some addicts are doing and contributing. Marc Lewis challenging with lucid thinking and science a whole paradigm and model. Vera Tarman sharing her struggles with food addiction to provide support and signposts to others. Addiction changes the brain and the mind but then so does Recovery in profound ways. We need more attention to the beauty of Recovery and what it looks like and the gifts it can provide.
Just a few thoughts from a fellow journeyer.
Many many thanks for the reminder Tim, my whole being has changed with recovery and it’s all, more or less, been done in the light.
Great discussion. Sorry to post another poem, but your darkness and light references hit close to home.
WHEN DARKNESS IS THE LIGHT
Dark, dangerous clouds cover the sky
A powerful storm unleashes its fury
The boy shaken to his core
Desperately seeks shelter
Running through the streets
Thunder roars, lightning cracks, the wind howls
Fear grips his body, terror in his eyes
Falls to the ground
Slowly opens his eyes, clutching the covers
Alone in his small room, his fortress
Walls of steel, a thousand pound door
Dim light soothes him, drifts back to sleep
Only a small peep hole to the outside world
Storm clouds rage outside, always dark
A magic suit and skin tight mask
Always protect him when he leaves the fortress
Now a young man, he loves his fortress
Cunning light dances in the space
Perfect hideaway his mind believes
The light of the fortress only deceives
Now a man, he glides through the streets
The magic suit and mask hide him from the world
He slips into the fortress
Light tantalizes, flickers, taunts him
A tornado roars overhead
The fortress is gone
Lying on the ground
Staring at the storm clouds above
Everything gone, even the magic suit
Shaking with fear
Through the dark clouds way in the distance
There is a tiny sliver of light
Pain so intense, please let me die
Struggle slowly to my feet
Glancing down, the mask!!
Slipping it on, slowly start to walk
Towards the tiny sliver of light
Yes, the disease model is wrong but doctors can do a lot of good for addicts if they go easy on the harm.
I’ve only recently come across Marc Lewis’s writings. They make a lot of sense, especially as I’ve been saying and writing rather similar things for at least a couple of decades, though in the early 1990s, the ‘brain disease’ merchants and their PR people had hardly got going. I suspect part of the reason for their subsequent rise and current prominence was that fMRI was invented around the same time and those sexy technicolour images were not only more informative but also much more attractive to the media than the boring old black-and-white CT and early MRI versions.
Before the brain disease era, we on the other side of the Atlantic were similarly troubled by the widespread American insistence that addiction was a ‘disease’ tout court, unattached to any particular organ except that peculiarly American one called the spirit. No other nation talks and writes so much about addiction as a ‘spiritual’ affliction and the importance of ‘spirituality’ – a word that seems to have almost as many definitions as definers. No other nation devised a response to addiction – AA and its sister churches – that not only became the dominant treatment modality but widely regarded itself as the only treatment and bad-mouthed all others. It still often does, though it’s becoming less intolerant in its old age.
I write this as someone who trained in general psychiatry after a year or two of general practice. At first, I had no special interest in addictions and like most European doctors who eventually moved into the field (and again, unlike many American doctors) I have no personal experience of substance abuse. Hell, I was at medical school in the early sixties but I never met anyone who smoked dope until the end of the decade. When I did try it, it didn’t do anything for me until I worked briefly in Jamaica, where the medical and surgical in-patients used to give the doctors and nurses a bag of homegrown when they left hospital because they couldn’t afford chocolates or whisky. I was never one of the heavy-drinking crowd and I exemplify the fact that in those days, if you hadn’t developed an illicit drug problem before the age of 30, you were not very likely to do so later. Even the easy access to opiates that many doctors had never led to more than experimental use out of curiosity.
For me, addiction was never a ‘disease’ but a ‘condition’, rather like pregnancy – wanted or unwanted. My generation of doctors can do a lot to make life easier for women with this condition in terms of prevention, timing and management but that still doesn’t make it a disease. It does mean, though, that we can offer them a wide range of interventions (or ‘treatments’, if you prefer) and I’ve argued that addiction services can learn a lot from family-planning services, who – unless they’re run by and patronized by devout Catholics – generally encourage their patients/clients to choose from a large menu the intervention that best suits them, rather than the one-size-fits-all, take it or leave it approach so typical of addiction services.
Doctors can do a lot to help some sorts of addict as well without making addiction any kind of disease. Obviously, we can make withdrawal a lot easier, more certain, more comfortable and – especially in the case of alcohol – safer. That doesn’t treat the addiction, any more than temporary splinting treats a fracture but it’s a good start and also a great way of beginning the professional relationship. Opiate maintenance is much like nicotine maintenance with e-cigarettes and if it weren’t for your well-intentioned but utterly catastrophic war on drugs (started 1919, still going strong, no end in sight) addicts would buy their own maintenance treatment, as they did in the golden days of laudanum. The war on drugs is another American initiative into which the rest of the world was reluctantly dragged – rather like the war on Iraq – because you helped us win the first world war and we were prepared to let you ban other peoples’ traditional drugs provided we didn’t have to ban beer and whisky. We were too polite to say ‘we told you so’ when you unbanned alcohol but by then the Mafias had moved in. They’re still there and doing just fine, thank you. So methadone and buprenorphine maintenance programmes have to be strangled in red tape and working addicts may have to get up at 5am to drive to the clinic before starting work.
Apart from maintenance and civilized withdrawal, what we can do for alcoholics and opiate addicts is to greatly increase their chances of staying abstinent once they are ready to try; and for long enough, ideally for abstinence itself to become – as it was before they started – an established habit. Some of them want to try as soon as they realize they have a problem; others want or need a period of maintenance to let the dust settle, give their veins, lungs and other organs a break, treat addition-related but unequivocally real diseases like hepatitis, resume work and relationships and settle their financial and social debts. Some, especially if they have the misfortune to suffer prolonged opiate withdrawal symptoms, may be better off resigning themselves to indefinite maintenance. It’s no big deal if they keep quiet about it. My maintenance patients included doctors, lawyers, engineers, chemists (including a chemist who synthesized his own methadone until it became too difficult) businessmen, tree-surgeons and just ordinary folk as well as more colourful citizens and people who had totally lost out on their childhood and adolescence and would never be employable on any regular basis.
I know that most people grow out of addiction without any professional help. Since I started doing a bit of medical journalism in the 1970s, I’ve written a lot about the power of placebo and non-specific effects (and spontaneous improvement) and I think most doctors wildly overestimate the specific effectiveness of most of the drugs they prescribe. Even surgery can have large placebo effects. I think that’s possibly linked to the way the ‘brain disease’ people wildly overestimate the importance of their pretty pictures and the potential therapeutic usefulness of their research into pathways, synapses, neuropeptides, receptors and ‘anti-craving’ drugs. Like Marc and his readers, I have often wondered if any of these people have ever been in love and to paraphrase Hitler’s mate Hermann Goering, every time I hear the phrase ‘nucleus accumbens’, I feel like reaching for my revolver.
Now, here’s the therapeutic meat. In disulfiram (for alcohol) and naltrexone (for opiates) we have two very powerful drugs that, for different reasons, have powerful deterrent effects on the consumption of the target substances. Naltrexone deters because there’s not much point in whacking heroin into your veins or orifices if it has no effect except to make you poorer. Disulfiram deters for the same reasons that speed cameras and police cars in your driving mirror deter: that there’s not much point in swallowing alcohol if all that happens is that your day is spoiled without even the pleasure of intoxication or oblivion. We call naltrexone an antagonist but disulfiram was the first antagonist; it’s just that it antagonizes at the behavioural level rather than the pharmacological one. Provided adequate blood levels of the two drugs are maintained, the target behaviour – intoxication – will be prevented. Depot and implanted naltrexone now make those levels much easier to achieve and to maintain for long periods – up to six months with some Australian implants. That’s long enough for most people to at least start getting used to abstinence as a normal part of life and for people who don’t have any major problems apart from their addiction, it may be enough for them to stay lastingly clean. Think of it as AAA – Antagonist-Assisted Abstinence. Most people probably need at least 18 months and some, as with methadone, need indefinite treatment.
Disulfiram is more demanding because there isn’t a pharmacologically effective implant, though the ineffective ones touted by some clinics can have powerful placebo effects. (I’ve occasionally referred patients who begged me for an implant to a surgeon who duly inserted a piece of silicone while intoning the word ‘Antabuse’ at frequent intervals. They had amazingly good outcomes, but don’t tell anyone.) However, oral disulfiram can and should be supervised by family members, colleagues, employers These people are often highly motivated to keep sober a spouse, friend, employee or workmate who is a decent and useful human being when sober but tedious, comatose, profligate or violent when not. Probation officers can also supervise disulfiram for recurrent alcoholic offenders who have no reliable friends and have lost their spouses and employers if they ever had any.
Disulfiram and naltrexone are not usually treatments in themselves, though they may be for more people than you might think. They primarily help to keep people abstinent for long enough for them to learn new and useful habits and skills or regain old and useful ones. This may occur spontaneously or with rather minimal therapeutic input for the surprisingly numerous ‘easy’ patients but requires much planned and focused psychological, psychopharmacological and social help for the many damaged, challenging and generally ‘difficult’ ones. It also requires a good therapeutic relationship with either one person – usually but not necessarily the prescribing physician – or with a small team whose composition doesn’t change much over a year or two. In an age of tick-box psychiatry, professional mobility and the dissemination of care, this can be a challenge but it isn’t very difficult and – if one is allowed to say this – it can be great fun, initially for the therapist but eventually, if it’s successful, for the patients too. When abstinence is established, they can be cautiously weaned off the antagonist drugs, with plans in place for a rapid response to any slips. Eventually – and I know this is anathema to the AA people – some of them manage to become long-term, successful controlled ‘social’ drinkers.
I was disappointed that Marc’s book didn’t mention either of these drugs. Also, while I’m a fan of the brain (my first addiction paper was about alcoholic brain damage and was the the last pneumoencephalographic study before CT scans made brain imaging easy in 1974) I (slightly) question the therapeutic importance he attaches to the various bits of neuro-anatomy. After all, if most people recover spontaneously; and if sudden major life-events like falling in love or moving to another place can precipitate recovery; and if the most important step for patients is to accept that they have a problem and need to change, then how important are the specific¬ approaches to psychological management that he seems to recommend?
The best predictor of future behaviour is past behaviour. If we can help that past behaviour to include a long period of abstinence in the real world (i.e. not in a clinic, a prison or a therapeutic community) then that becomes a predictor. Surely that is, in principle, a good idea?
Since I’m new to this blog, I don’t know the unwritten rules but I will happily provide references to my own and other people’s papers if readers would like them. The only one I’d like to mention now was co-authored with Emmanuel Streel (a psychologist, by the way).
Brewer C, Streel E. Learning the language of abstinence in addiction treatment: some similarities between relapse-prevention with disulfiram, naltrexone and other pharmacological antagonists and intensive ‘immersion’ methods of foreign language teaching. Substance Abuse, 2003, 24(3) 157-173.
It expands on the comparison I first made in 1988 between learning to be abstinent and learning a second language. I think Marc may like it.
“After all, if most people recover spontaneously; and if sudden major life-events like falling in love or moving to another place can precipitate recovery; and if the most important step for patients is to accept that they have a problem and need to change, then how important are the specific¬ approaches to psychological management that he seems to recommend?”
Because:
“The best predictor of future behaviour is past behaviour”
Except in the 80% of the case’s when it’s not .
So , that might be a thing .
Hi Colin. I don’t know if there are any actual rules. Though very lengthy comments will probably not be read all the way through by most readers. In fact, I wish you’d let me put this up as a guest post… It would follow the current post very nicely. In fact….maybe we should consider that, regardless.
I won’t get into any details now. Packing up for another trip, starting tomorrow. But your discussion is full of very important themes, argued persuasively — and you’re right that my book missed most of them entirely — for example the role of naltrexone and disulfiram (or Antinbuse) etc. Maybe that should have been another chapter, or maybe another book.
Please see my description of Percy Menzies’ criticsm of Chasing the Scream, a couple of posts ago. Your position and his have a lot in common. And when you think about it, “access” is the issue whether you’re keeping drugs away from the individual or keeping their effects away from the receptor sites. Your (and his) emphasis on giving addicts a chance to reknit their habits and their lives is one I fully endorse.
I’ll try to respond to more of your fascinating account here, but I do think we should publish it on its own.
Really great discussion regarding “addiction”, which, is cracking the old mold, model and idea of addiction as a “Dis-Ease”. I do believe, however, that thoughts, habits, ingesting chemicals etc…are cause for changes to the brain in terms of the Neuroplasticity and due to the very nature of neuroplasticity one can change, recover and/or “Discover” betters ways of being. Change can only occur from the inside and is an inside job. The actual fact that the brain’s ability to change in order to accommodate repeat thinking, behaviour or ingesting toxic substances doesn’t mean you have a disease.
I never got too hooked up on the label (Disease or Addiction) but instead focused what causes a problem is usually a problem be it ones’ thinking and/or behaviour. If the actual fact that addiction is a disease and I internalize this idea, which I did many years ago, then I could feel even more “powerless” to change. This wasn’t the case for me. In fact, attending A.A. helped model change for me, got me rooted in discovering for myself that I could change then I actually “out grew” A.A.. There was a point where if I had continued attending A.A. meetings, “For Me” it would have held me back.
I had often said that long before I developed a “Drinking Problem” I developed a “Thinking Problem” about drinking. The use of alcohol was rampant on both sides of my family, my older siblings, friends and neighbors etc… The term “social drinking”, for me, meant getting totally wasted because this was a behaviour that I witnessed over and over again. This is not, by any means, about blaming anyone and until and/or unless I could take full responsibility for my own actions change would never occur because the problem would be on the outside.
However, many people who use alcohol and/or other drugs for purposes of coping might also be deemed as being resilient though many folks may have trouble digesting this idea, but, I know for me that many times this was the case. May not have been the best coping mechanism but at the time it seemed to work.
On my journey of “Discovery” I also became quite aware that I see the world the way I am and not necessarily the way the world is and if I change my view I can change my world. Moving people from “environmental support” to “self-support”, in my opinion, is empowering. Perhaps not so empowering for all clinician’s if the ego is involved. Many clients can and have become dependent on treatment (external) and can only function reasonably well for a period and then spiral back into treatment counseling and/or therapy etc…
In many ways its the complextiy of simplicty… In summary I would like to share Portia Nelson’s Autobiography In Five Short Chapers which inspire me back in 1988 when I got clean and sober!~
Chapetr 1
I walk down the street. There is a deep hole in the sidewalk…
I fall in.
I am lost…
I am hopeless.
It isn’t my fault.
It takes forever to find a way out.
Chapter 2
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I’m in the same place.
But it isn’t my fault.
It stils takes a long time to get out.
Chpater3
I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I stil fall in…it’s a habit.
My eyes are open; I know where i am.
It is my fault.
I get out immediately.
Chapter4
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.
Chapter 5
I walk down another street.
Thank you, Gary! I have always loved this passage and its very human characterization of maladaptive habituation. It is what we do, till we do something different.
I think we mostly agree that “disease”, “addiction”, and “recovery” are woefully inadequate terms that we’re saddled with, but are part of the common parlance, for better or worse. They stigmatize, polarize and slow progress. We need to approach the situation differently with positive action, approaches that effect change, that don’t just bemoan the status quo. What are we willing to do about it?
It caused so much harm to me personally believing I had an incurable disease. It kept my bad self image in place I never would have found the true source of my real problem if I had went on believing it was a disease. I understand now why I hated being sober and I hated AA. It was because the problem was still there. I felt terrible inside. When I began to say this to other members I was told I wasn’t working my program. I did everything they told me as I went on hating myself and how I felt inside.There should be a real effort to stop these 12 step programs from claming they understand addiction because they are ruining people’s lives with bad science. It should be a crime for government to force people to go to those voodoo doctors. We have millions of sick people claiming to be addiction experts but they don’t don’t even know what causes addiction. They call me a dry drunk because I don’t work the program.Those people think I in denial wow! Thank God for CBT or not only would I still have the same miserable life I would have been out there brainwashing newcomers into admitting they had an incurable disease and believing they must never stop coming to meetings or they will surely die. Then those people would do this to more people…. My God doesn’t anyone else find this disturbing? How can this be happening?
HI David
What I think is unconscionable is that the medical establishment has let this go on for so long, and how rehab has become a cottage industry to line people’s pockets, not realign desperate lives. To me, it always seemed a matter of convenience and availability, and much easier than establishing a real treatment model. Addiction oversimplified. AA is not at fault and the premise of non-stigmatizing social identification, inclusion and support is huge. The antiquated notions of religiosity, labeling, disease and anonymity are hangovers from a bygone era, promulgated by humans, not the foundational philosophy of AA. Bill Wilson took acid and pushed niacin therapy looking for a cure, but was silenced and discredited.
Until some grounded change is effected, people need to take the longer view, which is not usually feasible when one is in withdrawal. Nobody is putting a gun to our heads and telling us to believe some doctrine or die. There is always a choice, and if something doesn’t seem right and isn’t working, then it’s not for you.
I go to all sorts of meetings and it’s the people in them that are important. I did not get a sponsor. I had my own friends and support system. I did not do the steps. They are an amazing tool, a moral compass for those who have lost their way. But I didn’t need a compass or to accept I was powerless. I needed to accept I HAD a problem, come up with a solution and get on with the rest of my life.
And that is what all who overcome addiction ultimately do, regardless of the route they take.
Dear Bill,
Thank you for the critique, but it’s time we move on from this black or white thinking.
RE Point #1: Just because the treatment system is broken doesn’t mean the definition of addiction is incorrect. It’s actually counselors that view addiction treatment as you do that perpetuate bad treatment. How often do you think addiction is treated by an actual doctor? If we had more continuity in the way addiction was treated based on the science (which I would argue is not “bad science”) – aka evidence-based treatment – the addiction treatment field would be much better off.
RE Point #2: When was the last time anything met the criteria of either/or? Just like everything else, addiction is more nuanced than the “either it’s a disease or a choice” debate. We could classify addiction as a disease and maintain that the person retains some agency. Maybe it’s more difficult for some than others. Maybe a person’s circumstances make self-empowerment near impossible. Your viewing the problem through your own lens. You must think outside of this. Yes, addiction is probably less of a problem than we want to admit, and yes most people stop using or drinking heavily on their own, but there are still 15-20% of people that are addicted, that have a bona-fide medical disorder.
I apologize. I’m getting really frustrated with this either/or debate. It’s not helping to shape new treatment. Some people will be able to recover like you did, but others won’t. Rather than focus all this energy on discrediting people, let’s figure out solutions. You found one. Great! Now, which people will it help? Everyone? Probably not. Help us figure that out. Also, please check out my new piece about this: https://therealedition.com/addiction-choice-or-disease-lets-just-move-on/
Paul
I have to agree. It just further muddies the bathwater we’re throwing the baby out with. Sorry to mix an unmanageably mangled metaphor but that’s what this is all starting to look like.
As Paul indicates (and everyone else pretty much), agency is key in this. How do we go about developing that more effectively?
Hi Paul. Thanks for sharing these views. But I disagree, at least in part.
When you frame the either/or as between disease and choice, you’re right, it doesn’t work. It doesn’t make sense. But I think that’s a false dichotomy, because choice is anything but rational. Choice works off of context, associations, desires, biases, etc. So your dichotomy, between disease and choice, works out to be a supposed dichotomy between helplessness and rational behaviour.
Once we understand choice to be irrational, then that’s no longer the question. No one in their right mind would call addiction a rational choice.
But I still think it’s worth emphasizing that addiction is not a disease, so that we can get to the actual (irrational) mechanism that it works off. Calling it a disease is, to me, lazy thinking. Oh well, that’s that. Need medicine. Call it learning and now you’ve got something substantial to work with.
Marc, I completely agree. You don’t have to convince me that choice is irrational or that the choice/disease debate is a false dichotomy (for the record, I discuss these very things in the article I posted in my previous comment – as well as advocate for “choice” advocates). You have to convince everyone else. The problem is Nora and NIDA are not going to back down from the disease model, because they want to minimize stigma (understandably), and the media is going to use “choice” advocates to stir up drama. “Neuroscientist claims addiction is a choice” makes for great headlines, and most people won’t understand the nuance. The debate around my recent article consisted of, “It’s a choice!” then “You’re crazy! No one chooses to be an addict!” and so forth. People stop listening after I say, “Well you know, it has disease-like qualities but people still retain some agency. It’s like any other habit that can be ‘unlearned'”. By the way, medication may help with this process. AA may help with this process. The key is figuring out which people will be helped by what. I think we need a new term for the addiction disorder that captures both the disease-like qualities and the ability to retain agency. Thanks for the message back. Cheers, -Paul
PS. There are some people who think addiction is a rational choice: Becker, G. and K. Murphy (1988) “A theory of rational addiction”. Journal of Political Economy, 96, 675-700
Bill, like you, I can only speak of personal recovery experience here in the States. When reading your article, the notion of an external solution for an internal problem – and the standard “You need help” approach sparked a memory. I recalled a time many years ago when my younger brother visited me in treatment. It was not my finest moment, My poor brother was the recipient of my bubbling-over frustrations from people attempting to shove an external solution down my throat for a problem I knew was internal. I had my fill of people – professionals and family/loved ones alike – telling me “You need help”. I forget the exact words my brother said to me during his visit that triggered my outburst, but it was something along the lines of, “I am glad you are in a place where you can get the help that you need”. Innocent enough, right? Well, in my mind, I had done so much for my brother and never once had I said to him “you need help”. Instead, I simply helped him – NOT because he was deficient, but because I loved him and believed in him. So that was antagonizing my already short-circuiting brain and disastrous opinion of myself when I unloaded on my brother. Just for the record though, I did realize that it had to do with my experiences in treatment and not specifically about my bro – and apologized. He’s awesome. His visit was was just super bad timing.
My experiences in and out of detoxes and treatment – inpatient, outpatient, meetings, counselling, only managed to further alienate me from my inherent ability to resolve my issues – not to mention further piss me off. In retrospect, I needed someone to just say to me, “You can do this, Richard” I desperately needed permission to believe in myself. Instead, all I got was validation of the very feeling (inaccurate feeling) that compelled me toward binge drinking to begin with – that I was bad, defective, worthless, etc. So while desperately grasping at straws to find my own strength to save myself, I was essentially being told I didn’t have what it took to recover. It was being aggressively drilled into my head that I was fundamentally defective, diseased, powerless, incapable, etc. To make matters worse, the very parts of me that ultimately led to my successful recovery were being dismissed as sick-mindedness. This was not a good recipe for recovery.
Ultimately, I had to literally and entirely shut out the Recovery world, Then I had to do the very thing that you and Marc claim is the only genuine answer – rely solely on myself. As painful and difficult as it was back in those days, I feel a certain gratitude for my experience because it made me “fight” for – and reclaim something that I may never have realized was missing. It’s tough for me to articulate, but there’s something about me going entirely against my entire family, social world, and against the grain of conventional recovery beliefs and practices that toughened me up in a way that I personally needed. I honestly feel that if I had succumbed to the disease concept and its recovery methods, I would not be here today to discuss it. Something inside me – even in my darkest, sickest, most unstable moments – knew that the beliefs and methods that people were demanding I accept would lead me to my own demise.
Today, I am extremely protective of those who look to me to help them with their drug or alcohol struggles. I discourage them from treatment, except detox if they need it. I never tell them they NEED help. I just offer my help, which conveys my belief in them for having everything it takes to turn their struggles into triumph.
I think that part of the problem, specifically here in the US is that generally speaking, we have become over-dependent on medical intervention/treatment. Treatment is not necessarily being campaigned because it is in people’s best interest, but rather because there are massive profits at stake. Sad, but true.
I am one of the “lucky” ones, who survived conventional treatment in the United States. Not everyone is so lucky. I’ve heard it asked, “what’s the big deal if people view it as a disease or not”. I think it is a HUGE deal. The truth is important. When we are aligned with the truth, healing occurs. When we are aligned with self-misconceptions, and un-truths, “dis-ease” occurs. I know many people who have died because they were so fundamentally incompatible with the invalidity of conventional recovery methods, but they saw no other way out. I’ve personally observed countless treatment professionals strip people of the very things that would lead them toward genuine recovery. It’s tragic.
If there ever is a medical professional who claims to be able to successfully work with “addicts”, it would have to be someone who believes in the patient’s inherent abilities – and subsequently nourishes those abilities. Anyone – medical professional or otherwise – who seeks to help another human being with “addiction” struggles – and claims to be necessary as part of that person’s recovery, in my eyes, deems himself incapable of truly helping. The only necessary component to a person’s recovery is within he who struggles. Therefore, the only effective method of helping someone is by acknowledging, respecting, paying tribute, and believing in his or her fundamental abilities. If that is the premise, than only good can come out of it.
Great article. Thank you, Bill.
Richard
ou will never hear me utter the words, “You need help”. Instead, in whatever ways seem most appropriate in any given situation, I convey the fact that they have within them the ability to make this better for themselves and I offer my help. That may sound like semantics to some, but in my mind the message conveyed are entirely opposite from each other.
sorry about leaving a bunch of senseless words at the end of my post. leftover, I guess.
Sorry, but some of what’s written doesn’t make sense to this reader. For example: “If addiction is a disease, doctors will be expected to “treat” it. That may not be too bad in theory, but unfortunately the medical profession (in the United States at least) is ill-prepared by virtue of knowledge, training, and — most problematic — insufficient time.”
So we’re going to classify a condition as a disease or not depending on whether doctors have time for it? Or are trained enough? If a patient has a cancerous tumor but there aren’t any doctors available or trained to operate, that means the patient doesn’t have a disease?
A big wide smile full of compassion, love and recovery resulted from reading this blog, thank you! All the complicated neuroscience and models of addiction with referencing have already been captured.
I have been reading blogs, books and papers on addiction since 2000.
I have drafted many a blog and blog response but never posted.
Especially more recently to Peter Sheaths wonderful blogs.
But have never posted.
Before I get home to the world of my beyatiful little clan I want to say that in my opinion, in my experience, in my study of addiction and recovery you have highlighted key points and yes we have known for years!!
Doing less and focusing our resources on what works would be a good step towards recovery but it’s too simple, it’s not saturated in process, governance and systems therefore can’t be evidence based
But that is changing, the recovery revolution will not be televised but won’t need to be as it will be in every community in every city in every country
Recovery is love, you can’t control, tame or control love
All you can do is appreciate, see it clearly and enjoy every second you are fortunate to experience.
Before I burst into song I will say good bye for now
All the best
Grant
I agree that addiction, to 90% of people using addictors, is most likely no more than a bad habit. These are the people that can use addicors with impunity, more or less. And to be honest I’m really not too concerned about most of them. They’ll work it out & be just fine. Its the 10% or so that cant that I’m concerned about. These are the people, in my view, that are born with a brain disease, genetic in basis, that use substances, behaviors, beliefs and even ideas to change the way they feel against their will. And in these cases, addiction is (still) not a disease but a symptom of a brain disease. Huge difference. Their brains are genetically programed to constantly seek out and use addictors in an entirely different way than others. These are the people at risk and these are the people with who I’m concerned. In both situations, however, addiction is not a disease. In the latter, it is most definitely a symptom of one though. This is what needs to be sorted out and differentiated for any progress to begin to occur. Its also among the reasons why the war on (certain) addictors has been and will continue to be a massive failure. When the laws create more harm than they prevent, its time to change the laws. Clearly we are at that point.
I so wish I had the time I use to, to address these comments but I do not. So, in short I think this author is spot on. Thank you.
This might sound arrogant, because I don’t have any medical training.
I’ve been addicted to internet porn for about 5 years. Not knowing it could be addictive, I fell into it seeking relief during a stressful time. I’m not free of it yet, but I’m making progress, getting closer day by day.
I can’t speak for others, but counseling, recovery books, recovery programs and on-line support groups have convinced me that the only one who can get me past my addiction is myself. People offering help with recovery often mean well, and some of their ideas are helpful, but the field of addiction recovery is fraught with confusion and a host of conflicting opinions.
Reading about brain plasticity has clarified addiction for me. No, it’s not a disease. I see it as a learned behavior that changes the brain in adverse ways. Fortunately, replacing addiction behaviors with healthy behaviors changes the brain in beneficial ways that weaken the addiction pathways and allow one to regain control and live a meaningful, fulfilling life. As Tim Greenwood says above, healthy replacement behaviors include meditation, exercise, mindfulness and gratitude. They are light indeed!
I’m an artist, and sliding past temptation and getting to work is the best thing for me. The challenge captures my focus, stops time and immerses me in flow. Fortunately my addiction hasn’t hurt my ability to focus or the joy I get from working. I love my work but my addiction has stolen time from it–which shows how insidious addiction can be.
I’m not giving myself ultimatums. I’m changing my behavior, redirecting my attention, and thus changing my brain. In time urges to indulge in the addiction will fade into the background, if not away completely, and will not trouble me further. This is what happened when I quit smoking cigarettes years ago. Emerging brain science shows that brain changes are remarkably consistent across addictions, as are the brain changes that accompany not indulging. I’m confident that if I keep doing what I’ve been doing, I’ll free myself of this addiction.
I’m very grateful for what I’ve learned. Nevertheless–forgive me for saying so–I don’t give a damn if anybody agrees with me or not. I trust my experience.
I just heard Marc Lewis interviewed on Radio New Zealand National, and what he says tallies really well with my experience. I have long felt that the mind is quite plastic, and can develop all sorts of new skills, even when it’s not young any more. I’m not surprised to hear that “grey matter” increases in the brain during “recovery” from addiction, to levels beyond what was there even pre-addiction.
The medical model – I recall a young pharmacist informing me that because I had relapsed into depression when I stopped taking antidepressant drugs, I would have to take them for the rest of my life. He was wrong. I used many of the things Marc mentions, such as meditation, willpower and talk therapy, as well as dietary changes and exercise.
I was only ever addicted to cigarettes, sugar, and possibly narcissistic people, but I’m not any more.
From my experience, I think growing up in an abusive environment, hinders a child from developing a sense of the future, and therefore the ability to delay gratification. (Abuse, in whatever form, involves the abuser manipulating the target’s thinking, including their sense of reality and their sense of the future.) My healing from abuse coincided with the development of a sense of the future. You need a sense of the future to develop many life skills; delaying gratification, time management, money management, healthy eating, holding down a job.
Even with physical diseases, going to the doctor and just doing what they tell you, I have not found to be the best approach. There are quite often alternatives – complementary medicine, lifestyle change – that can be just as effective.
Bill,
Thanks for your thoughts on this topic and pointing out the unique and difficult position doctors are in.
As you stated in your first point, ” if addiction is a disease, doctors will be expected to “treat” it.”
Believing a doctor can “take away” the problem with a specific medical treatment or medicines, is an attempt, (and a hope) during a persons recovery process.
This may sound odd, but a few doctors let me try Prozac, Effexor, and I think Zoloft ( I am dating myself here, this was back 15-20 years ago) and a few others, in the later efforts to free myself from the alcohol addiction. Personally, I was able to discover for myself that these were not going free me, and was able to go on with my eventual recovery.
For a certain percentage of the people struggling with an addiction, it is a long but natural struggle to turn over all the stones, before getting to the actual realizations that can free a person from an addiction and finding fro themselves that it is “untreatable” by a doctor or by the medical field. It have to be discovered by the person to be realized, not simply told by someone else, despite the authority of the person telling it.
And one side-thought:
Since going to a doctor for help with an addiction is a natural thing to do, perhaps physicians could be issued an official definition/ explanation of the two (or more) current models of Addiction, and go over these with people seeking help with an addiction.
Physicians could then ask the person which one seems to resonate with them,, and possibly try that first. This way, the choice remains with the person.
Carlton
Bill,
A New Model may account for the 80% in a different, surprising , yet also in a common-sense way.
The work of both Stanton Peel and Marc Lewis are pointing to an area that has not been rather overlooked. A new model based on feelings/desire could change the paradigms is a profound way and put the various models of addiction into a larger and non-confrontational setting.
It is hindsight speculation on my part, but I think the 80% you mentioned, and a percentage of the people that are no longer active or reliant on recovery groups or recovery environments have had realizations, changes, that are not relating
self-management, control, empowerment, or reliance on another power.
A few years ago a few of us in the NYC SMART Recovery group, pursued the idea of having ex-recovery people come to recovery meetings,
But it never materialized and the folks that were involved are basically no longer active. Which is a paradox, but indicative of a new model to.
I don’t want to change the subject of your Post , but read your pronouncement;
“This is the epitome of self-management and empowerment” and felt compelled to comment.
Best,
Carlton
Thanks, Carlton. I think I see what you’re getting at, and it’s important to remember.
Who is this putative 80%, and how do we know what they did to recover?
I don’t think SMART empowers people any more than AA disempowers them. Meetings help people become more aware of the issue, then accept it, then stay motivated to change. We don’t know what allowed the 80% to recover. But I’ll bet it had something to do with both power and powerlessness…and the wisdom to know the difference.
This is an area that has been largely overlooked, but when it is looked into, the findings will probably be helpful for defining and establishing a new model for addiction.. and decrease the shame and stigma that addiction currently has with the public at large.
It is unfortunate, but understandable that it is not something people want to do with their time.There is little or no motivation to express or communicate what occurred.
In general the term “recovered” may not even be a term people would use for what occurred.
But there are, I consider myself one of them.
A pithy aphorism on empowerment:
The more you do of what you’re doing…
The more you get of what you’re getting..
Emphasis on YOU!
Bill,
Regarding the harm you are defining in the second point. Here is different view of this.
It is clear that for a large percentage of the addicted, a lifelong struggle with the problem seems inevitable. to never to be un-tethered to the problem seems unimaginable.
For them, addiction seems like being a victim of a disease.
There is no harm done in depending on group such as AA,and it can improve
that persons quality of life.
At the same time, there is percentage of people that innately feel that addiction is something other than a disease, and these people probably account for the people that naturally recover and perhaps the people that leave the various recovery groups and programs, such as SMART Recovery.
From this point of view, the harm occurs when group insists that their definition is the definitive one and imposes it.
An analogy:
Is the World round or flat.
If there are people that believe the world is flat and find that it helps them in their life, than what is the reason, motive, or purpose on insisting that they realize and except the scientific truth that is is round?
Fortunately are other beliefs about addiction other than the disease model.
The fact that there are people going to, and then leaving these recovery programs, is the most compelling evidence of this.
And in the same way of seeing the flow of people entering and leaving a physical rehab, these addiction recovery programs will naturally attract certain people who seek help with an addiction.
Carlton
Hey Carlton
Here’s another analogy. You’ve fallen in the river and are being swept away. There are hands reaching out from the shore to save you. Does it matter which hand you grab? No. It just matters that you grab one before you are swept away. All the hands are trying to do the same thing, for you and for each other.
As humans, we’ve got a lot of cognitive biases. They can turn into cognitive distortions that can lead to addictions. Three biases common to pretty much everyone are: We don’t like change, we don’t like difference and we really don’t like to be wrong. They are adaptive, there to keep us alive. They reinforce each other. They’re there to hold us back from the river’s edge. Maybe it’s time we took a risk, let go, and got swept away. We’re all headed to the same destination.
I just wrung every last drop out of my tortured little metaphor, but hopefully it makes sense to someone.
Hi Matt, The concern many of us have though, is the harm that can occur when a rigid mind-set of addiction is imposed.
However, I was tying to point out that Bill may be a bit of rigid in the other direction.
Currently, the rigid, disease-based model is being imposed, and it can be limiting and arresting development in an un-scientific way, just as the Ptolemic Model of the solar system was limiting and arresting world scientific and cultural development before the Copernican model was proposed, understood and accepted.
But once an accurate definition of addiction is arrived at, that too should not be rigidly imposed on people that have different beliefs.
It is like not demanding and imposing scientific proof on the fact that Santa cannot actually exist.
Let those who want to believe what they want. but we as a society have to establish the fundamental scientific understanding of addiction first, and I think we are nearing that understanding.
Agreed. In the meantime, those of us at the street level need something to hang our hat on, to help as many people as we can. Marc’s explanatory model is the most inclusive of all the things I know that help in recovery. I’ll be happy when science further validates this.
Meanwhile, this model is grounding for me, and helps me feel I’m doing the right thing. To further mangle the previous metaphor, it’s the riverbank I feel comfortable reaching from.:)
Hi Bill,
I found the term that was excaping me, it is called
“Inform and Consent”
Stanton Peele decribes it at 21:55 in this podcast titled:
“Recreating Addiction Treatment for the 21st Century, Tom Horvath Interviews Stanton Peele
https://www.memoirsofanaddictedbrain.com/connect/a-doctors-view-on-what-doctors-cant-do-for-addicts/
The choice of the various approaches could then placed the authority in the hands of the person, not the doctor.
Duh!
copy/pasted the wrong address-
Here is the correct one :
http://hwcdn.libsyn.com/p/c/e/a/cea97c427390116d/Stanton_Peele__Tom_Horvath_May_2015.mp3?c_id=9025700&expiration=1448077802&hwt=ac4f909ba07346ede434a3b18f1bf190
Recovery program center provide best environment.
great article. A known for drug addiction treatment residency in Canada, http://www.lifechangescanada.com would encourage a strong recovery.
Some doctors are addict or some doctors not are addict. well doctor is also human. but they help addict society and change life without addiction.
Doctor very well know whats good for him. addict center is best job.