Understanding Addiction, Part 1: The Disease Model
"Why? Why do I keep doing this?" I get this question a lot, especially from new clients who are struggling to comprehend why they keep engaging in an addictive behavior they don't want to keep doing. They struggle in understanding addiction.
I get it. I've been there.
I wondered the same for a long time. I couldn't understand why I continued to drink when I felt as ashamed about it as I did.
Eventually, I came to understand why I started to drink and why I continued to need to drink. Eventually, I came to understand that I drank to alleviate my own shame and anxieties.
Understanding what alcohol was doing for me helped me learn to be more authentic and manage my feelings differently. When I didn't need alcohol anymore, I spontaneously stopped when I got tired of how much it was taking from me. Maybe you're trying to understand your drinking, gambling, sexual behaviors, or other addictive behaviors. Really, you're asking about what you don't understand about yourself. That's where looking at a few models of understanding addiction can help.
Finding a Way of Understanding Addiction that Makes Sense to You
It's important to keep in mind that addiction can have many contributing factors; addiction has psychological, emotional, spiritual, biological, and environmental factors that all play a role to varying degrees.
That is, the factors that influenced the start of addictive behavior for one person may not have been all that important for another.
That's why it's important to find a way of thinking about your substance use or problematic behaviors in ways that make sense to you. I'm all about giving you information and letting you make your own choices. I welcome feedback and dialogue. With that in mind, let's start with a brief look at the disease model of addiction as well as its pros and cons.
The Disease Model of Addiction
In the 1940s, an AA member hired alcohol researcher E.M. Jellinek to investigate alcoholism. Jellinek postulated that alcohol use was a disease, a medical condition that was progressive. In this view, alcohol use inevitably gets worse and ends in imprisonment, loss of family, employment, health, and eventually death. That addiction was a biological disease came as a welcome relief to those struggling with substances as their behavior was no longer a moral failing or a spiritual problem, as it was from about the 1930s with the founding of AA.
Much research has been conducted in the field of neurobiology such that today, addiction is often conceived of as a brain disease. The National Institute on Drug Abuse defines addiciton 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 the structure and how it works. The changes can be long lasting and can lead to many harmful, often self-destructive, behaviors" (bold added; quoted in Denning and Little, 2017, p. 69). So in this model, constant drug use causes changes in the brain's reward circuits activated by dopamine and other changes elsewhere in the brain related to memory and learning. These changes motivate repeated use and the user becomes addicted.
Implications of the Disease Model for Recovery
Viewing addiction as a disease in this way means that addiction is a chronic, lifelong condition that can never be cured, it can only be managed.
Viewing addiction as a disease in this way means that addiction is a chronic, lifelong condition that can never be cured, it can only be managed. Thus, the individual must understand their "triggers" for using and be careful to manage their triggers successfully as relapses are to be avoided. A return to use might result in resumption of the progressive onset of the disease, and with it self-destruction or death. Even terms like "relapse," "tolerance," and so much of the other language around addiction reflects the disease model understanding of addiction. The individual in recovery is often encouraged to continue participating in treatment, usually through a 12-step program, for the rest of his life to further his recovery. Without such participation, the disease may return.
Pros of the Disease Model
Understanding addiction as a disease in this way can be an enormous relief for some individuals as it can help explain why they may have been so unsuccessful in reducing their use or problematic behavior on their own. The disease model is also helpful in that it's easy to understand. What's more, it often helps reduce the shame that many who struggle with addictive behaviors feel. Indeed, I think that one of the reasons that the disease model has endured is that it speaks to the powerlessness and loss of choice that many experience with addiction.
Cons of the Disease Model
Many have argued persuasively that the disease model is overly simplistic and does not account for the emotional, environmental, and psychological reasons why people develop problems with substances or behaviors. Neural processes and reward-seeking are not the only motivations for our behaviors; there are many reasons why people use and continue to use drugs.
As empowering as it may be for some, the disease model can also instill a sense of hopelessness in others that they can ever overcome their struggle. Many feel disempowered by the idea that they must manage their disease for the rest of their lives. Nor do they like the idea that they can never use any drug ever again, as a corollary of the disease model stipulates.
Furthermore, the ways in which the disease model is implemented in many treatment settings smacks of the moral model of addiction that it replaced. People who struggle with addiction are often called liars, confronted with about their denial, viewed with no small amount of social stigma, and many of our social policies about drugs reflect this condemnatory stance.
Understanding Addiction: What Works for You?
Next time, we'll look at a learning model of understanding addiction that explains the biological changes in the brain a little differently. Then, we'll look again at the self-medication hypothesis, which I've discussed before but it's worth visiting again. Then we'll wrap it up with some concluding comments that I hope will bring some of this together.
I can't emphasize enough that addiction is such a complex phenomenon that it cannot be fully explained by one model. In all of this, different ways of thinking about addiction emphasize different aspects of addiction, and sometimes in complementary and contradictory ways. I'd welcome dialogue with you as you discern your own understanding of your addictive behaviors. If you need help or want to talk, please don't hesitate to email me.
About the Author
Jeremy Mast is a licensed marriage and family therapist, a Certified Sex Addiction Therapist, and the founder and director of the Center for Integrative Change. He is passionate about helping those struggling with substance use and problematic sexual behaviors and their loved ones find lasting healing. In his spare time, he enjoys reading, rock climbing, health and fitness, and trying out new recipes while cooking at home.