For decades, the accepted view on alcoholism and addiction was simple: addiction is a disease. This disease model of addiction shaped treatment, changed social outlook on addiction and became the acceptable excuse for all individuals suffering from addiction to alcohol. Even for those not struggling with alcoholism or addiction, it is difficult not to be aware of this flawed belief. Recently while watching television, I found myself looking at an actor posing to be a medical expert, wearing hospital scrubs and a stethoscope around his neck, telling me “Addiction is a disease!” But is there truth in this, and is alcoholism really a disease? To truly understand the most effective treatment for alcoholism, it is first important to understand why the disease model developed, and the negative impact of considering alcohol addiction an illness.
History of Disease Concept
The concept that alcoholism is a disease began with Dr. Benjamin Rush in the 1800’s to promote the prohibitionist political platform and was based on the idea that individuals that drank too much were diseased. This concept was continuously used through the early 1900s by those involved in the prohibitionist movement and the Temperance Movement, all based on a political agenda. This disease model belief of alcoholism as an illness gained additional popularity in the 1930’s with the rise of Alcoholics Anonymous and was supported by a study published by E.M. Jellinek. The evidence behind this study could be easily debated, however through understanding alcoholism as a disease, it helped change the common perception of the time that alcoholics were sinners, and instead removed the stigma. Shortly after Jellinek’s questionable findings, the American Medical Association identified alcoholism an illness, and then in 1955 officially identified alcoholism a disease. To say that alcoholism is a disease only because of social and political reasons negates the evidence that does support the disease-like qualities of alcoholism. The National Center on Addiction and Substance Use states “addiction is a complex disease of the brain and body that involves compulsive use of one or more substances despite serious health and social consequences. Addiction disrupts regions of the brain that are responsible for reward, motivation, learning, judgment and memory. It damages various body systems as well as affects families, relationships, schools, workplaces, and neighborhoods.” Alcohol over time and with chronic abuse changes brain chemistry, including pleasure centers, which causes functioning to change. Furthermore, an individual in the throes of long-term alcohol abuse, experiences physical alcohol withdrawal symptoms characterized by shaking, nausea, dizziness, sweating and risks of seizures when they stop heavy drinking without the care and support of medical personnel. For these reasons alone, attempting to stop drinking suddenly and without support and attempting to detox from home can have long-standing medical implications. Just as not seeking treatment for a physical ailment can have potentially drastic health consequences.
The Global Concept of Disease
Further understanding the disease concept of alcoholism comes with understanding the global concept of disease. Disease by definition is an abnormal condition not caused by an external force that causes an identifiable group of signs or symptoms. Using this definition, we can compare alcoholism to heart disease, lung cancer, diabetes and hypothyroidism, all which require treatment. It may be argued that heart disease or lung cancer may be a result of an individual’s choices, whether it includes an unhealthy and cholesterol ridden diet or smoking cigarettes daily, however, the diagnosis does not change. The ability of the heart to pump blood without restriction or the lungs to provide oxygen to the body shifts from the natural state, and is therefore considered a disease. An individual born with Type I Diabetes or who develops hypothyroidism is not to blame for the physical disorder or the need for treatment and furthermore is not refused care because of choices that they made. Similar to heart disease or lung cancer, the diabetic’s pancreas stops producing insulin and in the case of hypothyroidism, the thyroid slows down with less production of hormones. In the case of alcoholism, changes in the brain’s chemistry occur as well as damage to the heart, liver and pancreas. Additionally, without treatment, the only remedy for the physical withdrawal signs experienced by the alcoholic, is to consume more alcohol. Just as some individuals are more prone to heart disease, diabetes or certain types of cancer, the disease model argues that some individuals are more prone to develop alcoholism. Years of research on alcoholism has explored this concept to help answer the question is alcoholism really a disease. It is fair to say that not every individual that drinks a beer, indulges in a cocktail or enjoys a glass of wine with dinner develops alcoholism. Studies have attempted to link genetic and biological markers to alcoholism to help explain the difference between the individual that is able to engage in moderate drinking behavior, and the individual that develops alcoholism. Despite these studies, there has not been evidence to support the presence of genetic predisposition, but rather significant support of the biological, social and environmental development model. In this development model, it is clear that when raised in a chaotic home, when exposed to alcohol and drug use at an early age, and when not taught the necessary emotional regulation skills, the likelihood of developing a substance abuse disorder increases. Using this information and understanding the similarities between other physical illness and disease, it makes sense why alcoholism is a disease. The problem with considering alcoholism an illness comes from the concept associated with chronic disease, as chronic disease is considered a long-lasting condition that can be controlled but not cured. But if alcoholism is not a disease, then what is it? Gene Heyman, a psychologist at Harvard University, takes a different approach in his book Addiction: A Disorder of Choice. Heyman presents research that 80 percent of individuals with an addiction overcome the addiction by age 30 and can do so because of the demands of their adult life. If keeping a job, paying bills or being a parent can be a significant incentive for stopping use, then this directly contradicts the idea that addiction cannot be cured. With this, begins the argument that alcoholism is not a disease.
Before the disease model is entirely debunked, it is noted that labeling alcoholism as a disease has some benefits. It helps conceptualize alcoholism as a major problem requiring treatment and therapy and helps make treatment more accessible as it is thought of as a disease and not a deviant behavior. When conceptualizing alcoholism as a disease, it helps provide hope for treatment and implies that similarly to other diseases, relapse may occur and should not be a source of shame The problem is not in labeling alcoholism an illness, but rather in understanding the treatment for alcoholism, which begins with moving away from the disease model. And as we move away from the disease model, we also move away from the term “alcoholism” and “alcoholic” and move towards the terms “alcohol use-disorder” and “person”. Traditional treatment for alcoholism and addiction based on the disease model was the 12-step model of Alcoholics Anonymous. AA and the subsequent 12-step groups are based on the concept of powerlessness, with step one stating “We admitted were powerless over alcohol” and subsequent steps referring to “defects of character” and personal “shortcomings”. Additionally, AA preaches that the alcoholic can only live “one day at a time”, that the alcoholic can never be cured and that if an alcoholic does not attend meetings, that they will certainly relapse. The problem with treatment for an issue when there is belief of lack of personal power and ability, is that a self-fulfilling prophecy occurs. With the belief in lack of power and choice, the individual absolutely does relapse and begins to act in which they do not have the ability to control themselves. It is in this that the alcohol use becomes chronic and “incurable”. This model simply does not work in helping people to move towards recovery and living a fuller and more stable life. So if alcoholism is not a disease, and substance use disorders are in fact a choice, and the 12-steps do not support long-term recovery, the question of how to treat the disorder presents itself. In the late 1970s, a model commonly known as the Stages of Change Model was introduced, which then influenced the development of a technique called Motivational Interviewing. This model was based on the idea that every person has different and unique motivation for quitting a behavior and that they move through a series of stages that begins with not recognizing that a behavior is problematic and ending with sustaining positive behavior change. To understand this, think of a young adult female that smokes cigarettes. In the beginning stages of change, she does not believe it will negatively impact her health and does not seem to be swayed by rising levels of tobacco tax and the cost associated with smoking. Despite friends telling her the smoke makes her smell, she continues to puff away. This same woman marries and gets pregnant, in finding out that she is with child, she throws away her cigarettes and never smokes again. This same concept can be applied to alcohol use, with the idea that with the right motivation and sufficient reason for change, and individual can move from not recognizing the need to stop drinking, or denying that there is a problem, to wanting to treatment, making changes, and eventually achieving long-lasting sobriety. In this non-traditional model of recovery, not only is recognizing the need for change and identifying reasons for wanting to change important, but the idea of self-efficacy is necessary. If I believe that I can make a change and be successful, I become more likely to be able to handle challenges and make continued choices that support that change. Self-efficacy is the exact opposite of AA’s notion of “powerlessness” and the need to rely solely on meeting attendance. If an individual adopts the belief that alcohol use disorder is a choice, and that they have the power to choose another option, they are able to use coping skills and will able to maintain their forward progress, despite challenges to their sobriety. Just as the disease model normalizes the concept of relapse, this model recognizes that challenges will arise, however with the belief in personal power and choice, a person is more likely to choose behaviors that support health and well-being.
Importance of Support System
The last and most important missing piece in the disease model of alcoholism, is the inclusion of family, friends and a support system in treatment. From a systemic approach of the treatment substance use, helping the individual to navigate relationship challenges and develop personal meaning in their lives is imperative. In his Ted Talk “Everything You Think You Know About Addiction Is Wrong”, Johann Hari addresses the concept of creating loving and supportive relationships. He highlights Portugal and their decriminalization of drugs that began in the year 2000, specifically with Portugal’s policy towards rehabilitation. In a country with one of the highest rates of addiction, Hari shares that through redistributing money spent on incarceration to rehabilitation, addiction rates drastically decreased. Most importantly, Portugal helped addicts find meaning in their daily lives, as addicts were assisted in identifying vocational goals and engaging in work in which they were able to find meaning. Similarly, the founder of empirically-supported Emotionally Focused Therapy, Dr. Susan Johnson discusses the importance of attachment and connects the importance of finding meaning to connecting with people. We as human beings have an innate need to securely attach to others, and she argues that the individual in the midst of addiction has turned to their drug of choice, rather than to others, to find the security that comes with connection. Dr. Johnson teaches that when individuals learn to turn safely to their loved ones, their relationships replace the need for addictive substances and become an antidote to addiction. Through this research, the need for treatment providers, friends and family, and even the substance user themselves to learn to implement compassion is clear. Threats of disengagement and detachment are not working, and instead replacing those threats with tools to assist with engagement and secure and positive attachment may be more effective. With a fuller understanding of the disease model of alcoholism, similarities between alcoholism and physical diseases is clear, however this model is not the be all end all to understanding alcohol use disorder. It is only through identifying alcoholism as a choice, that a new recovery model can be implemented and truly be effective. To impact long-lasting and positive change, a person abusing alcohol must first recognize their choice and power, develop the skills to combat challenges, and create relationships that support their recovery. At APEX Recovery, we help you identify motivating factors for long-term change, develop necessary skills to maintain recovery and include your loved ones in your recovery. We treat individual patients and their unique needs through a model that we recognize is not a “one size fits all”. Our admissions coordinators are available 24 hours a day to give you the support you need to make positive changes. Call APEX today.