By Steve K.
As someone who’s in long-term recovery from alcohol and drug dependency I’ve often reflected upon the various causal factors associated with addiction and what these suggest in terms of successful recovery. There seems to be many diverse opinions, often polarising voices, in relation to the causes, nature and treatment of addiction.
There are those that focus upon research into the neurobiology of addiction and consider it to be a “brain disease”. This approach is often associated with genetic inheritance in relation to biology (metabolism) and character traits (personality type). While there is ‘no single specifically identified genetic factor in relation to alcohol and drug addiction, it’s generally accepted within mainstream science that about 50% of the risk is carried genetically’ (1). Addiction is often a familial trait. Scientific research in this area has increasingly promoted the development and use of medications in the treatment of addiction.
Then there are those that focus primarily upon the developmental (e.g., insecure attachment, trauma and maladaptive learning) and environmental (social conditioning, circumstances, peer group etc) aspects of the disorder, who favour behavioural learning psychology in relation to understanding its causes and psychosocial interventions in relation to its treatment.
These opposing viewpoints can be thought of as pro and anti “disease concepts”, although there are a range of views within each category and many that offer a combination of the above perspectives. The result of all this diversity in the field of addiction is often confusion and strongly held dogmatic beliefs.
In the vein of a combination of the above perspectives is the voice of Gabor Mate. This Canadian doctor and author suggests that all addictions are the result of childhood trauma and attachment problems (2), and that these developmental experiences then create deficiencies within the individual’s brain structure and chemistry. As a consequence Mate views addiction as an attempt to correct the resulting brain disorder.
Psychologist Stanton Peel, who’s a strong critic of the disease-concept, argues that Mate’s viewpoint is reductionist and points to research that suggests not all traumatized children becomes addicts. (3) This maybe the case but the same research (ACE study) also suggests that childhood abuse and neglect greatly increases an individual’s vulnerability to addiction and various other illnesses and behavioural disorders. Peel seems to play down this influential research study conducted by Vincent Felitti into Adverse Childhood Experiences (ACEs). The study found that:
“Adverse childhood experiences have a dose–response relationship with many health problems. As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioural problems throughout their lifespan, including substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring….. The ACE study’s results suggest that maltreatment and household dysfunction in childhood contribute to [the probability of ] health problems decades later.” (4)
Other voices offering a similar perspective to Mate’s include science and addiction journalist Maia Szalavitz (Unbroken Brain) and neuroscientist and developmental psychologist Marc Lewis (The Biology of Desire). Although they are both strongly against the concept of addiction being a “disease”, they integrate the neuroscience of addiction and the role of epigenetics in relation to how genes are expressed. They both contend that addictions are behavioural adaptions and therefore can be unlearnt.
No doubt these two commentators in the field of addiction have been influenced by the contentious voice of Stanton Peele who’s been writing about addiction from a behavioural and environmental point of view since the early 1970’s. Peel’s book ‘Love and Addiction’ greatly influenced the idea of behavioural addictions outside that of substance misuse. He’s been a strong voice against the “disease model” of addiction and has promoted the idea of ‘natural recovery’ – a pathway to recovery which modern research suggests is common for the majority of those that experience alcohol and other drug dependency. Although this is true it’s important to note that this research applies to all who experience addiction at whatever level of dependency; the majority of which will no doubt be at the least severe end of the spectrum. Those with severe, chronic and complex histories of addiction are much more likely to require professional treatment and/or mutual aid group participation and support according to the highly regarded addiction researcher William L White:
“People often note my reference to resolution of alcohol and other drug problems without professional treatment or recovery mutual aid involvement, but they often fail to mention (because it doesn’t support their argument) the tandem conclusion that the probability of this sharply declines as problem severity, complexity, and chronicity increases—this is the major difference between follow-up studies of community samples and follow-up studies of clinical samples.”
Bill White. November 6th 2015.
The behavioural learning model of addiction leads some to claim that alcohol and drug dependency is purely a consequence of choice. This viewpoint has been advocated by academics Gene Heyman (Addiction: A Disorder of Choice) and Jeffery Schaler (Addiction is a Choice) and adopted by organisations such as ‘Rational Recovery’ (Founder, Jack Trimpey) in the US and ‘Intuitive Recovery’ (Founder, Peter Bentley) in the UK.
Simply put the ‘choice model’ suggests that people make decisions about payoffs and pleasure, particularly in the short term, and the decision to use alcohol or other drugs is often most attractive at the time and in the circumstances. It’s a view that’s given to explain people’s decision to stop using when the consequences of doing so become too unpleasant, or when their circumstances change.
The choice model of addiction is against the medicalization of the disorder and advocates often strongly criticise the disease-concept and by association the 12-Step approach to recovery from addiction. In my opinion, as someone who’s suffered the compulsive nature of addiction, the choice model is too simplistic and ignores the neurobiology of addiction and other predisposing influences upon choice. There seems to be two viewpoints where the ‘choice model’ is concerned, one that focuses upon the role of cognition in choosing whether to drink or use drugs, and the other that considers the influence of environment and economic circumstances. An example of the latter being the “Rat Park” experiment and the role of social isolation and austere surroundings in relation to choice.
Critics of the choice model contend that it encourages an attitude of moral judgement towards those with addictions, and is a return to the concept of moral failure of character prevalent in the past (moral model). Stigma, they suggest, prevents persons’ suffering with addiction seeking access to help and support. To the contrary, some choice model advocates consider that the social stigma of addiction is an incentive in the decision to change self-destructive behaviour. Perspectives on the nature of choice are complex and not all who consider choice a facet of addiction view it as a moral failing; although some do. (e.g., Jeffery Schaler Ph.D.)
The ‘medical model’ supports the view that while there is clearly some capacity for choice even when severely addicted, this capacity is diminished to varying degrees by a complex mix of biopsychosocial factors. This perspective gained prominence in the mid-20th century and it is argued by disease model advocates that it has helped to reduce the stigma and shame associated with addiction. However, choice model advocates and others often contend that the idea of a ‘disease’ actually increases stigma.
The ‘disease concept’ advocated by mainstream medicine views addiction in the following way:
“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to harmful behaviours seen in people who abuse drugs. The disease of addiction affects both brain and behaviour, and scientists have identified many of the biological and environmental factors that contribute to the development and progression of the disease.”
Recognizing Addiction as a Disease Act 2007
The medical model isn’t purely reductionist in its view of addiction and does consider the role of choice and the relationship of the addict’s neurobiology with developmental and environmental influencing factors. This quote by Dr Nora Volkow demonstrates these considerations:
“The non-inevitability of addiction is a point frequently emphasized by people challenging the brain disease model, with the faulty reasoning that it cannot be a disease because the condition is initiated by a decision to take a drug, which is viewed as a voluntary behaviour, and also because most individuals never escalate their drug taking. However, this is no different from many other diseases that also have complex genetic, environmental, and developmental origins, may be triggered by voluntary behaviours or their omission, and may only affect a small subset of those at risk.
I often compare drug addiction to another chronic, relapsing disease, diabetes. In diabetes, the pancreas is not able to make the insulin necessary for our cells to use glucose as fuel. No one thinks that, with sufficient willpower, a person with this condition could push through without medication. Their disease, even if it had behavioural antecedents and may have involved free choices in a person’s past — such as decisions about food or exercise — has a physical basis and requires medical management once it has developed.”
Advances In Addiction and Recovery. P17. Vol.3, No.3, 2015
Multiple Pathways to Addiction and Recovery
I see truth in all of the above pathways to addiction and would suggest that there is a complex interplay between them, and that this interaction is unique to each person who develops an alcohol or other drug problem. I think that an over emphasis upon any one particular pathway is reductionist and not helpful, and that a holistic approach to treatment and recovery that’s tailored towards the individual is best. Despite the above controversy there’s a growing consensus in the US and UK, led by addiction research experts like William L White, that there are multiple pathways to addiction and recovery; as well as styles or types.
I personally think that the degree of alcohol or drug dependence is important in terms of language used, how it is considered, and the treatment or interventions offered. The DSM-5 uses the terms “alcohol use disorder” and “substance use disorder” in an attempt to represent the wide spectrum of alcohol and other drug problems; which can range from mild to moderate to severe. I think that once an alcohol or drug problem has developed into a severe and chronic addiction, it can be appropriate to use the language of illness or disease; certainly as a metaphor (even if not technically true) in order to convey the serious and corrupting nature of the condition. In the earlier stages of misuse though the terms behavioural problem or disorder are probably more fitting.
The different pathways to addiction and there often complex interaction with each other, as well as co-occurring difficulties, lead to a large diversity in terms of type, degree and nature of alcohol and other drug problems. This reality indicates that a diversity of options for treatment and recovery from addiction are surely warranted in the pluralistic societies of the 21st century.
Note: The above essay is a revised and companion article to a post written by myself in 2015, titled, ‘Is Addiction A Disease?
‘Genetics: No More Addictive personality‘, by Maia Szalavitz, Nature, 24/06/2015.
‘In The Realm of Hungry Ghosts‘, by Gabor Mate.
‘The Seductive (But Dangerous) Allure of Gabor Mate‘, by Stanton Peele Ph.D.
‘Unbroken Brain‘, by Maia Szalavitz.
‘Addiction As A Disease: The Birth Of A Concept‘, by William L White. (A series of papers on the history and future of the disease concept of addiction)
‘Recovery Rising‘, by William L White.