During my 19 years of working as a counselor (with an addictions specialty) in community mental health, I have witnessed the final stages of the takeover of the disease model of treatment. Prior to this I worked for a few years in two detox/rehab facilities that treated all types of substance abuse problems; in the field of addiction treatment the takeover of the disease model had already been completed. While there are some differences, there are many common threads to understanding the nature and treatment of addiction problems and those that get labeled as “mental illness,” and they often intersect on many levels. Biological Psychiatry and their disease model of treatment has had the same damaging effects on people experiencing both types of mental health problems and has also severely handicapped well intentioned people in the field trying to offer help.
In 1951 The World Health Organization acknowledged alcoholism as a serious medical problem. The first DSM categorizing mental health problems was published in 1952 and then in 1956 the American Medical Association declared alcoholism as a treatable illness. In 1960 E.M. Jellinek published his famous book The Disease Concept of Addiction. In 1965 the American Psychiatric Association began to use the term “disease” to describe alcoholism. The history of labeling and treating both addiction and mental health problems as “diseases” has a parallel period of development. While the disease concept was originally applied to alcoholism it has since been generalized to other drugs as well. And today even excessive gambling, sex, shopping, and social media use are now being declared addictions and more often also called “diseases.” The newly proposed DSM 5 scheduled for publication in 2013 may even have a category called “behavioral addiction.”
Biological Psychiatry together with the pharmaceutical industry has embraced and promoted this disease model and they use the same type of language to describe the nature of addictive “diseases” as they do with so called “mental illness.” They say it is genetically based, brain altering, and chronic, and they are ever so quick to prescribe several types of medication that they claim are needed to stabilize and manage this so-called disease, sometimes even for a person’s entire lifetime. In the treatment of opiate addiction, in particular, they even equate the prescription use of drugs such as methadone and suboxone with the use of insulin for someone with the real disease of diabetes.
So if addiction is not a disease then how should we try to describe it in a different way, provide helpful treatment, and understand its connections to extreme states of psychological distress or to what gets labeled as “mental illness?” After more than two decades of trying to understand and help people work through both types of these issues, often at the same time, I would make the following observations in direct opposition to Biological Psychiatry and their disease model:
There is no definitive evidence of genetics being a CAUSAL factor in addiction. Just as with so called “mental illness,” their billions of dollars in research for the “Holy Grail” have come up empty. Their temporary hits and near misses receive tons of publicity, but their failures are hidden on the back pages.
All human beings are genetically predisposed to develop addictions and the symptoms that get labeled as “mental illness.” Nobody stands above or is immune from potentially developing these problems. In the right combination of circumstances ANY human being can develop an addiction and/or a state of extreme psychological distress. This will occur if any particular person is exposed to enough stress or trauma and/or if they use certain substances for a long enough period of time in a certain set of environmental conditions.
While there is probably something called a “genetic predisposition” for these two types of problems, we must question how this concept can ever be very useful. For example, in the case of psychotic like symptoms, if we take two people and subject them to a certain number of hours of torture and one person starts to show signs of psychosis after 18 hours and the other at 21 hours, should we spend millions of dollars to determine why there was a 3 hour difference between the two people? Shouldn’t our society be more concerned with why there was torture going on in the first place and what gave rise to those conditions and how to eradicate the material basis for such conditions?
In addition, and perhaps more importantly, there IS a genetic predisposition for RECOVERY from addiction and for what gets labeled as so-called “mental illness.” Human beings are born with a cerebral cortex in their brains and are quite capable (over time and under the right circumstances) of distinguishing the difference between thoughts and behaviors that are useful to themselves and to our species and those that are harmful and self- defeating. And also, human beings are quite capable of creating nurturing type environments with special forms of emotional support, thereby developing the most favorable conditions for these problems to be identified and eventually overcome.
There is no scientific evidence to call addiction a disease. Name another disease that you can wake up one morning and decide to no longer do a certain behavior ever again and then you will no longer ever have the symptoms related to that behavior. You cannot wake up and decide, “I don’t think I’ll have cancer or diabetes today”; they will definitely need specific forms of medical treatment. But you can make a decision to stop drinking or using other drugs and then make it happen in the real world, and for many people this can be a permanent behavioral change. Likewise, some people who experience severe psychological symptoms can also have an epiphany like moment and/ or decision which leads to a major transformative shift away from a debilitating mental state of mind.
With addiction, we don’t know why certain people, and not others, seem to cross a line from social/recreational use, or self-medicating use, of alcohol and drugs, to full scale out of control addictive use. When this occurs most people make multiple attempts to reestablish control, contain and limit the use of these substances hoping to return to an earlier stage when they were having more positive experiences than negative. People who develop a major addiction problem ultimately fail at these attempts to moderate their use, and their choice now becomes, either maintain the current dysfunctional behavior pattern or decide to become permanently abstinent.
For some people the decision to stop a major addiction problem can be quite difficult and complex, but it is not mysterious. Millions of human beings have broken major addictions with what is referred to as “spontaneous recovery”, that is, without any medical treatment, therapy, or self-help groups. I believe we can also say there are many examples of similar types of spontaneous recovery for people with extreme states of psychological distress, people who were fortunate enough to never be misdiagnosed and perhaps ultimately mistreated in an unjust mental health system.
Based on anecdotal evidence it is reasonable to conclude that, in examples of both these types of spontaneous recovery, there were supportive friends or family and a relatively safe environment that created positive conditions for a full recovery. And of course we are all too well aware that both addiction and extreme states of psychological distress can also become so severe and persistent that they may require more intense human intervention. Currently the theory and practice of these treatment interventions have, at best, very mixed results with frequent relapses and many inherent injustices that have been so well articulated on this website. Hopefully, future interventions can soon become the various forms of mainly drug free (with the exception of necessary detox medications) and nurturing support models of treatment developed and practiced by many of the knowledgeable contributors to this blog.
In opposition to the disease model we might find it helpful to conceptualize and understand both addiction and symptoms that get labeled as “mental illness,” more simply as useful coping mechanisms that over time “get stuck in the on position.” Let me explain. Human beings are driven to repeat behaviors that are pleasurable and/or take away pain, and they usually have sound cognitive rationalizations for doing so. These tendencies are very much related to our survival as a species, especially when you look at the drive to eat, drink, and procreate. In other forms of pleasure seeking and pain avoidance most people who use alcohol and other mind altering drugs more often feel very good in the earlier stages of their use. This is especially true when there are generally fewer negative consequences associated with their consumption. Some people have also postulated that human beings are, at times, attracted to altered states of consciousness. This can be a way to avoid boredom through experimentation, or, perhaps more often, become a creative way to escape or rise above the resulting discomfort or trauma experienced in a threatening environment. In the beginning stages of drug use, these substances may provide a temporary pleasurable escape from a harsh reality and/or become a very successful short term coping mechanism that actually prevents more dangerous reactive behaviors (including suicide), or perhaps even helps prevent the person from going “crazy.”
Similarly, extreme states of psychological distress can lead to altered states of consciousness that are mislabeled as a “mental illness” and a “disease,” but could instead be better looked at as a creative and necessary coping mechanism dealing with an experienced and/or perceived hostile and threatening environment. This coping mechanism, as with addiction, may also prevent more extreme reactive behaviors or provide an escape or temporary relief from intense physical or emotional pain. < Many contributors to this website have made similar descriptions of their own experience and drawn somewhat similar conclusions. I have learned from their experience and their resulting theories describing their journey. I have attempted to incorporate aspects of their ideas in my attempt to find a better understanding and description of addiction and its connection to so- called “mental illness.”>
Here is the rub. A problem often arises with both substance use leading to addiction and also with extreme states of psychological distress, when these behaviors and related thought patterns are sustained for extended periods of time, the formerly helpful coping mechanisms can gradually, or even suddenly, turn into their opposite and now become primarily self- destructive, self-defeating, and socially unacceptable*. This is especially true when the short term benefits of the behavior and resulting thought patterns start to shift and begin to cause far more immediate, as well as long term negative consequences for the individual and the people around them. Some people may now actually get stuck in this new state of being and be unable
to find their way out by themselves. This is the point when we might say that these once helpful coping mechanisms have now seemingly become “stuck in the on position.” * I am aware that socially unacceptable behavior can be both useful and necessary in changing the world for the better.
Ironically, people already showing symptoms of a persistent altered consciousness, such as depression, excessive anxiety, hallucinations etc. often ADD mind altering substance use to the mix as an additional coping mechanism only to have this behavior gradually (and sometimes quickly) exacerbate or intensify an already fragile emotional state. A few people writing on this blog about their own personal journey into a state of psychosis, have mentioned pot use as being a factor that may have contributed to their state of extreme psychological distress (marijuana use needs to be explored in greater detail in a future discussion). AND we can also say that the very use of these substances when combined with a stressful environment can become THE major contributing factor to the actual initiation of extreme distress symptomology. What may feel good in the beginning and dampen uncomfortable feelings, can soon become a CATALYST for increased anxiety, paranoia, depression, and possible psychosis.
In some situations many people who end up labeled with a psychiatric diagnosis are actually exhibiting symptoms that have developed over time through the chronic use of alcohol and other mind altering legal or illegal drugs. Psychiatrists and other medical doctors have very little training in addictions and often dismiss the significance of their patient’s drug use experience (if they even ask much about it at all) and are quick to assume that the patient is “self-medicating” a more fundamental psychiatric “illness,” rather than just plain, “self-medicating.” What usually follows is a primary psychiatric diagnosis coupled with multiple prescriptions for psych meds. Unfortunately the underlying substance abuse problem is not fundamentally identified and treated, and the new prescriptions only add to the chemical cocktail already circulating throughout the patient’s brain; all this ultimately makes recovery even more difficult, if not impossible.
Most people who enter treatment for drug problems have used and abused many different kinds of substances (usually both uppers and downers), therefore severe mood swings come with the territory. And most people who have abused drugs for any length of time have quite often already been labeled “Bipolar” by some doctor. Any review of the listed symptoms for this so-called mental “disease” clearly overlaps with the symptom presentation of many forms of drug abuse (and you could also include in the mix, prescribed stimulants and antidepressants) and all this becomes just another reason to critically analyze the use of the ever popular “Bipolar” diagnosis.
Taking a larger view of society, the symptoms of addiction and extreme states of psychological distress, if labeled as “diseases,” can shift attention away from their origins in a trauma laden and unjust society. This becomes especially important for those people on the bottom of the social and economic pyramid. The ruling classes find it both convenient and necessary for their survival on the top of the pyramid to blame “bad genes” or “broken brains” as the cause of these problems. Ashley Montagu, the famous sociologist (when targeting the Sociobiologists, the forerunners of today’s theorists for the disease model) labeled these similar types of “blame the victim” explanations as “genetic theories of original sin.” Both addiction and so-called “mental illness” are far more prevalent where there is poverty, patriarchy, and other forms of mental and physical violence; all this creates fertile ground for various forms of trauma experiences on a daily basis. Addiction and extreme states of psychological distress can become more humanely treated through some reforms, but they will never be fully eradicated, or even humanely treated on a broad scale, until the material conditions from which they have emerged are transformed in a truly revolutionary way.
Part 2 of this blog contribution will be titled: “Confronting The Addiction Voice On The Road To Recovery.” This will address issues and controversies related to the treatment of addiction problems, including the dominance of the disease model in 12 step philosophy programs and self-help groups, combined with a discussion of other alternative approaches and forms of treatment. Analysis of the pervasive use of marijuana and the growth of large scale methadone and suboxone programs for treating opiate addiction will be fodder for future blog discussions.
Disclaimer: The above views are based on my summation and study of direct and indirect experience working in the mental health field for over 20 years. In no way does this represent criticism of any particular human service organization or detox/rehab facility. I have worked in the past, and continue to work with many dedicated professionals who, under very difficult conditions, do great service for people with all forms of extreme states of psychological distress.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.