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Monday, February 10, 2014

Some Thoughts About the 'Disease Model'

I've posted here before on my discomfort with the standard 'disease model' that is commonly used in professional addiction treatment.

Addiction certainly has a disease-like effect, and I think it can be classed as a disease in the way we think of mental illness, which does not differentiate between organic disorders and those that are strictly thought-based.  In the case of addiction, it is clear that both can come into play.

Organically speaking, addiction not only involves the organic process of stress reaction (some people are naturally wired to have higher anxiety levels), while others have an inordinate response to certain substances that is often referred to by the AA characterization of an 'allergy.'  Then, when the brain begins to reroute neural pathways to accommodate addictive behavior, you indeed have some real organic problems.

However, to classify the organic problems on the same level as organic schizophrenia is ludicrous.  Addicts are not passive victims the way most schizophrenics are.  Addicts make choices to start and to continue.  The non-organic side has the ability to reel in the biochemical side of the disease, because we see people do it all the time.

As I have said before, I consider the 'disease' of addiction to be more about the spiritual disease of the Passions.  Addiction is a symptom.  Sure, when someone asks us if we are sick, we can say, "I have a runny nose" and everyone knows what we are talking about.  The runny nose is a symptom that we identify with the disease.

The addict who thinks that having a disease excuses his behavior is dead wrong.  Too often, counselors, when confronting a pitiful and remorseful addict, try to soften the blow by saying, "Yes, but you were in your disease" as if that excuses his conduct.  The AA Big Book certainly makes no claim, and does not differentiate between conduct inside or outside the disease.

If you want to get sober, you have to own up to all of it.  There are no excuses.

Modern thinkers hate this.  That is because they will say, "But, he was sick, so how can you blame him?"  We look at the mentally ill this way, excusing their mis-behaviors because they don't really have a bad intention when they act out.  The only problem here is that addicts are not mentally ill in the strictest sense of the word.  Addict are and will always be 'voluntarily ill.'  They chose to be sick.

By my book, that means they must own all their own garbage, and so they have to pick it up.  Again, working the Steps does not mean categorizing which of your behaviors are really your fault and which are not.  If you did it, you own it... plus you must own your attitude as well.

If you are looking for excuses, you've come to the wrong place.

If anyone tries to use the disease model to avoid responsibility, then they simply don't understand recovery.  Addicts need to take full responsibility for EVERYTHING that they have done.

The funny thing that most of us have experienced is when we own up to something that, when we finally admit our wrongs and become willing to do what is necessary to make them right, they suddenly become far less embarrassing or fearsome than they once were.  Our minds tend to over-emphasize some events either accidentally or because of the influence of pride.

At the same time, we often see our actions which we minimized turn out to be far more catastrophic.  It is not all chocolate and roses when it comes time to make amends.  When we experience these awakenings, the most harmful thing that can be done is any attempt to minimize the sorrow.  We must mourn.  Only then can we begin to heal.

So, disease is an explanation but it is never, ever an excuse.


  1. This is why the Big Book defines it as a physical and mental disease. You can't start work on the problem of the mind until the drink is out of the picture. The 12 & 12 makes a solid point that everyone has to hit the bottom whatever that bottom is. It's a nasty little whirlwind that messes up a lot of lives in its path. Without owning up to that mess, no one stays sober. Even if I am powerless over what happens to my body after I suck down that first drink, I am not powerless when it comes to picking it up.

  2. Does Eve Tushnet read your blog?

    1. I don't know. She and I have never met or communicated that I am aware of.

  3. I've seen the disease model run amok. With the person I'm thinking of, it led her to this mentality of "I have a disease and you all have to deal with it." Not pretty. Responsibility doesn't even have to be a moral question, practically speaking, it really seems to be the only way out of addiction and into recovery.

  4. The problem with the "disease concept" is the terminology communicates poorly to the public at large and especially to those who don't understand alcoholism and addiction. Therefore, I have never used the term "disease model." While I don't believe it's quite at the level of antinomy, it comes very close. What I mean here is that we now know with factual scientific certainty that alcoholism is a genetically inherited condition that accounts for the biological component of that condition AND "addicts need to take full responsibility for EVERYTHING that they have done" (Fr. George above). (I tend to try to reserve the term "antinomy" for things spiritual.) Perhaps I could just say it is the truth of "both/and" rather than "either/or". As I indicated in my review of the new Orthodox recovery book published by this blog, the author, in spite of seemingly contradicting himself presents very good articles in his Appendix that nicely summarize the more recent research evidence. This is especially true for alcoholism. The problem in the professional community (and the nonprofessional one as well) has always been the word "alcoholism" or "alcoholic." These words have been thrown around by professionals without being accountable to defining precisely what they are meaning by them.(I previously noted in this blog that DSM has specific definitions for the terms "Abuse" and "Dependence" but the word "alcoholism" is no where to be found. The new DSM 5 has done away with these two terms but still does not use the word "alcoholism".) With the bio/genetic research we are able to more precisely come to a more satisfactory definition. Not all drinking problems are alcoholism. In fact, in my own practice the vast majority of drinking problems I see in clients are not alcoholism. Therefore, it is more applicable to discuss "free will" and choice in these situations. With genetically acquired alcoholism, the individual has alcoholism from birth (or is a carrier in recessive genetic composition). How the bio/genetics of the individual affect the choice of the person depends on the genetic impact, its progression and a variety of other factors. What I have learned in my years of professional practice is that, just like there are fatal medical conditions (e.g., certain cancers, etc) some inherited varieties of alcoholism are fatal as well. That is, there is an impact on the will of the individual, that aside from Divine intervention, will kill the individual. I have also seen this with mental health conditions as well. So I disagree, somewhat, Fr. George, with your statement above regarding the comparison to schizophrenia. (And let's eliminate the word "victim" or "victimized" in this context. It is entirely countertherapeutic whether it's alcoholism or schizophrenia that is inherited.) It is BOTH, in practice, consistently without wavering, challenging the excuse making apparatus within the character structure AND communicating a Christlike attitude of compassion based upon improved scientific understanding. Therefore, alcoholism (and I believe we will find the genetic evidence for addiction as well) is all three--physical/biological/genetic, psychological and spiritual, not just spiritual.

    So it can't be stated, Drew, that alcoholism doesn't affect the ability of the individual regarding choice for the first drink. To various degrees depending on the variables I've cited above the free will choice IS IN FACT affected variously. Yes, Fr. George, "we do see people do it all the time" but we also see many examples of people who don't do it all the time. It isn't a matter that the latter are simply "weaker willed" than the former. This is different from the comment by Thomas above, which I agree with entirely.