The Heart of Addiction

How psychology drives addictive behavior.

Is Addiction Really a Disease?

If not, what is it? A new look at an old idea.

For many decades it's been widely accepted that alcoholism (or addiction) is a disease.  The "disease concept" is taught in addiction training programs and told to patients in treatment programs.  It is unquestioned by public figures and the media.  But is it true?  And if it is not true, is there a better and more helpful way to define addiction?

Let's start with a short history.  In the bad old days, before the disease concept became widely popular (about 40 years ago), our society was even more prejudiced against people with addictions than it is now.  "Addicts" were seen as different and worse than "normal" folks.  They were thought to be lacking in ordinary discipline and morality, as self-centered and uncaring.  They were seen as people who were out for their own pleasure without regard for anyone else.  They were viewed as having deficiencies in character.

Then came the idea that addiction is a disease: a medical illness like tuberculosis, diabetes or Alzheimer's disease.  That meant that people with addictions weren't bad, they were sick.  In an instant this changed everything.  Public perceptions were less judgmental.  People were less critical of themselves.  Of course, it wasn't welcome to hear that you had a disease, but it was better than being seen as immoral and self-centered.  So, the disease concept was embraced by virtually everyone.  With all its benefits, it's no wonder this idea continues to attract powerful, emotional support.

Widespread enthusiasm for the disease model, however, has led to willingness to overlook the facts.  Addiction has very little in common with diseases.  It is a group of behaviors, not an illness on its own.  It cannot be explained by any disease process.  Perhaps worst of all, calling addiction a "disease" interferes with exploring or accepting new understandings of the nature of addiction.

This becomes clear if you compare addiction with true diseases.  In addiction there is no infectious agent (as in tuberculosis), no pathological biological process (as in diabetes), and no biologically degenerative condition (as in Alzheimer's disease).  The only "disease-like" aspect of addiction is that if people do not deal with it, their lives tend to get worse.  That's true of lots of things in life that are not diseases; it doesn't tell us anything about the nature of the problem.  (It's worthwhile to remember here that the current version of the disease concept, the "chronic brain disease" neurobiological idea, applies to rats but has been repeatedly shown to be inapplicable to humans.  Please see earlier posts in this blog or my book, Breaking Addiction, for a full discussion of the fallacy of this neurobiological disease model for addiction.)

As readers of this blog or my books knows, addictive acts occur when precipitated by emotionally significant events, they can be prevented by understanding what makes these events so emotionally important, and they can be replaced by other emotionally meaningful actions or even other psychological symptoms that are not addictions.  Addictive behavior is a readily understandable symptom, not a disease.

But if we are to scrap the disease concept and replace it with something valid, our new explanation must retain all the beneficial aspects of the old disease idea.  It must not allow moralizing or any other negative attributions to people suffering with addictions.  In fact, we'd hope an alternative explanation would have more value than the disease label, by giving people with addictions something the disease concept lacks: an understanding that is useful for treating the problem.

Knowing how addiction works psychologically meets these requirements.  Recognizing addiction to be just a common psychological symptom means it is very much in the mainstream of the human condition.   In fact, as I've described elsewhere, addiction is essentially the same as other compulsive behaviors like shopping, exercising, or even cleaning your house.  Of course, addiction usually causes much more serious problems.  But inside it is basically the same as these other common behaviors.  When addiction is properly understood to be a compulsive behavior like many others, it becomes impossible to justify moralizing about people who feel driven to perform addictive acts.  And because compulsive behaviors are so common, any idea that "addicts" are in some way sicker, lazier, more self-centered, or in any other way different from the rest of humanity becomes indefensible.

Seeing that addiction is just a compulsive symptom also meets our wish for a new explanation: unlike the "disease" idea, it actually helps people to get well.  As I've described in this blog and my books, when people can see exactly what is happening in their minds that leads to that urge to perform an addictive act, they can regularly learn to become its master, instead of the urge mastering them.

Despite all its past helpfulness, then, we are better off today without the disease idea of addiction.  For too long it has served as a kind of "black box" description that explains nothing, offers no help in treatment, and interferes with recognizing newer ways to understand and treat the problem.

And there is one more advantage.  If we can eliminate the empty "disease" label, then people who suffer with an addiction can finally stop thinking of themselves as "diseased."

Lance Dodes, M.D., is an assistant clinical professor of psychiatry at Harvard Medical School.

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