I just listened to the first 15 minutes of a lecture by Robert Sapolsky, a renowned biologist and Stanford professor. Sapolsky begins with an incisive lesson on why humans rely on categories. Categories, he says, make it easier to think about complex phenomena. And human social behaviour is nothing if not complex. My friend Tom insisted that this online lecture series was worth viewing, and he’s right. I plan to view the rest. But first, this post.
Take something a little simpler than human behaviour. If a colour falls between orange and yellow, you’ll have a harder time thinking about that colour and remembering it than if it’s either orange or yellow. Yet light frequencies fall along a continuum without boundaries. In other words, we actually invent colour boundaries, and different cultures see colour differently. It’s easier to remember a shape if you can call it a circle or a square than if it doesn’t fit any geometrical category. If the shape is squarish with rounded corners, or blob-like, you’ll have a harder time thinking about it, remembering it, and using it in a conceptual task. (Sapolsky demonstrates these examples on the white board.)
So, okay, categories are tools for simplifying perception and thought. But there are several down sides to categorical thinking. Sapolsky mentions a few, but here’s the one that inspired this post. Remember when 65 was 
the cut-off between a pass and a fail? (That was the cut point when I was an undergrad.) So you’ve spent much of the week partying, getting high, etc, and here comes the exam, and you cram for it that morning, give it your best shot, and wait anxiously for the result. A 
week later the prof hands out the exams, or you look up your grade on the bulletin board, and the thing you care about more than anything else is whether you got at least a 65. If you got a 64, you’re shit out of luck. If you got a 66, you’re sailing.
Now how much difference is there, really, between a 64 and a 66? How much information does that distinction actually give you, about your performance, your dedication, your intelligence, or your use of free time?
This isn’t the first time I’ve conceptualized addiction (intensity, duration, riskiness, etc) as a continuum — a continuum that does not lend itself at all to two categories, disease vs. health. Other addiction thinkers, researchers, treatment providers, etc, have also remarked that addiction 
is a spectrum, a dimension, a set of gradations at best — nothing like an all-or-nothing category. Yet the disease label cannot help but classify addiction as a category. You either have tuberculosis, or diabetes, or cancer, or you don’t. Never mind that, when it comes to addiction, the category label itself can do more harm than good. As soon as you classify addiction as a disease, you draw a line. (There is some discussion of this issue in the commentaries on an article of mine.)
Indeed, the disease labelling trend in the US and elsewhere makes it stupidly easy to put addiction in a wastebasket category. You’ve either got it or you don’t. And if you’ve got it, then free choice, self-control, empowerment, and so many other features of human thought and emotion are neatly defined. Easier to think about, right?
Sapolsky makes other cool points about how categorical thinking obscures real complexity. For example, falling into the same category doesn’t necessarily mean that two things are similar. As we know, two people, both categorized as having the disease of addiction, can be as different as giraffes and field mice (just two animals that came to mind).
Many of my readers will probably agree that categorical thinking, this mental-labour-saving device, misses so much — so much of the real complexity of addiction — that it can’t help but muddy the waters.
………………………..
This is remarkable: four hours after posting today’s post, I found an email in my inbox that contained nothing more than this link. If this man can face his addiction and challenge it, without submitting to the disease categorization, then…that’s all there is to say. The post is electrifying, extremely well written, and deeply moving. I’m honoured that my work figures in his thinking.
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
Dear marc
Nice story in the link. Touching. I do agree that addiction is not a disease. Its a habbit. In a way a it started a functional habbit. As when I was a child a very useful way to reduce the pain I musr have felt of abuse and emotional neglecting.
So further on the habbit became dysfunctional but as it is with habbits they continue and even create the circumstancesto persist.
So at time I saw this. Started to read you’re books and saw what my mind did to create thinking to get me continue my habbit as the addictions where so nice for my brain. But not for me. I kept changing my thoughts every day. Endured. In the conviction that I really could be in charge.
My desire to get healthy made me clean. And up till today I am grateful I did so. I can do with suffering and sadness cause I know its part of life. Its always oke
Sounds like you traded a beautiful new habit for an older one, no longer needed. I think most if not all habits start off because they serve a function. Then they take on a life of their own, and it takes effort and perspective to change them. Accepting sadness is a habit too, but it opens you rather than closes you.
Dear Marc
from the Netherlands. I dont understand youre last remark. Pain and suffering from it as in emotional way is part of life. Loved ones go away shit happens. It causes pain. why do you say accepting sadness is a habit too?? Im curious.
Maybe it has to do with the fact that thinking is an addiction too. As I remark the work of Jan Geurtz.
Addicted to thinking.
Thanks Marc! A profound post as ever – yaaaay, I want to shout! Categories are simple, and also really lazy. As Jung famously said:
“Thinking is difficult, that’s why most people judge.”
And Leslie’s blog was profoundly moving. For many, going to AA is like serving time, grounded as all the Anon meetings are in helplessness. Utter, frigging helplessness 🙁 I spent a few weeks in Al-Anon when my family had problems (and I didn’t want to own up to my drinking either.) It was so helpless, so many round the table looking back at the past, finding the present painful. Made me want to run out, screaming. So I left….
Most of us can grow out of our problem behaviour (which is how I prefer to see addiction), through neuroscience, and especially the company of honest, encouraging people who know that we can work/walk/hike/knit/draw/yoga/laugh/dance and love ourselves back to good health.
Here’s to us and common sense!
Cheers to that! Glad you read Leslie’s post. Like you, I think a lot of people will resonate with parts of his story, including the shuttering and shutdown of the self encouraged by components of the addiction treatment world.
I agree with Marc because if your alcohol drinking problem is called an addiction you are not responsible for your problem, but when it is called a bad habit you are in charge, you have a choice: to drink or not to drink.
Yup. A tough choice very often, but still a choice. Choices are not simple, either-or, black or white. Thanks for your comment.
I categorically agree, Marc! Wait…that came out wrong…
Seriously, though, one of the beautiful things about your approach, in this and other endeavours, is to start not with the expectation of how people should be but how they are. Yes, we think in categories. We all use heuristics for efficiency, the predictive brain making sense of the world, but this gets us into biases that don’t necessarily serve us well. That is essential info for “non-addicts” to consider as much as or more than those struggling with addictive habits.
And so happy to hear you’ve started the Sapolsky lectures. I have learned so much from that man and I highly recommend them to anyone interested in understanding the human condition.
Well I suppose you could categorically agree, Tom (this is the “Tom” I was talking about!), since after all, categories help us think in clear, simple terms. But, as you say, the simplicity can become a rut, a bias, such that a good deal of the information flow goes by without being caught, and soon escapes our attention entirely. Then seeing things clearly does not serve us well, because the clarity, the simplicity, becomes a stand-in for the textured nature of true insight.
Ok the convenience of the Leslie story, finally convinced me that addiction is not a disease. But that thinking then entails calling it something else. Habit? All the advanced degrees and experience in this blog we can call it conveniently, a habit. .All people afflicted, diagnosed, treated , non treated, former, current with a habit can just stop or not depending on their choice. Then if that’s the case, it’s a choice of habit ,why bother treating a not disease habit, just stop, or just say no.
Calling it a habit does not mean it’s easy to turn it off. There are millions of examples. Racism is a habit. Self-promotion is a habit. Habits by their nature have a life of their own, a momentum, a kind of determination. So…breaking the habit of addiction does take work, sometimes a great deal of work. That doesn’t make addiction a disease.
Hey, lots of diseases are on a continuum. High blood sugar can become diabetes, squamous cells can become cancerous, symptoms can consolidate into syndromes.
If you’ve got an organ (the brain) whose malfunctioning is driving a behavior that’s threatening to ruin or actually ruining your life, causing misery to those who love you, and is probably going to kill you if you don’t do something about it, and there are effective medications to help in the remission of this condition (process). . .
And in the real world of treating giraffes and field mice, who sure do look and act sick, it’s so much easier to frame the issue as a disease process rather than as a whatever. Of course habit and overlearning are involved, and the process can be interrupted at any point. If it isn’t, it inexorably gets out of control. If you have trouble stopping once you start or you do it when you didn’t mean to or want to, the cage door is closing. The g’s and fm are not responsible for getting the condition, but they are 100% responsible for their recovery.
Replying to myself: I just read Leslie Law’s blog. There are many paths to recovery as we know, and who gives a shit what we call it. I wish Leslie the best and hope that he has found a way to loosen the grip of the whatever-it-is. Early recovery is a baffling mix of elation, pink clouding, and horror (in my own experience). I heard someone say that stopping using was like slamming on the brakes of your car and all the shit that you’ve tossed into the back seat over the years ends up in your lap. Sustained recovery is a process.
I love that analogy, Nick. But as to the similarity/difference between addiction and medical diseases…well we’ve had that discussion too many times already. So, instead of focusing on aligning these two things, and deciding whether or not to include them under the same category label, let’s just acknowledge that categorical thinking has risks as well as benefits. It can work very well if there’s a clear solution or resolution or answer to the problem the category stands for. It doesn’t work as well if there’s a profusion of ways to deal with that problem, any one of which may or may not work for a given person or context. (see Matt’s comment below)
And these effective medications?? Naltrexone works for 10-20% last time I checked. Antabuse? Also a fairly small minority. Opioid substitution therapy…I doubt you’d call that a solution to addiction, though it can be absolutely the right means for helping people stay off the street.
Great introductory lecture by that Stanford professor- thanks for linking that
I work on the ground. Categorizing things is not helpful to me other than to helps me make generalizations about the behavior of a particular group. A disease should have a cause, a characteristic symtomatology, a potential remedy and an outcome. So what are the symptoms? Desire for relief, for feeling safe, lying, compulsion, desperation…I can go on. These aren’t symptoms of disease unless you consider the human instinct for survival a disease.
I think Sapolsky has some things to say about this as well.
Sapolsky is brilliant. I retired from college teaching 6 years ago, but when I was still at it I used Sapolsky’s work, particularly a video he did on his work on stress in baboons and British bureaucrats. I’ve watched pretty much all of his lectures on YouTube. He is truly a phenomenon and an amazing teacher. I wish I had had more lecturers like him when I was in university.
I highly recommend his recent book Marc:
Behave – The Biology of Humans at Our Best and Worst
https://www.nytimes.com/2017/07/06/books/review/behave-robert-m-sapolsky-.html
Hi , Russ
Thanks, Russ!
Hi Marc,
I fully agree with you that drug or alcohol related persistent behaviors are a habit and not a disease. But along with the disease concept, it appears that once an alcoholic or drug addict than always one? Through re-wiring your brain as you grow out of these habits there does appear in most re-wiring efforts, still a propensity to relapse more easily as compared to prior non-habitual people. Is it this propensity to more easily relapse than non-habitual users make a person always an addict even when not using for an extended period of time? Or should a former habitual user no longer be called an addict or alcoholic (because the term addict should subsumed within the disease concept) or rather a former addict or former habitual user? I have been sober from alcohol for over 6 years and don’t like being still called an alcoholic.
I think the terminology issue concerning “addict”, “alcoholic” etc. doesn’t jibe neatly with the disease/nondisease debate. I could call someone a racist or a sexist, without any implication that they have a disease. Then, if they’ve woken up and changed their thinking, I may no longer want to call them those things.
The term “alcoholic” has been roundly criticized and I think it’s pretty much dismissed by people who are sensitive to current thinking. I prefer “former addict” to various other terms and phrases….in fact that’s how I label myself, if such a label is called for.
The actual evidence says that most people who at some point in life qualify as having a substance use disorder (alcoholism hasn’t been in the DSM since 1980) recover, most with no treatment at all (no AA either) and about half go on to drink safely or moderately, about half go on to not drink at all. This is based on the NIAA’s multi-wave, giant epidemiological survey NESARC, that looks not just at people who went to rehabs but at the whole population. Great article that breaks it down, by our friend Kenneth Anderson. https://www.rehabs.com/pro-talk-articles/why-addiction-treatment-needs-to-be-informed-by-natural-recovery-data/
Hi April. I can’t keep up with all these comments just now, but I love seeing the dialogue progress. I particularly appreciate your link above. Many people have no idea that total abstinence is just one possible response to addiction, and it is very often disadvantageous, especially in the context of rather brief residential rehab. I recommend this article to everybody!
Thanks Marc! I’ll also see if I can find one of the articles about how residential rehab is usually the least effective option, and the lowest level of care (least restrictive, more outpatient) is usually best. I think the only real point of residential rehab is a) to get away from the substance for a bit b) to get away from family and friends who are freaking out and making one crazy c) to feel qualified to write about rehab someday. C may only be useful for a small percentage of the population. Just getting away to a safe environment can be helpful for just about anyone, but I think the way rehabs do it is awful. I wrote for Andrew Tatarsky’s an article about how I like to take silent retreats of 4-8 days a year at a Jesuit Center which is eerily so close to the rehab I went to that you can see the rehab from the hill trails. Silence, reflection, healthy air and food, and getting away from chaos is sometimes a good way to reset, but being around other people freaking out in detox, often around people who are way further into addiction that you are, being subjected to coercive “therapy” that puts all people into the same category and makes you lie if your story doesn’t fit the bill… not good. Kenneth Anderson and I often joke that we want to start a Cat Island Rehab. Like the cat islands you read about where there are tons of feral cats roaming around. People just show up and for four weeks all the have to do is pet cats. Not indicated for those allergic to cats (Dog Island Rehab? Snakes? Iguanas?) but probably of more clinical value. We will accept grant funding from public or private sources to try this. http://centerforoptimalliving.com/silent-rehab/
April, Kenneth Anderson’s article in ProTalk, that you linked above, points to some of the dangers of brief residential rehab, but if you find something more comprehensive, that would be great. Also, please consider a guest post here of your own. I’d welcome it, and I’m sure my readers would like to get to know you better.
Hi Marc,
I’d be happy to do a guest post! I have an idea…
I was looking at Tom Horvath’s site because he’s the one whom I’ve read most recommending lowest level of care. I can’t find an exact article there but I’ll keep an eye out. A lot of people have written too about the importance of not separating youth who are caught using drugs from other youth. Putting them into separate groups, often exposing them to people who use stronger or more likely to be contaminated drugs (think marijuana to heroin), putting them in touch with the criminal world (should be decriminalized of course but it’s not yet) and taking them away from kids who are high achieving at normal things like academics, sports and arts is really, really bad for them. Kinda makes sense for adults too. If you just talk about your dysfunction all the time and hang out with people who do the same, wouldn’t you get more dysfunctional?
I hear that you are the average of the five people you spend the most time with. That explains a lot. Every day, I try to be more like my cat.
Hi April, just to add to this:
“about half go on to not drink at all.”.
Yes, but currently, the apparent reason is because drinking again would open the flood gates back to full blown addiction again..which seems quite true for a large percentage of addicts.
However, for another percentage of addicts, there is quite a different reason for not drinking anymore, which the public-at-large would relate to also.
Here is simple analogy:
When people in marriage or a meaningful relationship have various troubles, a traumatic struggle useally occurs, and a breakup of some sort.
A certain percentage of the people may RETURN to a casual friendship.. which is like “moderate drinking” again.
But a certain percentage do not return because of what has transpired.
They avoid each other, NOT because they are afraid of falling uncontrollably in love again, but because of what has transpired.
they may even be thrust into a work or living environment, and not engage in even a casual friendship.
“The relationship will never be the same” is often said about an ended relationship.
I think alot of ex-addicts find this true about addiction, and currently, there is no venue or not much reason to convey this fact.
But it could help addiction research, and may cast new and important light on the nature of addiction and recovery.
That’s an interesting analogy. I’ve never been a fan of personifying a substance, but whatever works for you. Also, I’m friends with all my ex boyfriends – a long and impressive list if I do say so myself – so I guess I don’t identify.
Have you read the research on how the biggest determiner of whether or not one goes on to drink moderately successfully is not the severity of addiction previously but whether or not one has been to AA or “treatment?” If you’ve never been to AA or “treatment,” never been programmed to think that you are out of control after one drink, then you are much more likely to go back to drinking non-problematically.
Being told that you’re going to do x if you do y over and over again is pretty convincing. Being told that by authority figures and the whole culture, especially mental health professionals, is even more convincing.
Hi April,
No, “personifying a substance” was not intended, but thanks for pointing out the analogy could be misconstrued as such.
The rather unknown fact I am trying to make is that a good percentage of former addicts find that becoming inebriated is experienced differently after “recovery”.
Rather than feeling free and relaxed when drinking, it feels restricting and limiting.. in effect, undesirable.
Social or moderate drinking is not a goal, returning to alcohol dependence is not feared , and strength and control is not necessary, because it feels undesirable.
This fact bolsters the point that Addiction is something other than a disease or disorder and points to it being something else.
Sorry for not being accurate or clear, but using words is a skill that I never thought I would be needing ,but hope the gist is getting through 🙂
Hi Marc,
Just an addendum to the previous blog. If a person is asked to to describe another person, that person may be seen in terms of his occupation, his family make-up,or his
personality, but not a nicotene addict because he smoked for 10 years and quit 5 years ago. I think because smoking is considered a habit and didn’t involve the stigma that drinking or drugging seems to.(Smokers are not usually thought of as having a disease). So the addict or alcoholic label sticks with someone because of the stigma and disease attribution? So it may not be the propensity to possibly relapse because smokers might do that, but primarily the stigma that makes someone always an addict?
Of course the propensity remains to some degree, at least for many of us. And former lovers may have a propensity to love, and former racists may have a propensity toward racial generalizations, and former writers probably have a propensity to write. The brain never goes back to where it was. You never wipe the slate of the brain clean except with death. Yet the brain continues to grow new pathways, channels, tendencies, and habits. A propensity is just that. It’s a potential and nothing more.
Get rid of that label, man! If it’s weighing you down, just get rid of it. Seems you’ve got every right and every reason to do so.
Drug use is the spectrum not addiction – addiction, a term generalized to mean by many to relate to all drug users – is at the extreme end of drug use behavior – in my mind there is social use, dependent use (and much of that controlled and not necessarily problematic, and chronic and/or chaotic dependency. maybe 3-5 % at most of all drug users occupy the end of the spectrum, and even then that can waver and vary according to what happening in their lives at any given time
Marc, Thanks again for continuing to open up the way we look at human experience, including and embracing this thing called “addiction.”
Elaborating on what Nicolas says above about disease also being on a continuum, when we describe an organism (human or otherwise) that is suffering or failing to function well, as having a “disease” we have ignore the context of their life as a whole and their susceptibility to whatever has impinged on their well being.
The same way that tuberculosis ran rampant through impoverished and densely populated neighborhoods and the way that people with weakened immune systems succumb to external pathogens in vastly different proportions, the encounter between a person and the opportunity to misuse a substance or behavior to their own detriment must be seen as an interrelationship between the individual and their environment.
Focusing on “disease” is as simplistic and self-reinforcing as hysteria about alien invaders. Yes, healthy people get sick and some pathogens may overwhelm even the strongest immune systems but even then, some do not. Yes we need to strive to control the spread of potentially harmful pathogens, as we should of hyper-addictive substances (crack) or behaviors (virtual reality video game gambling).
But to continue simply demonizing the resulting condition (illness, addiction, etc.) without understanding the underlying susceptibility, either inherent (genetic) or environmental (abuse, poverty, etc.) is to leave the individual’s humanity out of the equation altogether.
I really enjoyed this post and the lively discussion that it has generated. It made me think of a first year psych course that I took where we learned about heuristics, which are simplified cognitive strategies for making sense of the world.
If my memory serves me there is a heuristic called “representativeness heuristic” which is essentially a shortcut that our brain uses for decision making (without it we would be bogged down by the massive load of information that our brains are receiving from the external world at any one time). As useful as they can be, just like categories and schemas (as we wouldn’t want to have to connect all the rational dots to figure out that a a car is a car or an orange is an orange everyday) they can sometimes do us a disservice, which is what I think you were getting at with your description of the tendency towards categorizing when it comes to addiction, its either “this” or “that”, “black” or “white”.
I’ve done quite a lot of CBT therapy and I always found it a bit suspect that folks would suggest that I am plagued with cognitive distortions like “black and white thinking” (which admittedly I fall victim to) when the field of psychology/psychiatry/medicine also rely on this same categorical thinking – they just have more categories!
I really like that you are putting forward a model that relies on a continuum as it truly reflects the spectrum of addiction. I think we might actually be moving into a period, much the same way that we have with recognizing the spectrum of genders as categories with addiction, and to me that is a good thing. It leaves space for the individual to find what works and grants them the autonomy to place themselves on the spectrum rather than lumped into some a priori category that was just waiting for them before they were even born. Kudo’s to you Marc Lewis and thanks so much to you and your committed, thoughtful readers who came to check out my blog.
My next post will be up Sunday @ Leslie.law.blog which will continue to explore your argument against the disease model as well as paths forward without that category!
Best,
Leslie Law
Addiction is a human condition and it’s brought on by society’s expectations, demands, scars, stigma and judgement. I’m sticking to what people taught me (I’ve worked mostly with disadvantaged populations but some “famous” and “successful” people here and there). There’s no way it’s a disease.
Thanks for sharing this blog, Marc as I will share it. I work with some mandated populations. Talk about categories, probation and parole are two categories that are unfortunately unforgetable. After years in Rikers Island NY, people don’t have a disease if their using, they have acquired trauma (and usually prior trauma from childhood as well). Many people tell me the disease concept makes them feel helpless, and that’s not a good combo for work on trauma, nor for any healing.
If you’re mandated, well, you’ve defiantly lost the freedom to choose how to get better, as you have to be told “what is best for you” and “go through the motions” to avoid jail/prison.
In the rehab/residential settings where I visit in NY, the aa/na approach is all that’s offered. Many are so relieved when they can speak freely to me about how aa/na doesn’t connect with them, and I can offer them tools of self-empowerment.
Ps I’ve been reading Gerald May, in his book, Addiction and Grace from 1988, he said,”we are all addicts in every sense of the word” ” addiction is at work in every human being”
He felt addiction was fed by society’s restrictive nature, because the human spirit is “irrepressibly radical” it seeks “the impractical and improper”. Totally agree.
As a former addict, Gerald May’s quote reads like this to me;
“We are all lovers in every sense of the word, love is at work in every human being”
Love, like the human spirit, can be “irrepressibly radical” too.
For example, people that really love Classic music may think its “irrepressibly radical” and perhaps even improper that people love Speed Metal Music for example… and maybe vice-versa too.
The point being, is that the same, ever-present and driving feelings of passion, want, desire, etc, exist, whether referred to as “Love” or “Addiction”.
In Hind-sight, I do not see my Alcohol addiction as a disorder or a disease… I look back and see that it was a deep love for alcohol that was very intense, rigorous, and seemingly unshakable…as Love is well known to be.
Yes, yes so true!!!
Beautifully said!!!
Hi Marc,
Thanks for a thought provocing post. I really see the value in your approach and understanding. For so many years it was the “worldly” accepted approach of the disease concept for me. All the rehabs in the early days preached the disease idea because as you said it was easy to categorize and it prompted the medical industry to get involved. However I never really bought into the idea, something was missing for me in the idea that I have this disease that can’t be cured and can’t be stopped by own choices and decisions. AA got me to a place where I was sober but I was so comfortable in that mess that AA was or is, I was comfortable in the dysfunction of my heroin addiction and now I was comfortable in the dysfunction of AA, I wanted more. Once I was clean for a couple of years I started looking elsewhere for answers…tired of the same old, if you leave AA you will relapse and admittedly when I did decide to walk away from the rooms I was terrified that I was going to use again. I had to risk it though, within a few months I had started realizeling alot more about myself than I had at AA. Firstly as I said before I was so comfortable with all the addicts around me, all of us living in some sort of dysfunctional universe and I felt different and awkward around “normal” people. I started to realise that maybe AA was just a bridge for me to a normal life. I wanted to feel uncomfortable with the fellowships dysfunction and comfortable around normal people. I was shrouded in an addict coat and blabbed about my recovery as some sort of medal of achievement to anyone who would listen probably because it was what my life and recovery were about at that time. Flash forward a couple of years and about 3 years out of the fellowships and I’m still clean and living a life far greater than I thought I could have. I’ve got a family, a good job and a LIFE. My recovery and my life have become one in the same but I’m not only free from addiction I’m also free from the catagorised idea that addiction is x and can only be treated with y. I feel like saying addiction is a disease kills more people than it saves, creating a self fulfilling prophecy of the disease concept. I really do have a choice today. If addiction is a disease than I don’t have it.
Cheers again
I completely identify with this!!! Well said! Kinda wish I had written it myself. 🙂
Shortly out of rehab, I picked up Marc’s books and they were my “gateway” drug to many others, such as Stanton Peele, Patt Denning and Jeannie Little, Kenneth Anderson, and eventually all the way back to the original harm reduction thinkers like Alan Marlatt. I got very involved in Harm Reduction, wrote about it full time, studied it full time, presented at the last Harm Reduction Conference on my MPH thesis work, and co-led an international group of people trying to change their drinking that accepted all goals: moderation, safer drinking or abstinence. I still co-lead that group, and love the people, information and freedom.
Yet I find that I am sick of living in a world of perpetual dysfunction. I’m moving my research more in the direction of mental health in general, particularly trauma, because I think that and poverty (one and the same, often) are where it all starts anyway. And neuroscience, because I love neuroscience, and theoretically we all have brains. I just don’t want to spend all my time talking to people who are living in the problem all the time. I’ve been teaching for work lately, and I find I love teachers, who with all their own issues, are basically able to show up and function. I completely agree with what you say about getting used to being around dysfunction and finding it odd to be around functional people. I recently moved away from a neighborhood and especially an apartment building that was filled with drug dealers, people on a lot of drugs, and kinda fun but kinda not dive bars. I was tired of being afraid that someone drunk and high would set my building on fire by falling asleep smoking and kill my cat (almost happened, many times.) I was sick of sirens all the time and not being able to leave my apartment without being accosted by drunk/high people. I’ve been as drunk as anyone, definitely more so, many a time, but I just don’t want to swim in any sort of sea of dysfunction anymore.
I find that almost all my friends are social workers or clinical psychologists, and I ask them a lot about setting boundaries. It’s one thing to work with people with serious problems – a laudable thing – but learning not to live in or carry those problems around with me has been essential to my mental health.
Of course, everyone has problems. But I’ve decided to surround myself with people who are not content to embody their problems.
Although I was an attendee of 12-step recovery for 20 years, I always fought with the black and white categorization of addiction (and a myriad of other aspects, incidentally) and never considered my problems evidence of a disease. It never felt right, intuitively, and didn’t seem to play out logistically. After I successfully left, pursuing a commitment to trust myself, I eventually dropped any identity of “addict or alcoholic.” Now I’m simply a man who had debilitating addiction issues in his far past. But the experience of just being a “normal” person with all the variations and idiosyncrasies of all the other “normal” humans around me is more liberating than this short post can covey. I am so glad that there are forums such as this where other like-minded folks can stand as support for a person like me, who may have benefitted from old-school addiction ideas on some rough level, but who could never embrace them or feel truly fulfilled through their incorporation. Furthermore, as a man who is not abstinent anymore, I am further reminded that I can travel along the continuum depending on what I am doing to take care of myself, finding healthy ways to regulate myself–I am a flexible ongoing project. And it isn’t just in addiction that there is a continuum, even within folks who have never had any signs of addictive substance-use there is a varying landscape of choice within their alcohol and drug-use. Most people who imbibe make decisions all the time about quantity and regularity, making sure that it remains balanced depending on their definitions and lifestyles. I find this last truth lacking in traditional addiction/recovery discussions. Thanks, Marc, and others for the belonging.
Well said!
Thanks April. “Well said” is a very positive response but falls short in comparison to the “beautiful response” comment you gave Alison. I obviously have work to do.
It’s not you – it’s me! I’m working on a grant application and more of my words and remaining brain cells are going towards it!
I’ll take it. Good luck on your grant.
Hello fellow disease dissenters!
I don’t want to impose but since Dr. Lewis provided a link to my first blog post @ Leslie.law.blog and I have followed up with a second I thought I might provide the link to my latest post for those who might be interested in my deeper analysis/commentary of Dr. Lewis’s work and its relationship to my won experiences. Feel free to follow the blog by signing up for notifications at WordPress.com and also free to comment as I will typically respond to comments within at least 24 hours.
Warmest regards and best wishes for continued development to all!
Leslie Law
Two things: I don’t think it’s helpful to use the word stupid in the title. If you are trying to convince, you’ve started by insulting the people you desire to convince…unless of course you want to preach the crowd and get lots of positive feedback from people who already agree with you.
Two, The DSM V does not call AUD a disease, but rather a disorder. And the language of its descriptors articulates a spectrum: “DSM–5 integrates the two DSM–IV disorders, alcohol abuse and alcohol dependence, into a single disorder
called alcohol use disorder (AUD) with mild, moderate, and severe sub-classifications.”
So the semantic debate is settled, really. I prefer the term syndrome rather than disorder, but since the lives of people who need to stop using are disordered, it makes a kind of grim sense.
What we’re really talking about here is the AA therapeutic model, which is deeply flawed. So why does AA continue to be the most suggested route…by “treatment” centers and courts. Because it’s the only game in most towns. Try to find a Rational Recovery meeting in, let’s say, Enterprise AL.
The challenge now is not continue this BORING semantic debate and exchnage insults as to who’s dumb. The challenge is to create some kind of network so that more people have meaningful, face to face options to AA…so that judges can stop sending people to drug courts with mandatory AA meetings (it’s so f’ed up….as your punishment/therapy I sentence you to something that works for about 5% of the people who try it…good luck!).
This blog is a great start. I own the book and share it with lots of people. But I think the next steps have to be more ambitious. You need AA meetings without the 12 steps basically: support groups where experienced people help new people with PRACTICAL options (hint: no one should ever ever say, “have you prayed about it?” Seriously. At AA when no one knows how to help some poor bastard, that’s what they tell him).
Thanks for your thoughtful remarks, Jim, but no, I don’t think the semantic debate is settled at all. It’s true that the DSM doesn’t use the d-word, but it’s still used overwhelmingly by the rehab industry, in policy and legal quarters, governmental deliberations, the DEA, the NIH (highlighted by NIDA), not to mention various spinoffs of AA, etc., etc. So much so that people often can’t believe I’m challenging the disease label in my talks and articles, especially in the US. They think I’m hitting my head against a brick wall.
More sophisticated thinkers recognize the flaws, both logical and clinical, in using this label, but that’s about it…again in the US. In the UK, disease vs. learning models are pretty much tied as far as I can tell. In Europe and Australia, the disease model is losing ground. But since the US forms the epicentre of disease talk, as endorsed by Big Pharma, the AMA, and the insurance industry, there’s lots of work to do around here.
I’ve pussyfooted around this debate for years, being very polite about my “rebuttal” of the disease concept. I’ve debated Nora Volkow in front of an audience in Amsterdam, politely, I’ve debated George Koob on the radio (CBC Canada), trying to stay polite. And sometimes I just want to lay it on the line. Besides the twisted logic of medicalizing addiction, I feel strongly that it harms people where they live. For a much deeper treatment, see the paper I published three days ago in the New England Journal of Medicine.
Yes, it gets boring. But it’s far from over.
Of course there’s lots more to do. Challenging the dominance of AA, and the logic of court ordering people to attend, is one thing. Creating networks, knowledge, expanding treatment options, promoting harm reduction, shifting public opinion, shifting legalities, are other important ventures. I strongly endorse Maia Szalavitz’s recent article in Filter, and I plan to post part of it soon. Filter, by the way, epitomizes your demand for networking. ProTalk also provides excellent perspectives which offer seeds for networking. See this great recent article by Kenneth Anderson.
We each have different parts to play. My part has been to push against the alive and well disease concept of addiction with as much logic as I can muster, and sometimes to just spit it out.
P.S. I didn’t say “stupid” — I said “dumb” …I was trying to be polite.
Jim, I, too, agree that the debate is far from over. While I don’t care for the DSM and it’s descriptions of psychological disorder (and I say this as an American Mental Health Professional who is expected to embrace it), I am glad that it has developed a more nuanced description of addiction. But as Marc points out, almost everyone in the recovery industry and in almost every media discussion still calls it a disease. I also don’t think it’s simply a semantic discussion since all policy, political and treatment related, is based on the disease paradigm. And the general reaction to challenging the disease theory is profound, as it is deeply embedded into western culture–especially in the United States. I am no less appalled that the general approach to addiction treatment, even by most professionals, is what amounts to joining a powerful subculture that practices faith healing as a means to treat this “disease,” as you point out. But certainly we can’t ‘rely on the DSM for evidence that we have moved beyond the disease model for two important reasons; first, the dominant social narrative has more impact on the addiction discussion than does the DSM. Second, the disease model (and the medical model, in general) is more and more tied to industry and marketplace and will probably always favor approaches that maximize profit and strip the patient of personal power and responsibility as a means to this end. I’d better stop now so that I don’t start to sound like a conspiracy theorist, but I fear that the discussion of disease vs. anything else is far from over.
Hi Eric. Thanks for these important refinements to the points I was trying to make. Both of the factors you mention, the dominant social narrative and the ties to industry and profit, are critically important. The fact that the dominant social narrative is increasingly SHAPED BY commercial interests (I guess it always has been, but somehow it seems more insidious with the glitzy and immersive quality of digital media) is what I find most distressing. It becomes increasingly difficult for normal people to rely on common sense or word-of-mouth experience to make distinctions between competing messages.
I take hope from the fact that, despite these intertwined forces, many people affected by addiction are still waking up to realities, talking to each other, and gaining some perspective. When I peruse rehab websites and so forth, I notice that increasing numbers are saying up front that they DON’T construe addiction as a disease. So the counter-disease message is perhaps growing even in the commercial sector. And, not to be too cynical, there are still a lot of good people in the treatment world who really do want to help.
Marc, there is, undoubtedly, a paradigm shift happening right now. There seems to be a movement away from the old dominant narrative (abstinence only/12-step philosophy) and a movement toward other modalities (MAT, secular groups, mindfulness). I have accidentally discovered a strange therapeutic niche in my practice where I offer services to recovering peoples who have been involved in 12-step groups often for years or decades, who find themselves wanting to safely extricate themselves. While certainly I neither initiate this discussion, nor disregard 12-step involvement as one possibly effective method (as you know from pervious discussions), I do see it as evidence of a paradigm shift and an evolving understanding of addiction. I am so grateful for the voices that are supporting this shift, yours being one of the important ones, of course. And yes, the marriage of profit and medical understanding is long-standing and will continue to have great influence on the addiction discussion so long as we prioritize markets over people, fundamentally (this is increasing instead of decreasing). More and more, especially here in the US, the people are becoming merely consumers in the machine of corporate profit. It’s very sad.
It is sad. And to lift my own spirits, I try to keep in mind all the good things that are emerging with the cultural changes linked to advances in technology. People can so easily connect with each other, across great distances, despite being stuck geographically or worse. The existence of online guided meditations — there must be thousands of teachers now connecting with meditators online — is such a beautiful expression of people’s needs to connect and care. Young people still seem more or less agnostic about the political upheavals so upsetting to their elders. And…life goes on. Legislation is changing. Drugs are being decriminalized and even legalized from one jurisdiction to the next. Here in the US (I happen to be visiting right now) it’s particularly easy to become cynical. The US is going through difficult and dangerous times politically and socially. But things look brighter from outside your borders!
Interesting to hear of your clients trying to reduce the harm of AA withdrawal. The irony is magnificent.
well Marc, good to know it’s brighter outside our borders! That does calm my fears that change is happening somewhere. What’s frustrating to me is that the American dream is an addiction that continues to remain unrecognized and can be very destructive…..and meanwhile, we keep stigmatizing the “illegal drug users” for their addictions…..
yes, and it’s frustrating that probation officers and drug court make people get signatures that they went to mandatory AA/NA meetings!!!! ugh, very fed up with that!
And I agree we need AA meetings without the 12 steps. We need more community period! Places to feel accepted and break down stigmas.
This blog keeps me sane!….after a day of dealing with rehabs and outpatients that dictate tx and throw a bunch of fear at people under the “tough love” approach, I’ve often lost my mind!
And….if I cant pay the heating bill and I’m gonna lose my apartment, so many people say go to an AA meeting. Ok and that helps how?
Thats why i started my community foundation, (a fund to help people when they need it, no strings attached). When you’re helpless, you’re helpless and no AA meeting is going to pay your heating bill!
It’s good that sane, rational, and civil discussion on such a bedeviling topic exists. Love reading all of it.
Hello Marc. I want to congratulate you for your work. It is a milestone in addiction studies and I feel lucky to have been able to find and understand your work. I would like to know if it is possible to have your email. I want to share with you some information about the horror that the 12 step movement has become in my country. Your findings can save many lives. I wrote my email in the form below. Have a wonderful day. And thank you for your hard work and persistence.
Hi Mark I have just come across your article and I have to say that im glad that you share my views regarding the disease model. I am currently in recovery in the UK. I got out of prison in December after serving two years of a four year sentence for robbery, during which I did nothing but read read read, from psychology to ancient philosophy, just trying to find answers. I learnt a hell of a lot about myself and so when I got out I decided to move to a recovery house and carry on working on my recovery. One of the requirements of this recovery house is to go to narcotic anonymous, I went for a few weeks but could not get my head around how it helps to tell somebody who is suffering that they have an incurable disease? It went against everything I had learnt and realised in my time in prison. The biggest issues I have with the disease concept is that you are giving people the chance to be a victim indefinitely, taking away any and all responsibility from them which not only leaves them wide open for excuses to relapse but also leaving them dependent which is good for nobody especially not somebody who needs to find independence more than most. My argument is this, addiction can affect anybody at any time, every human being is wired from years of evolution to pursue pleasure and avoid pain, this is a primal instinct one which has enabled us to survive, now we pursue pleasure and avoid pain for the most part automatically, through our subconscious, people who have subjected there subconscious to extreme highs either through alcohol or drugs for a period of time will automatically get urges to use to find that high again, this is not because they have an incurable disease but because our pleasure seeking/ pain avoiding part of our subconcious is simply doing it’s job. Recognising the fact that this part of our subconscious minds sole purpose is to make us feel better and has no notion of consequences, we will understand what addiction really is and then it makes it easier not to act on those urges. I could carry on and on Mark, please leave me some feedback or if you would like to discuss anything further I will send you my email address thanks, billy