A psychologist and former addict insists that the illness model for addiction is wrong, and dangerously so.
The mystery of addiction — what it is, what causes it and how to end it — threads through most of our lives. Experts estimate that one in 10 Americans is dependent on alcohol and other drugs, and if we concede that behaviours like gambling, overeating and playing video games can be addictive in similar ways, it’s likely that everyone has a relative or friend who’s hooked on some form of fun to a destructive degree. But what exactly is wrong with them? For several decades now, it’s been a commonplace to say that addicts have a disease. However, the very same scientists who once seemed to back up that claim have begun tearing it down.
Once, addictions were viewed as failures of character and morals, and society responded to drunks and junkies with shaming, scolding and calls for more “will power.” This proved spectacularly ineffective, although, truth be told, most addicts do quit without any form of treatment. Nevertheless, many do not, and in the mid-20th century, the recovery movement, centered around the 12-Step method developed by the founders of Alcoholics Anonymous, became a godsend for those unable to quit drinking or drugging on their own. The approach spread to so-called “behavioural addictions,” like gambling or sex, activities that don’t even involve the ingestion of any kind of mind-altering substance.
Much of the potency of AA comes from its acknowledgement that willpower isn’t enough to beat this devil and that blame, rather than whipping the blamed person into shape, is counterproductive. The first Step requires admitting one’s helplessness in the face of addiction, taking recovery out of the arena of simple self-control and into a realm of transcendence. We’re powerless over the addictive substance, and trust in a Higher Power, and the programme itself, to provide us with the strength and strategy to quit. But an important principle of the 12 Steps is that addiction is chronic and likely congenital; you can be sober indefinitely, but you will never be cured. You will always remain an addict, even if you never use again.
The flourishing of the 12-Step movement is one of the reasons why we now routinely describe addiction as a “disease.” To have a disease — instead of, say, a dangerous habit — is to be powerless to do anything except apply the prescribed cure. A person with a disease is unfortunate, rather than foolish or weak or degenerate. Something innate in your body, particularly in your brain, has made you exceptionally susceptible to getting hooked. You always have and always will contain a bomb; the important question is how to avoid setting a match to it. Another factor promoting the disease model is that it has ushered addiction under the aegis of the healthcare industry, whether in the form of an illness whose treatment can be charged to an insurance company or as the focus of profit-making rehab centres.
This conception of addiction as a biological phenomenon seemed to be endorsed over the past 20 years as new technologies have allowed neuroscientists to measure the human brain and its activities in ever more telling detail. Sure enough, the brains of addicts are physically different — sometimes strikingly so — from the brains of average people. But neuroscience giveth and now neuroscience taketh away. The recovery movement and rehab industry (two separate things, although the latter often employs the techniques of the former) have always had their critics, but lately some of the most vocal have been the neuroscientists whose findings once lent them credibility.
One of those neuroscientists is Marc Lewis, a psychologist and former addict himself, also the author of a new book “The Biology of Desire: Why Addiction is Not a Disease.” Lewis’s argument is actually fairly simple: The disease theory, and the science sometimes used to support it, fail to take into account the plasticity of the human brain. Of course, “the brain changes with addiction,” he writes. “But the way it changes has to do with learning and development — not disease.” All significant and repeated experiences change the brain; adaptability and habit are the brain’s secret weapons. The changes wrought by addiction are not, however, permanent, and while they are dangerous, they’re not abnormal. Through a combination of a difficult emotional history, bad luck and the ordinary operations of the brain itself, an addict is someone whose brain has been transformed, but also someone who can be pushed further along the road toward healthy development. (Lewis doesn’t like the term “recovery” because it implies a return to the addict’s state before the addiction took hold.)X
“The Biology of Desire” is grouped around several case studies, each one illustrating a unique path to dependency. A striving Australian entrepreneur becomes caught up in the “clarity, power and potential” he feels after smoking meth, along with his ability to work long hours while on the drug. A social worker who behaves selflessly in her job and marriage constructs a defiant, selfish, secret life around stealing and swallowing prescription opiates. A shy Irishman who started drinking as a way to relax in social situations slowly comes to see social situations as an occasion to drink and then drinking as a reason to hole up in his apartment for days on end.
Each of these people, Lewis argues, had a particular “emotional wound” the substance helped them handle, but once they started using it, the habit itself eventually became self-perpetuating and in most cases ultimately served to deepen the wound. Each case study focuses on a different part of the brain involved in addiction and illustrates how the function of each part — desire, emotion, impulse, automatic behaviour — becomes shackled to a single goal: consuming the addictive substance. The brain is built to learn and change, Lewis points out, but it’s also built to form pathways for repetitive behaviours, everything from brushing your teeth to stomping on the brake pedal, so that you don’t have to think about everything you do consciously. The brain is self-organizing. Those are all good properties, but addiction shanghais them for a bad cause.
As Lewis sees it, addiction really is habit; we just don’t appreciate how deeply habit can be engraved on the brain itself. “Repeated (motivating) experience” — i.e., the sensation of having one’s worries wafted away by the bliss of heroin — “produce brain changes that define future experiences… So getting drunk a lot will sculpt the synapses that determine future drinking patterns.” More and more experiences and activities get looped into the addiction experience and trigger cravings and expectations like the bells that made Pavlov’s dogs salivate, from the walk home past a favorite bar to the rituals of shooting up. The world becomes a host of signs all pointing you in the same direction and activating powerful unconscious urges to follow them. At a certain point, the addictive behavior becomes compulsive, seemingly as irresistibly automatic as a reflex. You may not even want the drug anymore, but you’ve forgotten how to do anything else besides seek it out and take it.
Yet all of the addicts Lewis interviewed for “The Biology of Desire” are sober now, some through tried-and-true 12-Step programs, others through self-designed regimens, like the heroin addict who taught herself how to meditate in prison. Perhaps it’s no surprise that a psychologist would argue for some form of talk therapy addressing the underlying emotional motivations for turning to drugs. But Lewis is far from the only expert to voice this opinion, or to recommend cognitive behavioral therapy as a way to reshape the brain and redirect its systems into less self-destructive patterns.
Without a doubt, AA and similar programs have helped a lot of people. But they’ve also failed others. One size does not fit all, and there’s a growing body of evidence that empowering addicts, rather than insisting that they embrace their powerlessness and the impossibility of ever fully shedding their addiction, can be a road to health as well. If addiction is a form of learning gone tragically wrong, it is also possible that it can be unlearned, that the brain’s native changeability can be set back on track. “Addicts aren’t diseased,” Lewis writes, “and they don’t need medical intervention in order to change their lives. What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place — while they reach toward it.”