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.