What is Addiction Really, and How do We Fix it?
MD Lukens, PhD © May, 2016
The Disease Model is Not Well Constructed
To start this discussion off I need to repeat what I’ve been saying for some time: addiction is NOT a disease. To be more precise and appropriately humble about it I would say addiction is not best defined as a disease.
In almost every way conceivable, I see the equating of addiction with disease as very unfortunate; it has always been unfortunate, and it will continue to be unfortunate if we don’t move past it. I assume the disease idea was created with the same good intentions I’m bringing to the job of defining addiction. Trying to be helpful. But I don’t want to simply critique it. I want to do away with it permanently and completely, except as a historical reference.
I look at definitions somewhat differently than almost everyone else, being a radical constructivist. Constructivists are outnumbered by a large margin — our counterparts, the naive realists, constitute the vast majority of people, scientists included. As a constructivist I make the epistemological assumption that we don’t come to know the world by simply making copies of what already exists independently outside us; our definitions of things are not handed to us by the outside, like preformed data is handed to a computer. Meaning and relevance are created by each person in the actual process of living. The world we “think” we live in is one which we have been busy constructing, creating inside models of forms and substance in order to create order within our minds.
Like you, I share my meanings with everyone I come into contact with, on some level. We then gather in schools and specialized groups to share our meanings and form “collectives” of shared meanings. Science and religions are clubs that have rules governing how and what meanings are shared among “insiders” who belong to the club, or aspire to belong to the club.
Addicts form social clubs too, especially if using substances starts out in adolescence. This is an allusion to the proverbial “bad influences” everyone’s parents warn their children about when choosing to affiliate with one’s peers. Addicts tend to exit certain clubs and join others in the process of recovering — maybe more mature clubs with something unifying them meaningfully besides their getting high.
Therapists, theoreticians and service providers of all kinds are together inside the club we could call the addiction field or the addiction world. Among the sub-communities within this arena there can be lots of friction and conflicts between people with differing “meaning allegiances.” Meanings are being exchanged and boundaries are created as sub-clubs form and idea sets are shown rule bound recognition and validation — separating them from one another. Members have codes of “meaning conduct” to observe in order to remain in “good standing” within any particular “school” of thought.
Our coming to know the outer world is an inside job. The so-called objective facts do not actually exist in the absolute sense that we’ve always assumed to be the case. The naive realist believes there is an objective universe waiting for us to identify, catalogue, and see the natural, already given order between things as all this “separate” and objective material of the universe is unfolding for us. And this universe would be doing its unfolding exactly the same with or without our perception or understandings because it really is independent of us.
The constructivist knows the world we make up is reflective of who we are, what we are all about, and our identifying it is actually a process of our defining it and not just discovering it as it “really is” unto itself. We tell the world what IT is, the world doesn’t tell us who or what IT is. Our biases make us see what we see “out there” and our mind is making sense of what we see in a way that is keeping with the mandate: “in the service of the self” in some way. When we are curious without much sense of a bias, we have biases already nonetheless, just of the more subtle kind. We don’t just come to know what we know based on what our biases will allow — we only bother to look where our biases make us bother.
We don’t come to know what is out there independent of us. That’s an idea we have . . . that there is such a thing as independent and out there. Or objective. Or neutral. Or purely intellectual or rational for that matter………..
I’m not the only constructivist — really there are hundreds if not thousands of us — but I may be one of a handful who are trying to define addiction. Coming from an assumption that we make up the worlds we find ourselves living in I don’t have to figure out what things “really” mean; I look instead for what things “truly” mean to the person or the groups of people who share a way of seeing and defining things. Theists live in a world in which the proof of God’s existence is not required, since their faith tells them they have all the proof they need.
That is their truth and so that informs how they live and what they “know.” People who like soccer don’t have to justify why they see it as the world’s #1 sport. Scientists appreciate the use of the scientific method and tend to be more ok than most with not being able to fully explain almost anything. Since science is not all that coherent, well articulated, or all that advanced in the addiction domain, we currently have to devise our definitions and solutions with little support from that pool of knowledge.
Perhaps this is why the spiritual take on addiction is still so popular, and why passionate advocates of all the approaches for defining and treating addiction speak so loudly once they “emotionally conclude” the path they themselves walked to recover from their addiction could or should work for everyone.
As a constructivist I’m left with a utilitarian sort of take on definitional “value.” Ultimate “rightness” or ultimate “wrongness” are discarded as possibilities from the outset. There are no objective absolutes, so that can’t factor into the value of a definition. A definition that moves us in better directions is preferred over one that does not. Defining homosexuality as a disease was, so clearly, seen now in hindsight, quite damaging and limiting. There was a point in time that “refrigerator mothers” were blamed for autism.
Bloodletting and the use of leeches were standard medical practice; and trepanning — the drilling of a hole into the skull to let out the toxic “vapors” or “evil spirits” — was viewed as a cure for mental illness. I’m suggesting history is repeating itself now with this addiction-is-a-disease definitional commitment.
To the utilitarian it is the usefulness of a definition that counts; it is the goodness of fit it demonstrates between what needs to be explained and its ability to get that job done; it’s how workable a definition might be for specific purposes; in addition, the fact that people “like it” also tends to matter a whole lot, especially since consensus is so often mistaken for correctness.
I like definitional schemes that fit the observations, and offer compelling and helpful perspectives on taking effective action and/or generating sufficient motivation for making substantive changes. The disease concept does none of this well, if at all. Except for its being well liked.
Disease and Reductionism Don’t Add Up
When that stuff we’re trying to define is meaning and experience it is NOT something we can boil down to neurochemical reactions per se. Reductionism is always a problem if it’s misused or over-stretched. Occam’s Razor stipulates that the least complicated framework for “comprehensively” explaining things is always preferred in science.
Not just the least complicated definition per se, but one that comprehensively “covers” the conceptual territory. Of course this “rule” is not always followed by “lay people” (or journalists who write about science) who are not so into science as a methodology or a philosophical stance per se. Our overriding preference for reductionistic explanations is a second problem, and it’s one that makes the first problem of having such definitions so much more likely.
The bottom line for me (perhaps making a short story longer than it needed to be), conceptually speaking — as a constructivist AND therefore also a utilitarian — I don’t think it works well for us to define addiction as a disease.
I vigorously reject all the claims of facticity on any front in this discussion, or from any proponent of a single model, or the apparent certainty of the various conclusions drawn by so many involved in these definitional debates. The overnight pill, the sure thing, the final answer . . . these have not been discovered.
The gene that accounts for addiction has not yet been discovered. The brain processes have not, the psychological dynamics haven’t either, etc.
If we were truly preferring honesty over some other bias we would all say we don’t know enough about any of it to be so certain we’ve found the key. We are all still conjecturing about addiction, somewhat feebly at this point still, regrettably . . . and the assumptions I have about the future, based on my constructivist perspective hold no promise of our ever getting past conjecturing completely. Our endless definitional debate is how it is for us, and it is how it is going to be. The debate may go through quiet periods, and it may go through more tumultuous periods. But the debate will continue, regardless.
This is true and is embodied in the inevitable projections stemming from my framework, since there can’t be any endpoint to the perspective driven nature of “reality” since more perspectives are always “possible” or potentially “coming soon.” We should avoid being lulled into the conclusion that just because we have widely held or even universal perspectives on something means we have some indisputable facts about the nature of existence. Widely shared opinion (or point of view) is nothing more than widely shared opinion.
As we approach ‘TOTAL’ consensus, or we are convinced this consensus is real and is happening as a validation of facticity we are vulnerable to the hypnotic pull of the easy way out, the path of least resistance, or a way of relating to reality that “blindly refuses’ the real nature of our own realities. We find that our species is especially vulnerable and riddled with fear when it comes to our being “mental sheep” when we just totally buy into ‘available’ definitions of things we have not yet truly considered on our own. The passing of the bias baton between generations is an effortless, seamless and almost inevitable outcome if there is no status quo challenging self observation “applied.”
The constructivist realizes there will always be debate about this phenomenon and everything else we think we know. Thomas Kuhn’s conclusions about the way science actually changes over time seem to hold on a universal level even as we witness the “competition” for theoretical supremacy in the physical sciences. Kuhn talked about scientific revolutions, and these kinds of patterns of connection between old paradigms and new “replacement” paradigms; he was discussing on a macro level what George Kelly was arguing happens for individuals on a more micro level, as they construct their own unique meaningful worlds. We make changes when what we know doesn’t work for us, and we often have to try “not knowing” for awhile in order to let go of what is known to be, what our shared and our individual science’ is telling us.
Psychological, medical and even physical science will never stop being a product of ever-evolving and perpetually ongoing debate. Just when we think all has been said and done there will be more to say and do. Ideas and edifices of understanding rise and fall just as buildings and skyscrapers, as well as cultures and civilizations.
According to Kuhn, normal science is disrupted gradually and increasingly over time by the discovery of anomalies. These are pieces of data or observations that don’t fit well within the existing “normal” framework. The gathering of anomalies leads to the creative generation of “new boxes” for understanding (new frameworks) and these alternative explanations for the anomalies begin “stacking up” and eventually undermine the existing paradigm.
In the addiction field new perspectives are being generated and considered. Normal “knowing” is now being perceived by many to be failing us. So we are now doing “unusual knowing being submitted as legitimate alternative for consideration.” This is where we are in addiction as far as I can tell. Lots of anomalies that cannot be explained by the existing paradigm . . . that’s what makes them anomalies in the first place.
The next paradigm explains them “better” and so it is considered as a possible replacement. The anomaly ridden nature of the science at this point is “Begging” for a new platform to replace the anomaly ridden one. It’s time for a new paradigm, starting with a consideration of the most popular “suggested” alternatives. Sooner or later one will be “born” into prominence (agreed upon significance) and become the set of abstractions to guide the next phase of normal science. .
When Teammates Disagree
My commitment to this way of understanding how we come to understand things runs deep, and so I argue that it would be more appropriate for everyone (me included) to speak in relative and tentative terms. The way I see it, despite our disagreements and definitional conflicts connected to so many central notions for defining addiction and its causes — disease, choice, genetics, habit, character defects, mood disorders, moral shortcomings, etc., — we’re all on the same team trying to figure out and find the best remedy(s) for this quite complex and inarguably harmful “thing” called addiction.
I’d like to suggest that the fact that we have varying opinions is only indicative of our being in an early-to-mid stage discovery process, that is at the same time a process that will have no final end point. But it is a process of moving the process of paradigmatic revolution along and that is something that I want to take part in.
All that calling for more humility notwithstanding, I am still pretty passionate about my own definitional conclusions. As a constructivist I argue for my perspective just because. How could I truly do otherwise?
Beyond the semantic elements that are making disagreement inevitable, one of the main reasons I don’t prefer this disease definition at all is that as a causal conclusion it tends to hijack and stop short the inquiry process, channeling our collective and individual resources into what I consider pretty much an unfruitful conceptual cul de sac — it offers so little that is actionable in terms of solutions or furthering the discovery of avenues for action. I recently worked with a client who was abusing his antidepressant medication because he fully believed depression was “corrected” by having better feelings.
His therapist and psychiatrist may not have said this directly, but this was his takeaway from their discussions. So taking extra large doses made perfect sense, since more meds should mean better feelings and better feelings meant no more depression. This rather primitive idea that seeking better feelings is the path to happiness IS the operating principle that gives rise to addiction — it’s anti-remedy. But it is still a rather pervasive understanding held by most people and the majority of addicts.
The disease model would direct all scientific traffic down this dead end street and similarly it directs people’s recovery efforts down a limiting and unnecessarily challenging path. There is so little benefit to the individual or the afflicted family members that results from their settling on this pseudo-scientific conclusion at this point.
In its place I offer what I think of as a set of definitions that has so much more going for it. People relate to it — it ties in well with their experience of being an addict. And it has a better platform for creative and compelling problem solving efforts compared to this go nowhere and offer so little idea that is the disease “model.” And it is being empirically tested, albeit in piecemeal fashion currently, so it can eventually be pitted head to head against other definitional frameworks and treatment models, where I am fairly certain it will prove its relative superiority — it’s usefulness will be established by virtue of its ability to help people more and to help more people.
Mind Issues Over Matter
Addiction involves a set of “mind issues,” not a collection of “brain problems”. “Addiction is something we do, it’s not something we have.” It involves volitional behaviors — our actions that have varying degrees of ‘intention’ behind them — that represent what the will “had in mind” at the time the behaviors occurred. And the behaviors can and do occur at different levels of awareness.
This means the mind may appear to have more to do with making the behaviors happen — at higher levels of awareness; or the mind may appear to have very little to do with the behaviors, such as when a person is in a trance, semi conscious, or totally unconscious state. We may not “feel” like our mind is in charge when we are dreaming, but it is. It is from a clearer understanding of the levels of awareness idea that we can effectively re-construe dependency, cravings, and compulsivity.
The intentioned activity of the living being cannot be directly mapped onto brain impulses. Even though we seem so committed to trying, we simply can’t identify willful activity occurring in meaningful space as being directly determined by brain activity occurring in physical space. My feeling a need to get clean mixed with some desire to relax that moves me to take a bath cannot be found in my amygdala.
My memory of my late mother’s face is not a matter of specific neurons or inner chemistry doing a specific bio-driven dance. It is my mother, and she is more than an idea, let alone the physical machinery that is perhaps “necessary” for there to be volitional action but yet is SO FAR from “sufficient” to explain it.
My feelings associated with my memories, and my feelings that occurred in relation to her over the course of my life were far more determined by the meanings that I held in relation to her and they can’t be reduced to the levels of dopamine and serotonin or the relative regional brain activity or the particulars of some pattern of cortical inter-stimulation. Mothers don’t exist for us as a set of physical inner activities.
They take up a large amount of space in our meaningful worlds; they’re pretty damn important to us, and there is no such “thing” as important that we can find inside the hardware of the brain. Only the mind can “do” important in this complex and nuanced way.
Instead of looking for the brain basis of what we do, we are better off trying to figure out the mind’s role in making addiction happen in the first place and in getting past it in recovering. A disease process is not the “force” that drives the mind processes and the behaviors that constitute an addiction. Drugs and alcohol may make people sick — a set of disease processes can show up in the middle of a person “doing” their addiction — but some underlying physical-mental sickness does not make people get addicted no matter how much the diseasing of the brain ends up being conducive to their staying addicted.
Drugs, addictive activities, and soothing behaviors (the binkie for child or adult) are the downfall of some people. For all humans Desire and frustration are linked meaningfully, and the dynamics involved in these sorts of links are what serve as the motivational forces for becoming and staying addicted.
Fuck you and fuck me and fuck the world — as stances we might take in relation to having more frustration rather than satisfaction of our deepest desires don’t lead to healthy outcomes . . . they are breeding ground for long term addiction.
The chip on one’s shoulder stemming from major losses, or for another person experiencing horrible damage to his or her self esteem . . . this is what makes addiction “happen.”
The argument that the brain changes over time with extended or chronic use I think is indisputable. People definitely can and do screw up their brains by frying them with toxic material. However, the argument that the brain changes that occur with exposure to toxins are evidence of an incipient physiological condition that “pre-existed” or is awakened by substance use, is specious.
It’s bullshit, to put it less technically. Overly simplistic, medical-model based, reductionistic bullshit. It’s limiting and it inappropriately misdirects people’s’ efforts, as I suggested above.
The disease “propensity” or physiological predisposition is not a disease at work in this case. The parallel would be cancer existing as a pre-existing “potential future disease manifestation” that makes people smoke in order to have the disease that is cancer have a better than chance chance of more fully developing in the future. If “future cancers” could make you smoke in the past or present, then the disease model of addiction could fit. Or, imagine that pre-existing type ll diabetes could make people eat and be couch potatoes in order to eventually produce the full blown syndrome. Seems pretty silly actually. We should not continue with this mistake of confusing what are clear ‘effects’ for putative causes.
Your learning history is what predisposes you to addiction — this is one primary conclusion to draw from the ACE study (Adverse Childhood Experiences study, Felitti and Anda, 1995). In case you haven’t heard of it, the ACE study was a large epidemiological study that originated in the 90s (and is still ongoing) that showed a very strong connection between number and degree of emotional/psychological wounds in childhood and the development of a whole host of problems in living AND physical diseases later in life, and this includes addiction. Traumatic and wounding experiences in childhood lead to manifestations of Mind and Body negatively valenced reactions throughout the lifespan.
You might argue such experiences change the brain, and you’d probably be right. But it is the emotional and “Meaningful” fallout that motivates the various self destructive and self defeating behavioral tendencies people develop.
What most therapists intuitively understand is there is some hard to clearly delineate but nevertheless very real and impactful link between your experiences in life, especially the more traumatic ones, and your emotional reactions to life. There is clearly a link of some kind between human being’s emotional reactions and their defensive responses.
There is clearly some connection between our emotional reactions, or defensive response patterns and our way of dealing with our emotional challenges in the course of our lives. Aside from traumas and the fallout from them, who you are in this sense is largely influenced by your developmental struggles and the interpersonal dynamics of your family of origin. Discussions about disease and brain function are not compatible with an exploration of causal contributions from learning histories or interpersonal relationships.
The Challenge of the Complexity
If we are going to claim that we truly understand addiction we have to be able to explain psychological or emotional dependency, compulsivity, cravings, moral decay, developmental arrest, obsession, interpersonal dynamics, individual differences, social conditions, and all the volitional behaviors and their ramifications involved in each person’s “doing” their addiction. That’s a tall order.
Unless you wholly buy the idea that the nature of the diseased brain is responsible for all the above, you don’t end up with a concept that is comprehensive enough or sufficiently coherent in terms of explaining cause-effect relationships.
The fact that we find PET scans and fMRI images that show changes occurring after a person begins excessive substance use does not prove anything about causation. It merely shows correlational correspondence. In my first year of grad school at UConn in my Statistics and Research Methodology course we all learned correlation is NOT to be confused with causation. It was like the “Newton’s first law” of statistics.
Legitimate neuro-scientists don’t just throw terms like nucleus accumbens around carelessly as if this ability to discern location and relevant activity meant they found the holy grail of causation. What shows up in the aggregate revelations gleaned from the pictures of brain activity may suggest the existence of some legitimate cause-effect relationships, but our current library of validated neuroscience findings does not come close to legitimizing our taking that explanatory leap.
I assume the researchers do actually see relative changes in activity (like X-Ray techs they can read the rads or their equivalent on films or their equivalent) and they argue the meanings of these findings to the limits of their ability to validly draw scientific conclusions: in other words, they responsibly speculate about a particular region and pertinent structures playing some sort of role in a larger process. Read that summary article or some other articles referred to in that article and observe how many times their conclusions are appropriately couched in tentative terms, e.g., saying “May” have an impact, or “May” be relevant.
They know they have not proven anything, at least not yet, or so far. They’ve observed some potential patterns that suggest the possibility of cause-effect linkages. We could instead end up concluding we are looking at effect-effect links, or coincidental occurrences, and more research (as usual) is required to further clarify the findings and the potential conclusions we could or would draw provided said findings are replicated.
Will and Compulsion
The hijacking of the pleasure center at the expense of sound judgment is not due to a disease per se. Our will does not stop driving the volitional behavior bus before the brain deteriorates, and just because the brain changes or deteriorates, the will doesn’t stop being “responsible” for the living system’s taking action. Judgment is clearly impaired by inebriation, so I’m not saying that there is no potential for there being causal influences stemming from the brain change elements; but our will does not suddenly become a slave to the brain. If there ends up being some slave/master relationship between the will and the substance, it is because the will has “abdicated” control. It has not been kidnapped.
This is a classic category mistake being made in terms of the effects being conflated or confused with cause. In the werewolf legends the will is taken over “against the person’s will.” Addicts are not werewolfs in terms of the addictive process. It is my will that “makes me” pick up the drink, or the cigarette, or the food, and it is the ongoing picking up that changes the brain, and while the brain “effects” recursively affect the structure of the will, it does not “take it over.”
On some meta-level it is inappropriate for us to think that the mind-body conundrum has been ultimately resolved. The “lazy” adoption of the disease concept does a disservice to the theorists and philosophers who to this day find themselves still trying to “solve” this very large puzzle of human existence. As a psychologist I am partial to leaning in the mind direction, while those from the medical camp tend to lean toward body-based explanations.
This split is reflective in all debates about addiction causation and it is well represented in the differences between psychology and psychiatry. We have not conceptually determined the “final answer” to this ongoing debate, and it is plausible that we never will.
Addicts are not zombies no matter how much they can end up looking or acting that way. The human has not become a robot to the point that he/she robotically would say: “My motivation and reward centers have been taken over by some foreign forces and I am now an automaton that has no power and no autonomy or accountability.” Again, if a person willfully did make such a statement it would be inherently contradictory.
Surely, some addicts end up feeling this way and will say so, but that doesn’t make it operationally factual. The person with Alzheimer’s still wills water drinking behavior when thirsty, and speech behaviors when interacting with others, even while the brain deterioration associated with this disease is making those activities a lot less “functional” and appropriate relative to history or expectations. The disease is not the will no matter how much it messes up the functioning of the will.
The discussion about compulsivity is a discussion of weak willed states, the origins of which are not caused by a brain process even though they could be presumed to be so. If my love of heroin makes my will go weak, so I can’t say “no” to it even after I’ve been verbalizing lots of “Nos” about it, is that my disease weakening my will, or my will BEING the problem directly? Surrendering of this “addict’s will” and submitting to a higher power is a starting point in the 12 step model.
This is an effective will/body re-clarification that helps a lot of people. To do this I have to take ownership of my history of failures to take ownership. Yes, it is paradoxical. It has to be since my will has to do the surrendering. Interestingly, when I’ve gone on roller coasters I willfully get on, then I fail to surrender as the riders who seem to enjoy the ride tend to do. I keep trying to control the action and it makes it no fun and even troubling for my body. Reclaiming all previously disclaimed action helps to re-orient me to my being in charge despite my feeling I have no ability to control anything important.
The addict is no more “diseased” in his or her compulsivity and dependency than the human infant is in its “overpowering need” for the pacifier or the security blanket. Do those babies that have an unusually difficult time giving up their “binkie” or “blankie” have a diseased brain? Are adult addicts really responding and relating to the “substance” and their worlds in general all that differently from the “resistant-dependent” baby?
Only Fools Rush In . . . Explanatorily
The penchant “lay” people (and journalists) have to draw hard and fast conclusions based on scientific “findings” that they don’t truly understand brings to my mind the implications of the Dunning-Kruger Effect. Wikipedia sums up this phenomenon nicely:
“The Dunning–Kruger effect is a cognitive bias in which relatively unskilled individuals suffer from illusory superiority, mistakenly assessing their ability to be much higher than it really is. Dunning and Kruger attributed this bias to a metacognitive inability of the unskilled to recognize their own ineptitude and evaluate their own ability accurately. Their research also suggests corollaries: highly skilled individuals may underestimate their relative competence and may erroneously assume that tasks which are easy for them are also easy for others.”
It should also be pointed out there is a lot of money at stake and an assortment of other significant vested interests in “buying and selling” the disease model and its implications to the masses. It’s big business, even if it’s so routinely bad business or “dirty” business.
From my perspective addiction is a mind problem first and foremost; it is a mind “dysfunction” that causes brain functioning problems, not the other way around. This mind problem leads to volitional behavior that eventually takes a toll on the body, including the brain. The ‘disordered’ mind can kill the body this way; and the ‘diseased’ body that results from lengthy addiction or severe addiction can “kill off” the mind, in turn and the body along with it. We can just as readily conclude that addiction is the mind trying to eventually kill the body, not the other way around.
Dr. Lukens has shared this excerpt from his upcoming book on addiction, which he has not yet “titled” but which will more fully explain his view of the Physics of Emotioning as these ideas are applied to the problem of addiction.
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