Addiction, Biological Psychiatry and the Disease Model (Part 2)
Challenging the disease model of addiction should not be viewed as just another interesting scientific and philosophical debate. Calling addiction a “disease” is not only wrong from a scientific perspective, but the promotion of this model of treatment can actually be harmful to some people trying to understand and recover from this life damaging and life threatening problem. If people believe it is a “disease” they may end up looking in the wrong places for the necessary solutions to their problem and limiting themselves to only specific forms of poorly designed treatment options, including possibly receiving prescriptions for potentially dangerous medications. Biological Psychiatry along with some medical doctors push several different drugs that they believe can treat this disease and/or provide some type of drug maintenance protocol for managing major symptoms. They rarely, if ever, talk about a cure or a state of permanent abstinence, even though millions of people have actually achieved this goal on their own or with other kinds of help.
As stated in Part 1, many psychiatrists see addiction as a set of symptoms related to an underlying psychiatric diagnosis such as depression, anxiety, or Bipolar Disorder, and because these so-called symptoms usually accompany most major drug addiction problems they will end up prescribing antidepressants, Benzos, mood stabilizers, and more recently antipsychotic medications as their treatment solution. Psychiatrists also frequently combine these particular drugs with various sleep medications (sleep problems also come with the territory of most addictions). We now know that all these medications carry with them a whole other set of their own problems (both negative side effects and main effects), including the potential for addiction and/or major withdrawal problems when people try to taper down or stop their use. Quite often all the above mentioned psychological symptoms are the direct result of an underlying addiction problem in and of itself; unfortunately this is either denied and/or ignored by both the addict and their doctor.
The medicalization of addiction, with all it overmedication abuses, only further complicates an overstressed brain that has already been temporarily altered by the chemical effects of legal and illegal drugs. And because we already live in a culture of addiction (opportunistically seized upon and made worse by Biological Psychiatry) people with these problems have been conditioned (and even promised) that their problems can be solved with the external solution of another pill or injection. This is why people with addictions often flock to psychiatrists; they are so ripe to become preyed upon and ultimately fooled into being used by Biological Psychiatry as a new source of patients and for more drug experimentation. And many patients who are addicts also know all too well that psych meds are mind altering by themselves or in combination with other substances, and they can now self-justify their use because they are legally promoted and prescribed to them by a licensed doctor. Look at all the psych meds, such as Benzos, Lyrica, and even antipsychotics such as Seroquel, that are today frequently sold in the streets. In the end all this just tends to make people even more vulnerable and overall dependent on mind altering substance use, thus making recovery a much more difficult struggle, if not totally impossible.
If the standard psychiatric meds do not become part of the mix, there are some newer drugs like Revia (naltrexone) and Campral (acomposate) which are advertised as pills or injections that will reduce cravings and/or block the desired effects of certain illicit drugs or alcohol. My experience tells me that these medications are over hyped (what’s new) and have very little long term success in overcoming major addictions. Addiction rates are definitely not going down and we are not reading any glowing studies showing any huge success rate with these particular meds stemming the high tide of addiction. It is interesting to note that when Revia first came out, if you carefully read the drug company studies used for FDA approval, they ever so conveniently took the liberty to redefine the concepts of abstinence and relapse. Most people believe that a relapse means a return to drinking any amount of alcohol, but with their studies, they redefined relapse to mean consuming more than 4 drinks per week. Therefore they could claim a false abstinence and/or efficacy of the drug if people in the studies were still drinking, though perhaps less than before they started the medication.
Given the high rates of addiction in our society if these above mentioned medications had any outcomes with even mild to somewhat moderate success they would have already received a huge amount of publicity; this is just not the case. Psychiatrists will often throw these meds into the mix just to cover their ass and hope something good happens. Who cares that they may have raised false hopes in treating this so-called addiction “disease” or added a whole new set of drug interactions into the patient’s body. And then there is the old standard drug for alcoholism called Antabuse; this was quite popular many years ago but is not currently used that much these days. This drug makes people violently sick if they consume any alcohol while it still circulates in their blood stream. In some cases “violently sick” could be very dangerous for people with certain medical problems or if they are in very fragile health; so this drug is not without risk. Antabuse can benefit some people who have been totally unsuccessful at getting started on even a short period of abstinence. Of course there is always the ultimate downside, in that if someone really wants to drink alcohol again they will just choose to stop taking the drug. All of this tends to delay the alcoholic’s inevitable and necessary big decision to finally quit once and for all; a decision that people in the end need to make, both by and for themselves, in order to successfully achieve permanent recovery from their addiction.
Finally, when it comes to specific medications directly used for treating addiction, I must mention the widespread use of methadone and suboxone for opiate addiction. I plan to address this issue in greater detail in a future blog, but I will make a few brief comments now. I stated in Part 1 that within the disease model these drugs are equated with the use of insulin for a diabetic; clearly a totally unscientific and bogus claim. Several hundred thousand people throughout this country are prescribed these drugs every day in programs that are openly called “maintenance” programs. Methadone, in particular, has often been nefariously referred to as the “orange handcuffs.” This reference is made because of the higher rates of crime connected to people needing to find illegal means to support their daily opiate drug habit. Methadone has essentially become a drug used effectively for the social control of a feared section of the population. It is an especially dangerous drug in certain situations, and is associated with a significant number of overdose deaths in this country. These methadone/suboxone programs cost the federal and state governments hundreds of millions of dollars every year and are very financially lucrative to certain “for profit” mental health organizations, and of course, the pharmaceutical corporations also find them very profitable. Full recovery from addiction is rarely discussed at all in these programs and it is quite common, and totally acceptable for treatment providers to say that many people (if not most of their patients) may have to remain on these drugs for their entire lifetime.
For many reasons opiate addiction has become a major epidemic in recent years and may be the most difficult drug problem to successfully treat. However there are millions of examples of permanent recovery from these drugs and it is not the huge mystery that the recovery establishment makes it out to be. Right now this disease model that dominates addiction treatment has become just one more obstacle standing in the way of higher success rates for recovery, and dare I say, with better models of treatment operating (most importantly) in a dramatically different world environment, the virtual elimination of major addiction problems on a broad societal scale, is not out of the realm of possibility (more on this point in a future blog).
It is accurate to say that at this time in history there are no medical/drug solutions for addiction, and calling it a “disease” certainly misdirects our focus and does not bring us any closer to finding an answer for this tragic human epidemic. (I would not rule out the possibility that in the future some medications could be developed to help with addiction problems in a more secondary role, especially with lessening drug cravings and withdrawal symptoms). So therefore according to the proponents of the disease model of addiction, outside of a medical solution, the only other successfully developed method that can provide a state of continuous management (not a cure) of this “disease” is a personal transformation in the so-called “spiritual” realm of one’s life. This is where Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Al-Non and other groups employing the Twelve Step philosophy enters the picture of the modern day recovery movement; and they all have a particular history that goes back to the 1930s.
The United States was supposedly founded upon the principles of a definitive separation of church and state, especially when it comes to the nature of government, public education, and of course, most assuredly the practice of modern science, including the practice of medicine. So how did it come about over 70 years ago, that when the phenomena of human addiction problems presented itself at the doorsteps of hospitals and the offices of common medical doctors, that these followers of the so-called scientific method would end up sending desperately distressed patients to essentially a religious organization hoping for what they referred to as a “medical miracle” to magically take place?
In the late 1930s addiction issues, such as alcoholism, were commonly viewed as a serious moral defect and a problem related to the absence of individual will power. Medical doctors could not fully comprehend addiction and had a terrible time trying to convince their patients to stop drinking; they simply had no effective answers for these problems. So out of shear frustration and ignorance they had no other recourse but to send their patients for a last resort “spiritual conversion” at the newly founded organization called Alcoholics Anonymous. And their decision was made somewhat easier by the fact that one of the group’s founders, himself a serious alcoholic, was also a medical doctor. In addition to this fact, a few very significant AA recovery success stories had recently received major national publicity in certain magazines and newspapers in that same time period.
AA has its origins in the Oxford Group; a small religious sect from the 1930’s that was rooted in a form of Lutheran religious fundamentalism. The original founders of AA, Bill Wilson and Dr. Bob Smith, were eventually thrown out of the Oxford Group for their over devotion to curing alcoholics and their deviation from the group’s strict adherence to the principles of the “Four Absolutes”, which was their version of the one true road to religious salvation. While AA, from its very inception, always welcomed any person needing help for their drinking problem, including atheists and agnostics, its founding members never abandoned their belief that recovery from alcoholism required a religious type spiritual conversion. An excellent brief history of the founding of AA and its religious underpinnings can be accessed at the following website: www.positiveatheism.org/rw/revealed.htm.
Alcoholics Anonymous and all the other twelve step programs that have historically followed in its footsteps may actually comprise the largest peer driven movement the world has ever seen. But it needs to be clearly stated that if a peer led human service movement or organization no matter how well intentioned, follows the wrong theory, it will end up with a poorly developed program and its real world practice will limit the numbers of people it can help and turn others away from potential recovery, and in some cases it may even harm people.
The value of Twelve Step programs clearly divides into two. Their group meetings are accessible on an almost daily basis in most parts of the United States and in many other countries in the world. Over the past seventy years these programs have clearly helped many people, if not from the shear fact that it was basically the only organized group option out there for people with addiction problems. And to those people for whom it was the only help available at a time of extreme desperation, many will naturally attribute their own recovery as being a truly lifesaving event, and therefore view the Twelve Step programs as not only extremely precious, but almost above criticism. This powerful allegiance may be completely understandable given that these individuals usually have no other recovery experience to compare with their own. But what if there were other recovery choices widely available with a more accurate scientific theory and a related program that contained no ideological or programmatic barriers to keep people from attending its meetings or from eventually being turned away by some overly religious and, at times, rigidly followed practices? How many more millions of addicts would have been helped or would have avoided the tragic end results of chronic addiction problems? For this question we will never know the final answer.
Today Twelve Step programs and the disease model dominates over 90% of all treatment facilities from detox/rehab centers to halfway houses and other residential programs in the United States. Unfortunately this domination leaves a significant segment of the addicted population with very few other viable options for finding compatible treatment. Many people struggling to obtain sobriety have already been exposed to the Twelve Step approach and have not been helped by it and are, in fact, turned off and away from recovery because of certain conflicts with its overly religious underpinnings and a rigid one road/continuous recovery approach to ending addiction. This even includes people who are themselves quite religious but reject the Twelve Step version of spirituality being an essential part of their decision to stop a particular substance abuse pattern.
People who end up seeking alternative recovery approaches are sometimes ridiculed or viewed as a potential threat to the Twelve Step program; they frequently are warned by some members that they are destined to relapse for deviating from the one and only accepted road to recovery. Over the years certain clichéd sayings that may not all appear in official Twelve Step literature have taken on a life of its own and have become accepted dogma that is repeated on a daily basis at Twelve Step meetings throughout this country and in different parts of the world. It might be helpful to take a brief look at the Twelve Steps themselves, as well as, a few of these commonly accepted sayings to see how the disease model is actually presented, and also examine the possible negative effects it has had on some people seeking a desperate recovery from addiction.
The religious component of Twelve Step programs is frequently downplayed and minimized by its members, this is especially true when they are defending it against the criticism that it is essentially a religious based organization. But looking at the actual content of the steps themselves and how they are presented at meetings, its religious presence cannot be mistaken. Seven out of the Twelve Steps either make a specific reference to God or a clear religious/spiritual word connection. And then of course there is the often recited “Serenity Prayer” and the much repeated phrase “Let go and Let God.” However even beyond the question of religion being a potential barrier for some people seeking recovery, let’s examine other programmatic or philosophical problems that addicts confront when introduced to Twelve Step programs at a very vulnerable time in their life.
The first step which contains the phrase, “We admitted we were powerless over alcohol,” needs to be critically evaluated in light of the fact that there are a high percentage of trauma victims who end up in the halls of Twelve Step meetings. In this society having a trauma history often leads many people to addictive substances as a coping mechanism. In addition other categories of people, such as women, minorities, and mental health patients labeled as “dual diagnosis,” who are already marginalized or treated as second class citizens, are also prone to seek out desperate ways to cope with all the intense stress or psychological pain that this society dishes out on a daily basis. Is it really helpful to tell an oppressed person who already feels powerless that they are once again powerless over something else in this world? Not only is it not helpful to tell people that they are powerless over alcohol (or powerless over changing the material world around them) but it is not actually true in the real world. Yes, an addicted person may never again be able to safely drink alcohol or use cocaine or heroin etc., but they definitely have the power to make the necessary decision to stop their substance use once and for all, and that decision and subsequent action is, indeed, very empowering and life changing when it finally happens. And yes, certain social groups of people, including friends and family may become critically important and empowering as a part of this recovery process.
In a similar vein, should we be telling people that in order for them to end their addiction they must “make a decision to turn their (our) will and lives over to the care of God” or some “Higher Power” as stated in Step Three? Many victims of addiction already believe their “will” has been controlled and violated by other people or institutions in this society, so are we not encouraging passivity and submissiveness by adding one more master along with additional feelings of dominance and inferiority? Leaving aside the question of whether or not there really is a “Higher Power,” it can be stated that having a strong “will”, or “will power,” is an important and necessary ingredient for anyone attempting to change themselves and the world around them. This “will” and related determination ultimately leads people to seek out an ideology and the social means to achieve a successful recovery or any other goal that is important to them.
“Addiction is the disease, AA/NA is THE medicine; if you stop taking your medicine then you will relapse.” Another often repeated phrase that not only promotes the unscientific disease model, but also attempts to scare vulnerable people from seeking other recovery methods, or threatens them that if they leave “The Program” they will fail miserably at abstinence and end up relapsing or, even worse, dying from their addiction. Once again a much better and more accurate phrase would be, “One journey; many roads.” In reality, millions of people have recovered from addiction using many other types of individual or group skills and techniques, and many of these people have never turned up at detox/rehab facilities, doctor’s or therapist’s offices, or Twelve Step meetings. And if they did receive help from Twelve Step groups they may have done so on a time limited basis and eventually got on with their lives without either long term or lifelong membership.
Taking this a step further, many people participating in Twelve Step programs have been taught to believe that relapse is almost inevitable, or it is waiting just around the corner ready to strike when they least expect it. For some people this can become almost like a “self-fulfilling prophesy.” They end up using their Twelve Step meetings almost like attending a church, in that when they ultimately relapse by engaging in “sin” (drinking or drugging) during the week; they quickly follow this up with attendance at a Twelve Step meeting on Sunday where they humbly ask for forgiveness and then the congregation (members of the group) forgives them (welcomes them back at the meetings) and then at different points in the future they end up repeating the whole process over and over again. For these so-called chronic relapsers true recovery becomes just an elusive dream. In certain ways this presentation of the disease concept has actually discouraged them from believing that permanent abstinence is an achievable goal; they end up believing that they will forever be stuck on a precipice of an impending relapse, never knowing when it might befall them and only hoping that Twelve Step attendance will keep the “germ” of their addiction “disease” at bay.
“Shut up and get stupid; your best thinking got you here.” How much truth is contained in this frequently repeated Twelve Step mantra? Isn’t this actually an example of “turning reality on its head?” Of course it is true that addictive thought patterns (or the more common AA phrase, “stinkin’ thinkin’”) plays a decisive role in preceding anyone’s choice to pick up a drink or drug and thus continue one’s addiction. But is it helpful to make a principle out of ignorance or make a complete mystery out of the addictive process? Isn’t it more accurate to tell someone that it was their “worst thinking” that led them to addiction or, in fact, now keeps them stuck in it? Don’t people really need to “get smarter,” and isn’t more talking about thoughts and feelings also part of the learning process as well as listening and learning? These are all rhetorical questions for which the answers should be obvious. Unfortunately, aspects of the Twelve Step philosophy tend to promote a certain amount of blind obedience to dogma while discouraging critical thinking skills, just the opposite of what is necessary for anyone seeking the truth and finding liberating solutions to complex problems.
These are just a few criticisms of the Twelve Step philosophy and its programmatic approaches to recovery. While I have stated that Twelve Step programs have helped many people by virtue of its overall dominating presence, I also believe it can be harmful to some people attempting to conquer major addiction problems. Some vocal critics of Twelve Step programs refer to it as a cult. While it is true that some members function in the organization in a cult like fashion, I believe its huge membership is extremely diverse and the character of meetings can vary from city to city. As a person who is a critic of the disease model and at the same time counsels people with major addiction problems, I have never discouraged people from attending AA or NA meetings. People in the throes of a devastating life of addiction often desperately need social/group support, especially from people who have some understanding and/or experience with this life threatening problem. A once a week counseling session can fall way short of the support necessary for successful recovery.
There is one other commonly repeated saying in the halls of AA and NA that does make a great deal of sense for those people attending Twelve Step meetings, “Take what you need and leave the rest.” I find myself repeating this phrase quite often when people I work with are attending recovery meetings in my area. People need to find as many tools as possible in their search for recovery. There are no easy or simple solutions to our pervasive culture of addiction with all the damage it does on a daily basis. The search for the miracle cure has clearly come up empty; we should not be surprised.
In the past, people in Twelve Step programs use to put up spontaneous resistance to Biological Psychiatry and their proliferation of psychiatric meds flooding our society. Group members would often be very critical of people in recovery who claimed abstinence while taking these legally prescribed drugs. More recently an approach of accommodation with Biological Psychiatry seems to have won out in Twelve Step groups. This is also not a surprise given the power of psychiatric institutions and the similarities of both groups’ presentation of the disease model. Until some positive new approaches to treating addiction begin to take hold on a broad scale throughout this country and beyond, we will be stuck with both the dominance and limitations of Twelve Step programs and its disease model of addiction. However this reality should not deter any of us from being critical thinkers and seeking out revolutionary alternatives in the coming period.
Part 3 of this blog will be titled “Confronting the Addiction Voice on the Road to Recovery.” This will explore some of the newer and more alternative treatment options that are now available. Although quite small in number and in size these newer options pose a direct challenge to the dominance of the disease model.
Disclaimer: The above views are based on my study and summation of over 20 years of direct and indirect experience working as a counselor in the mental health field. In no way does this represent a specific criticism of any human service organization or detox/rehab facility. I work with many dedicated professionals who, under difficult conditions, do great service for people experiencing many different 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.