Addiction is Not a Disease but It’s Not a Choice Either

Addiction is Not a Disease but It’s Not a Choice Either

There is nothing I love more than an evidence-based critique of the “brain disease” model of mental illness.

It’s a not-so-secret passion of mine. The books on my shelves have titles like The Emperor’s New Drugs, and Blaming the Brain. I sit around thinking about it on Sunday mornings. I google it excessively. I rant and rave to anyone who will listen (mostly my mother). I’m not anti-psychiatry, but the guy who overheard me questioning the purpose of psychiatry would be forgiven for thinking me so.

When a Guardian article titled Marc Lewis: the neuroscientist who believes addiction is not a disease popped up in my Facebook feed, I immediately clicked, and I immediately got that warm, tingly feeling I get inside my stomach when I read something intelligent and scientifically thrilling.

The article was everything I hoped it would be. Marc Lewis was using neurobiology to explain why addiction is not a disease. Yes, I thought. This is exactly the kind of controversy I need in my life.

Before Marc Lewis made the American Medical Association look stupid, he was an addict. He took drugs, robbed pharmacies, ruined relationships, and got arrested. In an interview, Marc Lewis says he tried quitting something like one hundred times, and he failed…until the one time that he didn’t.

When he was no longer an addict, he went back to school and completed a PhD in developmental psychology (which, as I had to point out to someone in the comments of the Guardian article, is an actual science and does involve extensive learning about the brain). He went on to write a memoir about his addiction, and now he’s released a book explaining why addiction is not a disease.

If you’re a human being living in the Western world, then you probably already know that this is an inflammatory statement. Addiction, not a disease? But the American Medical Association said it was so in 1956, and that’s basically the same as God sending us a memo.

In case you’re not as obsessed with these kinds of things as I am, here’s the National Institute on Drug Abuse’s definition of addiction:

“Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long-lasting, and can lead to the harmful behaviors seen in people who abuse drugs”.

Ten years later, in walks Marc Lewis who says that brain changes in response to booze are not indicative of disease, and in fact, are quite normal. According to Dr Lewis, what the brain is doing in response to drugs, alcohol, sex, or your tenth cupcake of the day, is responding in the way it is supposed to. The only way the brain can learn is to change. Addiction, he says, is an “exaggerated form of normal learning”, and this occurs due to neuroplasticity.

In case you’re new to the topic, here’s a short video that explains how neuroplasticity works.

The brain has amazing capacity to change. The more you practice something, the stronger the connections are in the relevant brain areas. Perhaps the only thing I remember from undergrad is this –‘neurons that fire together wire together.’ Meaning, each time you think or behave in a particular way, the stronger the connections between certain neurons become.

Perhaps the most striking example of neuroplasticity is when people who’ve had strokes learn to reuse a part of their body that became immobile due to brain damage. Neuroplasticity works in less dramatic ways too. Take London taxi drivers for example. Compared to non-taxi drivers, the back of their hippocampus is larger. Through repeated learning their navigational skills become phenomenal, and you see a change in the structure of the hippocampus. You also see changes in the brains of monks who’ve done a shit-load of mindfulness meditation, and in the brains of professional musicians.

According to Dr Lewis, a similar learning process happens in addiction. You don’t smell a whiff of tequila and lo and behold you have a drinking problem. Marc Lewis says, “You grow into addiction. It takes place in a sequence or a progression through repeated trials, through repeated exposure, repeated actions, and through practice.” This reflects neuroplasticity – the more you do something, the stronger that behaviour is wired into your brain.

When these changes are deemed positive, we label them awesome and we get hounded about improving our navigational skills and starting up a regular mindfulness practice. But when the changes are deemed negative, we (or should I say, the American Medical Association) label it “abnormal”, and indicative of a “brain disease”. Even though a) there is no conclusive evidence that those brain changes cause the behaviour in question, and b) it wouldn’t be considered a disease if the associated behaviours were socially acceptable.

Advocates of the disease model typically react to criticisms by pointing at pictures of brain scans and saying, ‘but the brain has changed, and that makes it a disease.’ Dr Lewis’s core criticism is that people are misinterpreting (or maybe ignoring) the role of neuroplasticity in addiction, “physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.

The Problem with Brain Scans

Something people seem to forget is that brain imaging studies are correlational. Typically, researchers scan the brains of people who already have an established disorder. Meaning, the only thing we can infer is that the brain is activated more/less so in certain areas in the “abnormal” person, or that there is more/less of some structure in the “abnormal” person. Brain imaging studies don’t tell us why that difference is there, and they certainly don’t tell us whether that difference was there before the abnormality began. It’s just as likely that the difference developed as a result of repeated thoughts, emotions, and behaviours. 

Why Does It Matter Whether Addiction is a Disease or Not?

Figuring outt what addiction is, and what drives it are essential to figuring out how best to help those who are suffering. We’re talking about scientific progress here. Scientific progress should not be held back by the dogmatic beliefs of the American Medical Association. I don’t want to stay in 1956 where homosexuality is considered a mental disorder, the mentally ill are lobotomized, and scientific articles are waffly.

The implicit meaning of ‘brain disease’ is that the problem is permanent and unchangeable. It transforms a problematic behaviour into a disease to be managed but never fully recovered from. It transforms people into patients who are dysfunctional right down to their DNA.

Conceptualizing addiction as a disease may not be the most useful way to help people recover. Instead, telling an addict they have a disease can disempower them. In a radio interview with ABC, Dr Lewis said “the notion of being a patient, having a chronic illness doesn’t make people feel much better and often makes them feel worse. Believing addiction is a disease is itself a predictor of relapse. It engenders a feeling of helplessness and powerless that in itself works against the process of recovery”.

But What About Stigma?

When I get into debates (okay, arguments) with people on the internet about the validity of the disease model of mental illness, this always comes up. Apparently, questioning the scientific evidence suggesting any mental illness (including addiction) is a brain disease is considered to take us back to the dark ages, where people are ridiculed and discriminated against. It’s a ridiculous argument. First of all, people are still ridiculed and discriminated against. Second of all, the scientific merits of the disease model are completely separate to the issue of stigma. Are you willing to lie about the nature of a condition just because it might prevent some people from being bigoted assholes? I’m not. And besides, the disease model of addiction doesn’t reduce stigma, and might actually promote it.

Think about it. Are you more inclined to avoid, denigrate, feel weird around, or otherwise treat differently someone who has something fundamentally wrong with their brain that makes them do behave in crazy and irresponsible ways , or someone who is experiencing problems that any one of us could experience? 

Are you Saying Addiction is a Choice?

No. I am not saying that. 

I’ve always been dubious about the disease model of addiction because that perspective tends to ignore the role of social, psychological, and environmental factors. What I don’t understand is why people assume it’s either a disease or it’s all your fault. Be logical. No one chooses where they are born, what family they are born into, or the multitude of life events that happen to them in the time between conception and the onset of their addiction.

Sure we make a lot of choices in our lives, but generally we make those choices because they make sense in the context of our lives. Sometimes we repeatedly make choices that look stupid to other people, but that doesn’t mean that they don’t make sense to us. People usually do what they’ve always done because it’s worked for them before. And then they get trapped there.

No one actively chooses addiction or any other mental illness. Just because something is psychological or behavioural (or has some psychological or behavioural component) does not make it any less problematic, disastrous, devastating, or painful, or any more chosen than, say, a cancer diagnosis.

The cancer patient and the addict are similar in that neither of them chooses their predicament. They might make some choices that make it more likely they’ll get cancer or become addicted to crack. But making a few poor choices here and there because you’re human and you think you’re immune to the horrible shit that happens to other people, is not the same as choosing a health problem.

The difference is, when you’ve reached the point of full blown addiction, you still have some wriggle room. You can assume responsibility. You can make a different choice. That’s not to say it’s an easy choice, but it’s still an option that is available to you. With addiction, your hands are not in the fate of your doctor, the skill of your surgeon, or the effectiveness of the drug. Your fate is up to you.

At least, that’s what I think Marc Lewis is saying.

Note: I did not interview Marc Lewis for this article. Instead, I listened/read to a bunch of interviews he did with other people, read his blog posts here, and here, and then I got mildly obsessed with him and bought his new book The Biology of Desire.

If you want to become mildly obsessed with Marc Lewis, you can visit his website. 

19 Comments

  1. This was a fascinating read. Thank you for sharing your insights! I love how complex our brain is and how we have the power to change our thoughts and habits! The video was a great addition to the post. Really helped to simplify the idea of neuroplasticity!

    Reply
    • I’m so happy you enjoyed it! Thanks for commenting :)

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  2. I enjoy seeing things I think written down with evidence and more coherency than I can ever muster. Very nice. This topic is super interesting!

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    • Thanks Una :) I’m so pleased you enjoyed it. And hey, you are way more coherent than you give yourself credit for. These words did not pop out of my head like this. It was a mess when I first wrote it down.

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  3. Wow that is a powerful argument that there is hope for people entrenched in an addiction. It is a super interesting read and full of surprises. I have learned a lot about the brain. I wonder do support groups like Alcoholics Anonymous do more harm than good if the facilitators believe in the brain disease model? No wonder people have such a hard time getting ‘on the wagon’. I wonder what can be done to change things towards more acceptance of the Marc Lewis model of addiction?

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    • In my research I read a bit about AA and whether they’re helping or harming. Undoubtedly they do help a lot of people. But for some, it’s just not useful. The whole idea that you are always an addict, and that if you have just one sip of alcohol and then stop then you’ve fallen off the wagon is probably not that helpful. If someone tells you, ‘once you start you won’t be able to stop yourself because you have a disease’, that’s probably true when you’re in the throws of addiction. But, later on when you have learned how to manage your behaviour and you have a drink, that’s not necessarily going to be true. It could become a self-fulfilling prophecy. I think the research says something like 75% of people with addiction issues recover and go on to moderately consume alcohol. So it’s not true for a lot of people. Don’t quote me on that figure though – I may be remembering it wrong!

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  4. What… challenge the medical system? Now I am addicted to reading your blog :-) Thanks for sharing and being transparent with what is your opinion vs that of someone else. Now if I could figure out how to apply this to my addiction to food we’d be golden :-)

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    • Thank you! You know I think changing behaviour is the most difficult thing to do. There’s this quote I love that was apparently said by Tony Robbins (or at least, that’s what google tells me) “Change happens when the pain of staying the same is greater than the pain of change.”. I think that’s why people can persist so long in these terrible situations, even though it’s worse, it’s not outweighing the pain of change. That’s why my issue with cakes is persisting, anyway :)

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  5. Mind boggling concepts here. I am completely enthralled. Talk about a disruptive paradigm shift. These ideas will have dramatic impact on addiction treatment (I hope, anyway) because they force researchers and practitioners to question the prevailing model. I’m already flipping through possibilities in my head, particularly around the question of whether sugar is an addictive substance. Thanks for your post!

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    • Thanks Maggie! You know, I’m not sure this model really will change anything. There are scientists in the background who speak up about controversial issues like this, and they are often belitted and personally attacked, their credibility called into question, simply because they are suggesting that the dominant paradigm might not be the most helpful. It’s big news one day, and then it’s quickly forgotten and the status quo remains. I admire people like Marc Lewis who stand up for what’s right even when there’s a bad backlash. The reaction to Marc Lewis’s book seems less problematic, possibly because it is addiction. The same arguments apply to mental illness, and boy if you mention that, people really go crazy.

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  6. This is a very important and compelling post. There is so much stigma and shame wrapped around addiction. I believe that designating addiction as a “disease” has partially been intended to dismantle that shame. However, I find the disease label strangely disempowering. For me, it doesn’t tell the whole story. The neoplasticity discussion correlates so much more with the presenting evidence, particularly the fact that more than one pathway can lead to deeper entrenchment in addiction. Thought-provoking and beautifully written!

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    • Yes absolutely, the disease model has been promoted as a way to reduce shame and stigma. Too bad it doesn’t work…well maybe it makes people who have addictions feel better, but it’s not helping them in the eyes of other people…at least, it doesn’t look like it is (I’ll have to do a bit more research on that to come to a more considered conclusion). Thanks so much for your kind words :)

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  7. A really informative article Roisin. Thank you.

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    • Thank you :) I’m pleased you enjoyed it.

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  8. Fascinating post! Very interesting reframing of addiction, great points made. Thank you for sharing this!

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  9. What an interesting topic, my thoughts on this are: just because the AMA declared addiction 1956 as a disease does not mean it’s gospel. Dr. Lewis’ theory makes so much more sense and is backed by enough evidence. But from what I have researched my suspicion is that keeping this classification helps the bottom line of the medical field and the pharmaceutical companies. And they have a powerful lobby that can pay other scientists to belittle and discredit anybody who comes up with an opposing theory.

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    • Oh yes, there are definitely social and political forces at play in the way mental illness is defined. I’m reading two books about these issues at the moment. It’s quite disturbing!

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  10. Finally! I have someone else who agrees with what I’ve thought for a long long time. I love your no bullshit approach to these arguments. I admire your enthusiasm for this- I spend obsessive amounts of time researching various things, but I’m glad you read all this stuff for us! To me, it’s just COMMON SENSE. I think humans, (and the AMA for that matter) have become so into their own egos that they think there must be a single answer for everything. It’s a foolish way of looking at things- our brains are infinitely more complicated than that! There is also the fact that all of the acronyms in our world are also businesses, and as my husband likes to say, “there is no prophet in the cure.” It is much better for business to keep treating people for their illnesses and diseases, rather than cure or prevent.

    Reply

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