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Some time ago, I wrote a number of articles in my Background Briefing series for Drink and Drugs News that focused on some of the theories of addiction, and some of the factors that are thought to contribute to addictive behaviour. I pointed out that looking at these theories helps us better understand the rationale behind certain therapeutic interventions.
Readers who are particularly interested in theories of addiction must read the excellent book by Robert West, in which he assesses a large number of previous theories and then develops a new theory of addiction that brings together diverse elements from current models.
I thought I would take the opportunity to add my earlier articles on addiction models and contributory factors to addiction to the community website. I start by outlining the disease model, a model that is central to the philosophy of Alcoholics Anonymous (AA) and related Fellowships, and to the 12-step Minnesota Model.
The disease model of alcoholism and drug addiction assumes that they are chronic, progressive illnesses (or diseases), similar to other chronic diseases such as Type II diabetes and cardiovascular disease. Addiction is considered to fit the definition of a medical ailment, involving an abnormality of structure in, or function of, the brain that results in behavioural impairment.
At the heart of this model or theory is that addiction is characterised by a person’s inability to reliably control his use of alcohol or drugs, and an uncontrollable craving or compulsion to drink alcohol or take drugs.
The loss of control can be manifested during either a short or long time span. A person may begin what they believe will be a short drinking session, but after one or two drinks find it impossible to stop drinking. Over a longer time period, they may make the decision to definitely stop drinking, but after an interim period (maybe days) resume drinking.
Carving was defined by E.M. Jellinek, a key player in the development of the disease model, as an “urgent and overpowering desire.” It can be viewed as a feeling that compels the person to do whatever it takes to obtain the object of the addiction, even when there are potential harmful consequences.
The disease model assumes that the impaired control and craving are irreversible. There is no cure for alcoholism and drug addiction; they can only be arrested. The alcoholic or addict must maintain a total and lifelong abstinence from all mind-altering drugs, except nicotine and caffeine.
In addition to their physical effects, alcoholism and addiction are considered to impact on the cognitive, emotional, social and spiritual functioning of those affected. Like other diseases, there is a natural progression, so there continues to be a deterioration in overall functioning until a “bottoming out”, unless a person enters treatment or receives the right sort of support (e.g. AA/NA).
The AA view is that alcoholism and addiction are also characterised by “denial”, or resistance to accept the essence of addiction – the failure of one’s own will power and the loss of one’s own self control.
The 12 steps of AA/NA and the Minnesota model are a suggested pathway for ongoing recovery. The essence of this recovery pathway is a changed lifestyle (habits and attitudes) and a gradual spiritual renewal. The person must accept that his own willpower is insufficient to conquer addiction – he must receive the help of others who have been there – and must avoid taking that first drink.
Some people find the concept of alcoholism or addiction as a disease helpful for understanding their condition and the path to recovery they can take.
They find consolation in the fact that they have a condition that can be understood in terms of the same model as diabetes or heart disease. They can feel less guilty about their condition, and they can join a programme that offers a clear personal goal (abstinence), a pathway for ongoing recovery (the 12 steps), and a life-time of support (via AA).
There is much (often heated) debate about the disease model and the implications that it has for therapeutic interventions.
In brief (and I could spend an article on the pros and cons), it is argued that there is no single constellation of alcohol related problems that could be described as alcoholism (there are a range of problems), there is no evidence that addiction and its core elements are irreversible, and progression of the problem is not inevitable.
Opponents of the model also point out that the disease model can lead to people avoiding self-responsibility, believing that the disease must be attended to by experts, rather than the changes come from within (albeit with help from others).
Opponents also point out that being labelled as an alcoholic or addict for a life-time, and spending a lot of time with other alcoholics and addicts, does not help the person attain a fully balanced lifestyle and re-integration back into society.
What is apparent, is that some people can be helped by this theory and the AA/NA approach, whilst others will not find it suitable.
Recommended reading:
The Addiction Project by HBO in partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Slaying the Dragon:The History of Addiction Treatment and Recovery in America by William L White, Chestnut Health Systems, 1998
A Disease Concept for the 21st Century by William L White, Counselor, 2001.
Theory of Addiction by Robert West, Blackwell Publishing, 2006.
Problem Drinking by Nick Heather and Ian Robertson, Oxford Medical Publications, 2001.
david,
this may read as arrogant or petulant, but frankly i’m beyond caring at this point. i’ve read (and/or viewed) everything on your list outside of the last two texts. when i have the time and/or inclination, i will check them out.
in the meantime, let me try to illustrate the ways in which AA tries to have its cake & eat it, too when it comes to the ‘disease model’:
“On the basic question, the data are clear: Contrary to common opinion, Alcoholics Anonymous neither originated nor promulgated what has come to be called the disease concept of alcoholism. Yet its members did have a large role in spreading and popularizing that understanding. …
“As is often stated in introductions but too rarely recognized in analyses, Alcoholics Anonymous is its members. That membership tries to live their program’s Twelve Steps, guided by their fellowship’s Twelve Traditions. The Tenth of those Traditions reads: “Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.” [1] The nature of alcoholism is an “outside issue.” Thus, Alcoholics Anonymous as Alcoholics Anonymous has no opinion on it, as most members will tell anyone who asks.
1 – The writing of this article was subsidized by a grant from the Behavioral Health Recovery Management project, a partnership of Fayette Companies and Chestnut Health Systems funded by the Illinois Department of Human Services Office of Alcoholism and Substance Abuse.”
later, from the very same article (hosted on the same server that contains white’s “disease model” paper)
“Among these statements is a reply Wilson gave when specifically asked about alcoholism as
disease after he had addressed the annual meeting of the National Catholic Clergy Conference on
Alcoholism in 1961:
‘We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with
alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady — a far safer term for us to use.’”
see: http://www.bhrm.org/papers/AAand DiseaseConcept.pdf
most contemporary medical or scientific professionals in the field are more inclined to use the term “brain disease” when discussing alcoholism/drug addiction. they’re also far more inclined to talk in terms of both those conditions being looked at in terms of a ‘continuum’ rather than AA/12X12’s preferred “chronic. progressive disease” notion:
“BLITZER: It’s estimated that 23 million Americans are struggling right now with some sort of chemical addiction. Alcohol is by far the most common, but many people don’t even realize they have a very serious problem.
Our chief medical correspondent, Dr. Sanjay Gupta, has been looking into addiction.
How do you, Sanjay? And it’s a sensitive issue. How do you know if someone you care about actually has an alcohol problem?
DR. SANJAY GUPTA, CNN SENIOR MEDICAL CORRESPONDENT: Well, you know, there are some specific criteria which psychologists and psychiatrists, other doctors will use to try and determine that.
But as we were working on this documentary, something sort of struck us. And that is that there’s not this bright line, sort of defined line between someone who’s an alcoholic or an addict vs. being not an alcoholic or an addict. It is more sort of this continuum.
And that’s sort of an important point as doctors try and figure out how to diagnose this very early. There is an institute called the National Institute on Alcoholism and Alcohol Abuse that after studying this issue for a long time, studying 43,000 people, they have come up with what they believe is a pretty good screening test to figure out who is most at risk of developing addiction.”
see: http://transcripts.cnn.com/TRANSCRIPTS/0904/14/sitroom.03.html
i’m not going to quibble about semantics when medical & research professionals are trying to tackle a social health problem in a scientific manner. that said, “brain disease” is light years away from the big book’s preposterous clamoring about “spiritual disease” & being “spiritually sick”. there’s no science in that & no verifiable efficacy.
see: http://tinyurl.com/lr7cbc
and: http://www.sciencebasedmedicine.org/?p=490
missing from your ‘recommended reading’ list is legal philosopher herbert fingarette’s “Heavy Drinking: The Myth of Alcoholism as a Disease”. readers of this blog might be inclined to give fingarette’s view on the matter some equal time — if only in the interest of gaining some perspective on the ‘disease model’ issue.
in my opinion, the ‘brain disease’ model & most of the sentiments expressed by white in his paper are indeed useful. but AA/12X12 goes too far in holding with a death-grip on to the “spiritual disease” notion.
for far too many people in genuine need, that notion is alienating, unproductive, and — in the worst cases — more hurtful than anything else.
closing your blog post with the qualifying, “What is apparent, is that some people can be helped by this theory and the AA/NA approach, whilst others will not find it suitable.” reads as equivocation to my eyes. it’s analogous to george w. bush’s imploring the american educational system to “teach the controversy” between the theory of evolution by natural selection & ‘intelligent design’. there is no controversy: ‘intelligent design’ is not science, just as ‘spiritual disease’ is not science.
my further thoughts on the matter:
http://donewithaa.wordpress.com/2009/06/18/the-cult-question-the-disease-concept/
Here at affinity lodge this model if you want to call it a model is the back bone of how we try to help people but I would also like to say that in some peoples life’s this is no longer a theory but a scientific fact.
We must remember that there are various reasons why people use mood altering substance not every one has the dis-ease . Then there is the phenomenon of people having the disease even before taking any substance by that I mean people who have had a life changing trauma especially in childhood or adolescence that results in a dysregulation of what is known as the h.p.a.axis which controls our stress response and the moment they take a substance they immediately get relief from internal stress.
This happens mostly with women who in later life have now developed a destructive addiction. In other cases the same brain changes can happen if the person pushes the drug without the predisposition.
You see we are now understanding this disease moving away from the old dopamine and serotonin focus part of the brain that produces pleasure effect although a different brain system, it has an intimate relationship with the h.p.a axis as far as the cognitive emotional social and spiritual aspects mentioned in the article.
The hpa axis is responsible for the control of corticotropin releasing factor. In turn releasing the killer neurohormone cortisol and when that is in the brain cognitive emotional functioning is impaired dramatically.
You are now in a state of survival and will do anything to get relief, we all know that story.
So the bottom line is in my opinion if you have the disease we call addiction you have a new state of being that is no longer the homeostatic free state but a permanent allostatic state i.e. achieving balance through brain changes. That is the entire definition of disease a malidaption between you and the environment.
New drug treatments are on the way that acts on the up-regulation of brain stress c.r.f. function .pexacerfont antalarmin and r121919 are some still to be passed for human use. Not that I believe in drugs as a way to recovery but I do understand some folk need this kind of help and support.
Disease or not disease when I was drinking nothing would have stopped me, this we call denial so readiness for change is a factor. If I knew then what I know now it would not have mattered one iota to me but when my time came it matters a great deal and is the underpinning of my recovery today.
On Tuesday I will be 7 yrs sober and some times it’s not easy when my disease flares up, the one thing I have is the knowledge that it’s my disease and that’s not me this is a physical disorder and human conscious is not physical and that’s where you find free will.
No one survives this disease without fundamental life style changes that we achieve through choices we make every day you know suicide is not often mentioned on the site yet is one of the biggest killers in addiction. In brains of diseased alcoholics who have committed suicide there are very high elevated levels of cortisol not alcohol and it’s that that causes all the autoimmune diseases that come along in addicts as it undermines the blood brain barrier.
Here is what Prof Kreek has to say about her patients.Dr. Mary Jeanne Kreek of Rockefeller University in New York City has noted. “For 6 months or so, they can walk past the street corner where they used to buy drugs and not succumb to their urges. But then all of a sudden they relapse,” she says. “When we ask them why they relapse, almost always they tell us something like, ‘well, things weren’t going well at my job,’ or ‘my wife left me.’ Sometimes, the problem is as small as ‘My public assistance check was delayed,’ or ‘the traffic was too heavy etc etc etc.
So it comes back to me now, she is talking about stress we can not hack living in our own skins sometimes so looking for therapeutic interventions must include stress management.
Stress involves perception so the first thing to change is the perception a new way of thinking. And learning about the disease education with the truth of what science knows today not 75yrs ago.
Bill Wilson once said this understanding will change, not meaning the 12steps that keeps the thinking straight but the cunning baffling disease theory is coming to an end as science moves forward, baring in mind that conscious is bigger than science and that by entering in to spirituality it counteracts the dis-ease for many reasons.
Just look at people with a chronic stress syndrome or PTSD and you find the same cognitive emotional physical and behavioural signs and symptoms. To find a solution to a problem you first must understand the problem; science is now doing just that finally relating it to stress the worlds leading cause of death.
The disease of addiction is simply an extension of that cause. Addicts don’t kill themselves for fun they do it because of the disease.
A dis-ease which tells us it inst one. Not just the person who has it but those professionals who are trying to help him also. i agree with speedy we should aways keep AA out of it when we talk about addiction as a disease he right about one thing its a spiritual illness.and aways brings man down to his lower animal level of motivation and needs.neurohormones give the body the feeling of well being if thay are not organized in a way to reflect reality we aways go back to the false solution and as wilsons good pal carl jung says a false spirituality.recovery is possible not cure.
This comment has been removed by a moderator.
dear speedy
i admire your straightforwardness. a disease that tells us it isn’t one meaning when we we get sober we tend to think we are well and pick up a drink .your right about wilson and jung but he did talk about alcoholics and spirituality.you must admit its the limbic system that’s the driver in chronic alcoholism.overriding rational thinking i did read the myth of addiction 6yrs ago and if i went by that i would 6feet under .as for the claptrap do me a fovor and read the work of koob and moal and get back to me please i love talking with you.
all the best for now.
Koob and Moal wrote about the neurobiology of addiction, not the “disease” of addiction.
Wilson never called alcoholism a disease because it simply did not fit the definition of a disease in his day. He used words like illness and malady as metaphors, a way that people could visualize their condition. Trimpey did a similar thing with “The Beast”; some of his followers also do not understand metaphor.
Marty Mann, often (incorrectly) called first woman in Alcoholics Anonymous, an ex-PR woman, convinced the AMA to vote on whether or not alcoholism was a disease. Only by calling it a disease, could doctors charge insurance companies for the treatment of alcoholism. She started the National Council on Alcoholism (now known as the National Council on Alcoholism and Drug Dependence) which set national policy on alcoholism and its treatment.
Calling alcoholism a disease may help with stigma, but it allows people to become mired in their “disease”. Throw in some powerlessness, and for many it gives them permission for relapse. How else do you explain the Brandsma study (one of the few randomized longitudinal controlled studies on the effectiveness of AA) in which the people of the AA group were five times more likely to engage in binge drinking as the group that received no treatment at all?
A “brain disease” is not the same as a disease, it would be more accurately call a brain disorder, but AA and the current treatment industry have too much invested in alcoholism being a disease.
I personally prefer to call addiction a disorder rather than a disease.
I also think too much time and energy is devoted towards arguing over this issue.
What we need to focus on is the fact that the problem can be a chronic or long-term problem for some people.
And focus on how we can help people overcome the problem and find recovery (when the problem has been severe enough for us to warrant use of the term recovery).
Just some thoughts before diving back into writing a business plan.
I work in mental health, the program I work for uses Motivational Interviewing, allowing the clients to set his or her own treatment goals which may be abstinence, moderation, or harm reduction. When a person is setting their own goals, rather than having them dictated to them, they are involved and more likely to achieve those goals. As HAMS (Harm Reduction for Alcohol and Other Substances) puts it: “When you make a plan yourself, then your SELF is invested in the plan.”
Kathleen Sciacca found that traditional 12step treatment rarely worked for her dually diagnosed clients and that by using MI techniques, her clients were invested in their recovery and managed a double digit abstinence rate at the end of a two year period. The majority of her clients that chose to moderate reported an increase in their quality of life.
Personally, I have seen clients quit cocaine and/or opiates while continuing to drink and/or smoke and turn their lives around. When offered a choice to decide what level of drug/alcohol a person wishes to continue with, a higher percentage chose and achieved abstinence than those in 12step programs.
The general public has been sold on the ideas that they need rehabs, treatment, and 12step groups for their addictions. They are told they cannot do it alone, despite that is the way 80% of all alcoholics get sober. It’s disempowering. Tell people they can’t do something long enough and they’ll believe it, some won’t even try.
After several failed attempts at sobriety using AA, instead of reading AA material, I read autobiographies. Every one of them involved people achieving their goals. Some of these books dealt with recovery, others did not, but the one thing they all had in common was that no matter what obstacles were put in their path, they did not give up.
First of all, I quit on my own. No group, or steps, or sponsor. I read books, articles, etc. And, simply, not drinking. So, I am ‘unique’. Alcohol abuse is a real problem. I see two important variables: severity of the problem. And, the state of mind of the individual. The state of mind includes all the varieties of ‘mental illness’/problems in living. This, to me, means that the individual concerned is the driver. The ‘program’ — whatever it may be – is not the driver. There are reasons why I quit drinking destructively — which no one needs to know – let us say that the drinking was ‘useful’. It stopped being useful [ fair is foul; foul is fair; for foul is useful and fair is not]. Logic dictated that I draw a line under it. I made it so.
I doubt that there is anything odd about quitting on my own.
I agree David… lets talk Solution, not Problem! Although I firmly believe for a person to understand the solution, they need to first recognise the problem. The disease concept of addiction/alcoholism offers this and the meetings/steps/principles etc offer a means to manage the condition/illness/disorder etc. I am more interested in working together to find ways to support people to live in the solution, rather than argue the toss about what the problem is, how its caused, who agrees, disagrees etc. Is the glass half full or half empty? I always to try to look amy my glass as half full!
