Dr. Kevin McCauley is a treatment professional who is dedicating his life to helping addicts and their families, and he makes a compelling argument for Addiction as Disease. Here is a comment made to the dadonfire website recently regarding the disease model of addiction and its counter argument’ the morality model of choice…
“I often find myself agreeing with both sides simultaneously. That, to me, is a signal that we’re getting very close to a problem that requires that we step outside our current method of conceptualizing a problem. In this case it is, I think, the way we conceptualize disease. Because of the single-causation model that doctors chose to define disease, and because that model invites patients to enter what Talcott Parsons called the “sick role” – one absolved of responsibility – we’ve got a problem: if something’s a disease, we aren’t responsible for it.
I think that’s wrong: addiction is a disease, and although SOME of the factors were in our control or that we chose (such as first decision to use, age of first use, drug of choice at first use, peer group, response to negative and positive consequences of use, narrowing of behavioral repertoire toward continued drug use), others were far beyond our control nor did they involve individual choice (genetics, socioeconomic status, pre-morbid or co-morbid conditions such as ADHD, bullying by others and trauma). Seeing the causation of addiction as multi-factorial, dividing those things that we cannot change from those we can, and taking responsibility for the latter is critical to recovery (and something that AA is very good at helping people do). For those things beyond our control we will need help in the form of treatment, social support, social justice, and compassion. Addiction is a disease AND we are responsible for our part in managing it. I don’t see the two as mutually exclusive, but I do think resting the responsibility for ALL of recovery on the shoulders of the individual addict is unfair.
Similarly, I do not think “choice” is some monolithic, unchangeable, supernatural capacity. It is a feature of our brains and odds are that we give it too much credit for always being there, every time, in equal measure. What, in the body, is not changeable? Even bone is a living, fluid organ, constantly being remodeled. It can break, heal, and require ongoing care to work correctly. Why wouldn’t that also be true of “choice?” Anyone who has ever had a piece of chocolate cake when on a diet knows that sometimes we are strong and sometimes less so. Multiply that by 1000 and you have the determination to stay sober, or the failure of will that goes with relapse … you have the brain disease of addiction. What if “choice” itself were diseased? We might not think it is – a failure of insight into how damaged our volition really is would be part of the cruelty of a volitional disorder. We would need others (whose brains are not so impaired) to help us, be kind to us, hold us accountable. We would need, for some time, to relinquish our will to them – to put our capacity for choice in a cast, just as we put a broken leg, so it can heal. I think AA does a nice job of retraining our capacity to choose: by dividing that which we can control from that which we can’t, we are on training wheels with regard to our capacity for choice. Other methods can do so as well, such as cognitive behavioral therapy – which simply asks us to look at the unrealistic and dysfunctional thought process that impair our ability to choose.
I think addiction fits the definition of “disease” as we use it in medicine today very well. But I also think the “disease model” has some problems that addicts get blamed for unfairly – namely this tendency to disempower patients for their own good. But by truly understanding how “choice” works in the brain, we can find out how it can break, and what is needed to fix it. In learning the limitations of choice, we are doing justice to its concept. But by making choice a constant, given, and immutable capacity we run the risk of turning it into a fetish. That would be consistent with everything our notions of American freedom and liberty have taught us, but they would be at odds with what neuroscience tells us about how such things are actually realized in the brain.
By calling addiction a disease, we don’t remove choice and we don’t absolve the addict’s need to take personal responsibility. People like to take responsibility. Why? Because it’s FUN to take responsibility! Humans are natural responsibility-takers. And most people will take personal responsibility to the exact extent they know how to, and are supported in doing so. But that requires us, as a society, to make an equal commitment to the addict seeking recovery as they do to their own. It would require us to …. well, make different choices!” Kevin McCauley