Addiction is not a disease
Treating addiction as a mental disorder helps no one
17th March 2023
Rudolph Lambert Fernandez
Health professionals and campaigners now define addiction as a mental disorder. But treating addicts as victims of their biology, and offering only medical solutions, denies them the agency that could lead to recovery.
According to Mental Health America (MHA):
Current definitions of addiction generally refer only to drugs and alcohol. But more and more mental health professionals are recognizing that anything that stimulates the reward pathways in the brain can be addictive. These “behavioural addictions” might include sex, gambling, food, and even spending too much time on the Internet. Whatever the behavior, the pattern is the same: you can’t seem to stop on your own, the behavior interferes with your life and relationships, and you lose your awareness of the negative consequences.
This describes what addiction as a ‘habit’ does: it is debilitating and destructive. But for those looking to change their behaviour, problems arise when society argues that addiction is purely pathological and offers solutions only in the realm of biology and science.
On February 6, 2023, MHA glibly tweeted:
Let’s be clear: people who struggle with #addiction are not “selfish” or “bad.” Addiction is a disorder of the brain. It’s a medical condition, just like heart disease or diabetes, and a #mentalhealth condition. 🧠
— Mental Health America (@MentalHealthAm) February 6, 2023
Talk of ‘tests’ suggests it is possible to find and report propensity to addiction in the same way a urine test reports blood-sugar levels.
The NHS takes a similar approach, calling addiction a ‘cruel illness’. With the Princess of Wales and Parliamentarians joining in, medicine and science are not alone in calling for more ‘compassion’, not just towards substance-addicts but towards gamblers and social-media addicts too.
But what do we really need more of: compassion or clarity? If earlier definitions of addiction were alarming enough, newer ones sabotage common-sense beliefs that humans can – and must – temper freedom with responsibility.
If the US and UK are representative of global approaches to stimulants abuse, then long-standing ‘disease’ models of addiction are clearly failing. Europe, which accounts for nearly half the world’s online gambling market, powers that market’s 12% compound annual growth rate. America is catching up. The FBI believes that those addicted to killing suffer from personality disorders, ‘including psychopathy, antisocial personality disorder … Most, however, are not adjudicated as insane under the law.’ Thankfully, the state still holds serial-killers, not their brains, responsible. Experts studying those addicted to sex offences intone what many believe to be true: reported rates are a fraction of real rates. These experts advise law enforcement to treat sex offenders as serial rather than isolated offenders. This vindicates common sense: impunity incentivizes pleasurable crime. Some behaviours are crimes in several countries, not misdemeanours. If you get away with it once, that is one less reason to stop. If you get away with it twice… You get the point.
First, some qualifiers. If you have self-medicated long enough, ignorant about possible dependence, or out of deference to medical/parental authority, or you have been bullied or tricked (perhaps had your drinks spiked) that is not your fault. On the other hand, if you have knowingly and repeatedly spent time, money, and effort to hard-wire dependence, then it is your fault. Addiction is not like lightning, striking arbitrarily the way a rare condition, say, Field’s Disease does. You are in charge of your actions, until you decide that you are not. Few addictions are instantaneous or once-and-for-all, most start with a first occasion, then a second, before habit kicks in; the whole point of marketing is to guarantee repeat use.
The Baldwin Research Institute (BRI) has studied addiction for 30 years. BRI’s team comprising Michelle Dunbar and Steven Slate (both former addicts) along with Mark Scheeren, in their book The Freedom Model for Addictions, explain that addiction is voluntary behaviour. They argue that purely clinical approaches to treatment undermine self-determination, raising rather than reducing dependence. Slate says treatment isn’t curing addicts, it’s creating them. Similarly, Dr. Stanton Peele, an addiction expert, and Zach Rhoads, a consultant for families and children, in their book Outgrowing Addiction, show that the ‘disease’ model makes recovery harder, never complete, and rarely sustainable.
Culture, not biology or science, is the crux of addiction: a culture of believing and behaving. Societies must weigh individual freedoms against collective responsibilities, private choices against public goods, such as health, happiness and life. If you irresponsibly refuse to wear a seatbelt or helmet, doctors will still treat you after an accident, but they know who is at fault. Health insurance disavows reckless endangerment; ignorance is no excuse. Legal-judicial systems protect others you have endangered and punish you, who ought to know better. So it is misleading to make addiction an immediately and exclusively medical issue.
Even in cases where the health of individuals or families is harmed by malafide or negligent others (industrial polluters, doctors guilty of malpractice), states fix responsibility, and often punish. When the individual himself is responsible for endangering his health, it is not too different. Health insurance disavows chain-smokers contracting lung disease or those contracting a sexually transmitted infection from casual or unprotected sex. If addiction is pathological, should not insurance ‘protect’ us and our children, as it does against blood or bone cancer?
Neuroscientist (and former addict) Marc Lewis, in his books Memoirs of an Addicted Brain and The Biology of Desire illustrates why calling addiction a disease is not only inaccurate, but dangerous. Even a critique of his work suggests that getting hung up on etymology, exceptions and definitions is counterproductive. The brain is not always telling us what behaviour is telling us. Usually, ‘free will’ and ‘autonomy’ remain intact. Usually, addicts need reminding of their agency, but not always intervention that presupposes a medical condition. Some scientists are revising entrenched views but not without a fight.
If substance addiction is a mental disorder, several conclusions follow: the addict is a victim, blameless for harm caused, and needs rehabilitation, not retribution via a fine or prison sentence. But advocates of a sympathetic approach to drug addiction baulk when it is applied to other addictions (paedophilia, porn, murder, or sex crime) because it lets serial-rapists off with as much compassion as it does heroin addicts. Absurdity follows. Harvey Weinstein pretends to be as much a victim as the scores of women he has molested. After all, by MHA’s definition, serial rapists are just mentally ill and stalkers are just people addicted to other people. Clinical psychologist Dr. David J. Ley, in his book The Myth of Sex Addiction, explains how sex-offenders use addiction to excuse offences. A sensible response is not — should not be — medical (sexual de-addiction ‘treatment’) but legal-judicial (trial, conviction).
Addiction is more a bomb than a bullet, wrecking entire communities. Acute addicts can lie, steal, cheat, maim or kill, and attack families who dare to interfere. Once judgement is impaired, it is harder to repair behaviour without belief in the extraordinary power of the human will. Many of us are disordered, to varying degrees. Not all of us are diseased. Hobbies can become ‘addictions’: gym workouts, fried chicken, the rush from bungee-jumping. The issue for society is whether the degree of harm and impaired judgement makes a habit debilitating and destructive. Sure, shaming addicts is counterproductive. Criminalising all addicts isn’t helpful. Not all are equally culpable. But warning against a disastrous belief or behaviour is not stigmatising. If we are all predisposed, no one wins any battle, let alone with addiction: it is simply brains doing what they do!
Here’s a thought experiment. Feeble teenage twins are told to use steroids to bulk up. Jake obeys. Jack takes the straight and narrow: diet, water, exercise. Both bulk up, Jake fleetingly as drugs take hold and his body withers again, but Jack stably as his body rises to meet the challenge. Millions like Jack know that muscle builds only through sufficient and consistent resistance-training. Millions like Jake ought to apply similar principles to the mind. You strengthen minds by repeatedly resisting the easy way out, not by buckling at the first sign of adversity.
We are prouder at beating addiction than disease because cure from illness, although seemingly miraculous, is typically a product of medical intervention. The former, less spectacular, is more a factor of individual agency. Recovering addicts exercise the power of will that we know in ourselves and recognize in others. They show us that choice remains. Unfortunately, our culture has made a fine art of convincing multitudes, before acute dependence sets in, that addiction is a disease, with many convinced that they ‘suffer’ from, or ‘catch’ addiction, like others catch a flu. So, regressive tactics proliferate. States know that most addicts retain an element of freedom, or they would not try non-chemical incentives to sway them; they would never try this with a recovering diabetic choosing to cut down on candy. But, when it comes to addicts, instead of incentivizing good behaviour (restraint, respect for self and others), they are incentivising the bad.
In 2022, California became the first US state to offer addicts taking baby-steps to recovery taxpayer cash and non-cash sweeteners, such as Starbucks gift-cards for ‘clean’ tests. This comes despite a third to a quarter of addicts reneging on rehab. Imagine the damage to taxpayers if money currently directed only at such short-sighted treatment is expanded to cover equally short-sighted prevention with the same fervour. Imagine getting paid not to snort coke!
If we’re sold on a scientific or biological worldview then we’ll parrot the staggeringly duplicitous Yuval Noah Harari: ‘human life has absolutely no meaning’. As the wise say, if you’ve only a hammer in your toolbox, everything will be a nail. But, apparently addiction clinics are discovering that our lives do have meaning and that we had better find it in the right place.
Addiction is not about haywire impulses, but decisions to act on impulses, based on values ordered around pleasure. Many feel lustful, only a few molest. Imagine male criminals peddling a ‘Testosterone made me do it’ theory! ‘Pleasure chemical’ dopamine may tell us we’re feeling good when gaming, but we, not dopamine, decide how to spend our time, money and effort. We choose to live responsible, fulfilled lives – making others happy, not just ourselves – by postponing and sometimes passing up pleasure altogether. Outsourcing decision-making to dopamine makes us lab-rats. Some addiction clinics are now telling addicts the same things about excess and hedonism that faiths, families and friends have for centuries: health, family and self-esteem make life more meaningful than short-term pleasure.
Presenting people as powerless before substances (or sensations) undermines those who choose not to believe and behave powerlessly, whose values steer them, repeatedly, clear of those very addictions. Children growing up in a culture that excuses bad behaviour as disease will struggle to acknowledge, let alone acquire, values that ought to be fundamental to adulthood, such as self-control and deferred gratification. Addiction undermines personhood, denies humanity, surrenders body, mind and will to a perpetual high, substituting one reality for another. Addiction tries to escape the reality of learning, unlearning, working, reworking happiness, and succeeding (and failing) at it. Addiction surrenders who we are to ourselves, who we can be to those who care for us.
Addiction is not a disease, it’s worse.
Rudolph Lambert Fernandez is an independent writer. He writes on a range of themes related to culture and society. You can follow him on Twitter: @RudolphFernandz.