Junkies and victims: addiction and the disease debate

Slate has an article by a psychologist and a psychiatrist who argue that addiction is not a ‘brain disease’, contrary to much of the recent rhetoric about drug abuse. This is one side of the debate that is driving our attempts to understand addiction.

The ‘brain disease’ concept (also known as the ‘disease model’) is one that is often thrown around in debates about mental distress or behavioural problems, but it is far from the neutral, scientific term that many of its supporters might believe.

In a sense, every problem of mind and behaviour is a ‘brain disease’, because we’ve identified it as a problem and it involves the brain, as does everything else related to thought or action.

However, a comprehensive explanation requires not only neuroscience, but also psychology and social factors to make it complete and meaningful.

Calling a mental problem a ‘brain disease’ often implies that these other factors aren’t important, and, most tellingly, suggests that the person isn’t responsible for the effects of the disorder, and, consequently, their actions.

The level of personal influence varies by condition, but, importantly, psychologists now know that the effects of all illnesses, from Alzheimer’s disease to the common cold, can be influenced by how we understand them and what we believe about our own ability to influence the effects.

There is no doubt that genetics and the development of nervous system significantly influence the risk of becoming an addict, but addiction, perhaps more than many other disorders, is amenable to personal choice, albeit to varying degrees at various stages of its course.

Theodore Dalrymple (the pen name of psychiatrist Anthony Daniels) noted in The Wall Street Journal that many people are quite able to choose to give up their addiction when sufficiently motivated and argues, in his usual provocative style, against the excess medicalisation of substance abuse:

It is not true either that addicts cannot give up without the help of an apparatus of medical and paramedical care. Thousands of American servicemen returning from Vietnam, where they had addicted themselves to heroin, gave up on their return home without any assistance whatsoever. And in China, millions of Chinese addicts gave up with only minimal help: Mao Tse-Tung’s credible offer to shoot them if they did not. There is thus no question that Mao was the greatest drug-addiction therapist in history.

However, we shouldn’t forget that there is now a large body of evidence highlighting the importance of inheriting a vulnerability to become addicted, and the most addictive drugs tend to modify exactly the bits of the brain that are involved in desire and wanting, making them less amenable to ‘will power’.

This research was recently highlighted by a Time magazine article on the neurobiology of addiction and Dr Nora Volkow’s recent radio interview on the drugs and the brain.

Both spin the ‘brain disease’ angle, and many argue that this reduces stigma. The trouble is, research has found that purely biological explanations of mental problems tend encourage stigma in the public, patients and mental health professionals.

One of the key findings of these studies is that purely biological explanations of mental disorders imply that people are less in control of their actions.

Psychological therapies are known to be effective treatments for drug addiction and one of the key components is to boost the patients ‘self-efficacy’ – that is, their belief that they can take control of their life.

We know that self-efficacy, essentially a scientific term for a sense of personal responsibility and control, is one of the most important predictors of recovery from addiction.

Genetic research has shown us that some people, through no fault of their own, have inherited an increased risk for addiction. Neurobiology has shown us that drug use modifies the brain to make resisting temptation harder.

Nevertheless, describing addiction as purely a ‘brain disease’ is neither useful nor meaningful, and may actually reduce the likelihood that someone will overcome their difficulties.

We need to understand addiction as a problem of mind, brain and society, and make sure everyone knows they play an important role in overcoming problem drug use, whether it occurs in each of us individually, or in the neighbourhood that we live in.

Anti ‘disease model’:
Link to Slate article on addiction.
Link to Theodore Dalrymple article in WSJ.

Pro ‘disease model’:
Link to Time article ‘The neurobiology of addiction’.
Link to Dr Nora Volkow radio interview

2 Comments

  1. popkes
    Posted July 27, 2007 at 7:37 pm | Permalink

    This is interesting information. However, referring to addicts as a single homogenous group or addiction as a single homogenous condition has significant problems.
    The brain has every bit as much variation as any other organ and we should expect a wide range of responses to addictive drugs just like we would expect people to have a wide range of responses to exercise, having children or learning how to ride a bicycle.
    Some addicts have more ability to kick the habit than others. Some have more freedom of choice than others. The drug has more effect on some addicts than others. To say “addiction, perhaps more than many other disorders, is amenable to personal choice” is likely true for some subset of the population of addicts and just as likely untrue for some other subset. This fact should be acknowledged and brought into the conversation. Any “one size fits all” policy for addiction will fail just like a “one size fits all” approach would fail for any other medical condition.

  2. Doctor X
    Posted July 27, 2007 at 8:04 pm | Permalink

    An interesting discussion (including popkes’ comment). What is important is that the debate is often framed around the question of whether “addiction” is or is not ‚Äúa disease.‚Äù That is the wrong framework.
    We should be investigating addictions as complex, non-discrete phenomena varying from person-to-person. The idea of treating the viewing of pornography, over-spending, gambling, heroin addiction, alcohol addiction, meth addiction, overeating and even so-called “love addiction” as a single ‚Äúdisease‚Äù with different surface manifestations has largely been driven by the self-help movement and a treatment industry that has grown up around this movement. An extraordinary number of addicts from these programs have gone on to earn ‚Äúcounseling‚Äù credentials and they have had excessive influence on conceptualization and treatment paradigms. Within the self-help movement and the treatment industry, there has been a strong tendency to ignore both the findings of researchers and legitimate challenges to simplistic, faulty conceptualizations.


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