The disease model of addiction is the dominant model of addiction. When I first heard alcoholism was a disease many years ago, I thought two things at once. First, I thought, “Oh wow, that explains it.” Then I thought, “Wait a minute, how do you catch alcoholism?”
Disease usually refers to medical conditions of the body, such as diabetes, the flu, or Alzheimers. These diseases have biomarkers, which are testable signs linked to anatomy, physiology, and biochemistry. Insulin supplement helps treat diabetes; fever and muscle ache indicate a flu along with a confirmatory RT-PCR test, perhaps; and Alzheimers is detectable by clinical interviewing for memory loss and helped by an MRI to rule out other causes, such as ordinary brain cell loss from age.
Addiction, however, seems to involve choice. Disease does not so clearly involve choice. Or does it?
Elements of Choice in Disease
Is addiction a disease like those listed above? There may be overlap when it comes to choice. For example, someone may be addicted to food and develop metabolic syndrome that results in Type II diabetes, the adult-onset kind controllable by diet. With the food addiction (involving the repeated choice of excessive consumption) under control, the disease we call diabetes may remit. But one does not really choose diabetes any more than one chooses hair color. Our human experience of disease seems to involve a real lack of choice.
Addiction, like the effects of some kinds of trauma, seem to be automatic in a sense, or “unchosen.” An exaggerated startle response, for example, is a symptom a trauma victim does not choose. Addiction also often seems to involve unchosen symptoms. Addiction seems to be an attempt to meet deep, unmet needs linked to deep pain. This gives addiction the character traits of impulses, intruding thoughts and desires, and compulsions. It feels like there is no control (or, no choice) over the desire and behavior to do whatever it takes to meet the need, to satisfy the desire that promises some kind of satisfaction, acceptance of self, or normality.
There are aspects that seem not to involve choice. Perhaps addiction is a disease after all. Or is it?
Addiction and Choice
Unlike other diseases, addiction indeed inevitably seems to involve choices. Other diseases do not so clearly involve choices. In the diabetes example above, metabolic syndrome was a consequence of the addiction, not the addiction itself. The addiction came before and was distinct from the disease in the form of choice, the choice to repeatedly consume excess quantities of food that becomes toxic over time (and specific types of food, such as sugars). Metabolic effects were secondary and consequences of behavior. In a deeper analysis, they are the physical signs of the soul’s non-physical actions.
Let’s take another example as we examine choice and disease. The flu involves choices in a secondary way. A mother may choose to treat her sick child who stays home from school and so contract the virus from him. But the flu itself is a “bug,” an observable organism, and not a direct result of choices. Nor does the flu virus have the nature of human choice, unlike addictive behavior. In fact, one may make virtuous choices and still contract an illness, such as a woman philanthropically treating victims of a deadly, highly-contagious virus and then dying of it herself.
In these examples, human choice and action appears to be different and distinct from a disease.
But, of course, choice alone does not define addiction. We must not swing the pendulum too far and simplistically reduce addiction to simple moral failure. Addiction is clearly much more than a moral issue, although not less. And we cannot forget that.
Avoiding Pendulum Swing and Shame
Just as a reductionist moralizing model does not explain addiction on one side, neither does the disease model seem to explain the human experience of addiction on the other side, which involves choices.
Addiction seems different than a reductionist disease-model allows. In an addiction, I choose to give into desire that I may personally find immoral, disgusting, or destructive of my relationships. Nevertheless, I choose, I give in, it is I who act and none other. Indeed, friends and family may actively try to inhibit my addictive behavior (behavior is human action based on decisions, however impaired). And yet, despite interventions, I find creative and secretive ways to act out, to behave, to choose.
Now, many in the mental health and medical establishment are worried that what I am saying here will induce shame, a version of the moralizing reductionist approach. That is, they are rightly concerned that the addict might feel shamed for their involvement of choice in their addiction.
Of course, I am not intending to shame anyone. Shame is often a gigantic part of addiction, a driver of addiction and an amplifier of pain. Shame is an intense, negative experience for the addict. Shame, therefore, is viewed as the arch-nemesis that must be destroyed at all costs in addiction treatment and recovery. Like hydrogen gas to an open flame, many professionals are highly reactive to even the suggestion that moral choice is involved in addiction.
So, to reduce such toxic shame, many professionals swing in the complete opposite direction. In this approach, therapists reassure addicts they have no control whatsoever over their addiction. Addiction is seen as a complete master, a tyrant. What is more, addiction is a disease, something that has happened to the addict. The addict is a victim. A hospital patient. The target of a terrorist disease, named Addiction. The victim must become a survivor, which is to say, get into recovery. And since their addiction involves zero control and chronic disease, recovery is life long. “I am an addict” is the label one must carry forever due to the nature of their illness.
Of course, these steps perhaps reduces shame for some. And many find comfort and sobriety in a hard identification as an (life-long) Addict. This approach certainly removes the planks of choice and morality from addiction, which may salve the conscience for some.
But does this really reduce shame?
Two Ways of Shame
For some, toxic shame is indeed evaded by identifying as “an addict.” They are not at fault for the addiction, and this eases their pain and guilt. Despite even 20 years of unbroken sobriety, one may still identify as an addict, a key identity marker that ostensibly empowers sobriety. The disease model of addiction, tied into the shame-reduction model, seems to address a type of toxic shame for some. These addicts are helped by this view. If shame-reduction is measured by the psychological comfort provided by this point of view, then perhaps it really does reduce shame.
Others, however, do not experience the benefits of this comfort. I worry that the shame-reducing-by-comfort-inducing model is too fragile to handle the hard realities of choice and consequences.
Some are crushed by the prospect of never getting away from a tyrannical disease. They experience the attempted reduction of shame as a power-sucking reduction of choice, which introduces its own shame, the shame of impotence, powerlessness, and helplessness. Far from experiencing freedom and power to recover, their plight becomes certain doom. There is no recovery, in fact. Not really. “Recovery in name only.” Despair creeps into the cracks of the recovery process. They relapse time and again as a result. “What’s the point? I can’t help myself. And now the unending anxiety of never fully recovering adds to the temptations to act out and relieve the stress. And why not? I am an addict.”
Conclusion
So, is addiction a disease? Some say yes. I will ask you this: What do you want it to be? Do you want to identify with your addiction the rest of your life? Do you want your “I am” statement, which is a hard label of your very being, to transform you into a forever-victim? Or do you have a more-real core belief of hope that you can be released from this devil, that you can choose to be without it one day? That your “I am” statement could rather be “I am healed. I am a victor.”