Psychologist and neuroscientist Marc Lewis has had run ins with addiction many times in his life. As a scientist, he studies the effects of drugs and alcohol on our brains in the lab. When he practices clinical psychology, the discipline under which he received his formal training, he has spoken to and counseled many addicts, both current and former. (He estimates that he’s talked to hundreds, if not thousands of addicts.) Finally, he himself was an addict throughout his young adulthood, a period of his life that he chronicled in his first book, “Memoirs of an Addicted Brain.”
All these experiences have led Lewis to a unique perspective: He believes that addiction is not a disease.
His new book, “The Biology of Desire: Why Addiction Is Not a Disease,” uses both scientific arguments and the narratives of five different addicts to make Lewis’s case. There are several reasons why we’ve been inclined to view addiction as a disease, he writes. Scientifically, for instance, addictions actually do change the biological makeup of the human brain. In addition, in a social context, proponents of the disease model argue that classifying addiction as disease will reduce stigma and shame, thereby encouraging addicts to seek help and treatment.
While Lewis acknowledges that the disease model has its uses, he generally believes that the rationale behind it is insufficient and, in many ways, completely false. Instead, we should view addiction as an issue of habit. This doesn’t preclude it from being a problem — of development, perhaps — but to call it a disease can actually be counterproductive and hinder many addicts from recovery, he says.
Lewis spoke to us recently about the problem of the disease model as it relates to addiction, but also about broader issues relating to medical practices of the Western world in the 21st century.
What exactly are the broader negative implications of calling addiction a disease?
In my mind, I divide it into a scientific debate and a social, terminological debate. On the scientific side, I present several reasons in the book for thinking about addiction as a learning phenomenon, a developmental process rather than a pathology. Let’s put that aside and talk about the social aspect.
Why is the disease label harmful regardless of its merit? First of all, the other side of the debate is pretty much exemplified by Nora Volkow. She is the head of NIDA, the National Institute on Drug Abuse. NIDA funds about 90 percent of the addiction research in the world, not just in the U.S. It’s incredibly powerful. Her position is we need to call addiction a disease because addicts need help: If we don’t call it a disease, they’re not going to get the help they need. Her second point is that the shame, the humiliation, the degradation, the notion of addicts being morally repugnant needs to be combated, and if we see them as sick, then we’re not going to denigrate them because we don’t put down people for being sick.
I think both those arguments are completely wrong. If addiction is a disease, then it has to be treated by medical processes and policies. So what does that amount to? In the actual treatment and rehab industry, you have people giving drugs that either simulate or counter the effects of the addictive drug. There’s suboxone, which is what they give mostly. It’s kind of like methadone, and it’s basically an opiate. You can give it to people to relieve withdrawal symptoms, and they might stay on it indefinitely or they might come off of it. But once you come off of it, you’re vulnerable. If there haven’t been psychological changes, you’re very vulnerable to relapse again. Maintenance on methadone and suboxone is really another form of addiction. You still have to take this drug every day. That’s a pretty heavy opiate.
The other kinds are opiate or alcohol antagonists, which make you sick if you drink, for example. The trouble with those kinds of medicines is that people stop taking them because they want to get high. If you’re on a medicine that keeps the drugs or drinks from having any effect, people very often just stop taking them.
That’s about all medicine has been able to offer. It’s a fairly small drop in the bucket. There are so many psychological, social and developmental factors in addiction, and these medicines are really just attacking one aspect of it.
The next point is that the rehab and treatment industry isn’t very effective because medicine doesn’t have a lot to offer. There’s a well-known revolving door phenomenon. People go back to rehab again and again. It’s not unusual for people to show up at rehab five or 10 or 15 times. They show up, they get clean, they get straight, they come out, they relapse, and they come back again. There’s something wrong with the whole industry. I think a lot of that is that it’s based on a medical model. We’re going to treat your disease, we’re going to give you your medications, you’re going to go home, and you’re going to be fine. But they’re not. Calling addiction a disease in that sense isn’t helping anybody.
The third point is that rehab is so expensive. The centers now run from $10,000 to $100,000 per month — the latter for the so-called high-end luxury rehabs. It’s way too much money. People can’t afford that. The high-end rehabs don’t actually do a better job than the low-end ones. They’re a lot more pleasant, which could be good to get a break, but that has nothing to do with medicine. For the most part, the rehab industry is sucking people in, charging them an enormous amount of money, making huge profits, and generally not helping people. We don’t know the numbers because they don’t keep good outcome statistics. In Anne Fletcher’s book “Inside Rehab,” she makes it very clear many people don’t answer the centers’ calls to report back and say how they’re doing, especially those who have fallen off the wagon. But a lot of the centers don’t even try. It’s really a twisted, corrupted industry. I don’t want to get too much into it because others have written extensively on the topic. Because the rehab industry is based on the medical model, calling addiction a disease is actually working against people getting better.
The other thing that Nora Volkow and others emphasize is that if we don’t call it a disease, we’re going to revert to the bad old days where we call it a moral deficit: People are basically sinners, they’re weak-willed, selfish and irresponsible. That produces a lot of shame, and shame is a pretty horrible emotion and it doesn’t really help people. Is that right? Should we call it a disease to avoid shame? I think no, partly because being told you have a chronic brain disease that causes you to act badly and there’s nothing you can do about it doesn’t actually reduce shame very much. It can produce shame, especially among young people who want to feel that they have some agency and a chance to construct their lives. This can seem like a death sentence.
I’ve talked to hundreds, probably thousands of addicts, and most addicts, especially recovered addicts, recoil at the idea of thinking that their addiction is a chronic disease, especially if they’ve worked really hard to get out of it. These people are trying to reconstruct their attitudes, change their perspectives, work on their willpower and self-control. There’s a lot of effort involved, and that doesn’t jibe with the idea that addiction is a disease and you have to give it to the experts to fix. I don’t think the disease label absolves people from guilt and blame. But when it does, that’s not necessarily even a good thing. I think a certain amount of shame and blame is probably appropriate. People don’t try to fix themselves if everything’s okay. You have to feel that you’re doing something wrong to work hard to repair it. Massive amounts of shame can be quite toxic in personality development, but a small amount is probably healthy.
One last point: When you call addiction a disease, that means that by definition, addicts are patients. They’re part of an expert-driven hierarchy. They’re told what to do and they’re supposed to follow a particular regimen. The whole notion of empowerment and self-efficacy gets completely quashed. And yet, a lot of people who work with addicts recognize that self-efficacy and empowerment are massively important factors that help people get better. You need to have the feeling that, “I can do this, I can get over it, I have the capacity to do so.” In addiction counseling, and especially motivational and cognitive techniques, that sense of agency is actually encouraged and nurtured. I don’t think we want to take it away by saying people have a disease.
Your book discusses the Alcoholics Anonymous approach to overcoming addiction as it relates to the disease model, and also as a rather powerless approach. How are the two models similar and different? Can seeking help through AA ever be empowering, as it’s often depicted to be in popular media?
It’s a messy and controversial issue, and it’s been in the press a lot. It’s hugely popular in the U.S. and throughout most of North America and Europe. People have strenuously argued against it because it’s not scientifically based. The first step is to acknowledge your lack of power. There’s a certain tribe of people out there, let’s call them “AA-bashers.” I’m not one of them. I’m more neutral about it. They often point to the first step and say, “Well, in fact, addicts require empowerment.”
There’s this emergent barrier between AA and the disease model. It didn’t necessarily start out like that. Bill Wilson talked about alcoholism as many things: a spiritual malady, a psychological issue, and also a physical issue. But the whole disease nomenclature didn’t catch up to AA until the ’50s and ’60s, and now they’re joined at the hip. That’s partly because AA has become institutionalized within these treatment centers and rehabs. When you go to group in a church basement, they don’t require the disease terminology, but when you go to rehab and you’re paying $30,000 or $50,000 a month, they say, “Your addiction is a disease, and we’re going to deal with it that way. By the way, we do 12-step meetings every night.” They merge the 12-step philosophy with the disease concept. You get this unholy amalgam that includes the worst of both worlds: Bible-thumping on the one hand, and pseudo-science on the other.
What do I think? I think the success rates of AA are notoriously not that great. That’s not entirely a fair accusation because the people that they do help are long-term addicts who’ve tried a lot of different things, and they need a stringent and maybe dogmatic environment in which to hold on. Also, AA stresses mutual support and brotherhood, and that’s important: feeling surrounded and loved by people when you’re an addict. But the powerlessness issue and the disease issue are really complicated. Intelligent people who support AA say it’s not about powerlessness — that’s just the first step. You move on from accepting the fact that you’re out of control to taking control of your life. Well, that makes sense to me. I think the AA bashers need to be a little more careful about how they vilify the 12-step phenomenon.
The book discusses how many behaviors that result in the same neurological changes as addiction are not classified as diseases. Notably, I’ve noticed that people generally don’t see tobacco smoking as a disease, even though it is widely known as an addiction. What do you make of this?
That’s a really good point; I haven’t thought about that very much at all. It’s true that nicotine addiction and smoking is one of the hardest things to kick. The epidemiological stats show that the median time to quit after starting for cocaine is four years. For marijuana, it’s six years. For alcohol, it’s around 12, I think. For tobacco, it’s 30 years. It’s the most troublesome, insidious addiction of all. We know it kills people more definitively and predictably than heroin or cocaine. You can take heroin for a long time and not cause your body long-term damage, but that’s not the case with tobacco. With smoking, we know what kind of damage it does.
Why don’t we call it a disease? I don’t know; that’s a really good point. It’s been socially acceptable in our culture for hundreds of years. You compare that with sticking a needle in your arms and shooting something that comes from some field in Afghanistan — yeah, there are some different social accoutrements there. I guess that really reveals the degree to which the disease terminology and concept is really arbitrary. It’s a function of our societal interpretations, our norm violations and stuff, rather than logical scientific concept.
And what about behaviors that aren’t classified as addictions at all, but have the same neurological effects?
There are other hard-to-break, seriously emotional habits, like falling in love or falling in lust — which can still get you into a whole lot of trouble, especially if you’re falling in love with someone who is married to somebody else. These things look neurologically similar. People don’t want to believe that, but the influx of the dopamine to the striatum, to the ventral striatum, the functional dissociation between the striatum and the prefrontal cortex, which in English means you’re no longer really thinking or judging very well. You’re acting on impulse. We all know that’s what happens when you’re deeply hooked in a romantic relationship. And it’s so many other things: It’s jealousy in a marriage, or societal habits, like a desire to keep making and spending money. These are driven by impulse and not by logic. A lot of the same brain dynamics underlie them. The idea that drug addiction is this phenomenon that’s cut off from all these other bad habits is just wrong. It’s a societal thing to want to put it in a cage, and to want to put the people who do it in a cage as well. Thinking of it as a disease helps us get away with that.
You’re fairly critical of the Western medical establishment as being a facilitator of the disease model for addiction. Have you looked into other health systems or philosophies? How do they view and resolve the problem of addiction?
Nora Volkow, her name keeps coming up because she is the spokesperson for the disease definition. Some people think she’s awful because she takes the stance so strongly. Some people love her for that specific reason and think she’s a savior. I met her at one-week dialogue with the Dalai Lama about a year and a half ago called “Creating Desire and Addiction,” and she came out with her usual stuff about the disease of addiction, not really thinking twice about it. Even though I disagree with her, I really respect her a lot as a scientist and someone who sincerely believes in what she’s saying.
But here we were sitting with the Dalai Lama for a week, and no one was questioning whether we should treat addiction as a disease at all. Finally, I got frustrated and said, “Come on, guys!” I talked about how Buddhism considers all of personality development to be a product of craving and grasping. These are the fundamental Buddhist psychological elements. We grasp for something and then we feel empty, and then you go back and you do it again. It seemed absurd to me that we weren’t talking about that more. I think in Buddhism, desire and grasping are fundamental to human nature. From that perspective, what’s addiction? It’s not that unusual. It’s an embodiment and an exemplar of how human beings get stuck in their attractions.
Here’s another viewpoint: I was in South America recently. In many other cultures, people will take intoxicants, often fairly mild intoxicants, throughout their lives. They’ll chew on coca leaves, or do this and that, and nobody thinks twice about it. Of course, we get the sense that to chew these things or to smoke this stuff, you feel a little different. Why shouldn’t you help direct the way you feel by nudging it this way or that way? It’s not in any way considered to be antisocial or evil or self-indulgent.
What are your thoughts on the broader mental illness discussion? Should we reevaluate our consideration of depressive disorders, anxiety disorders, or personality disorders as diseases?
That’s an interesting area. You go down the spectrum. Depression and anxiety are very common, so you might not call them diseases. Then you keep progressing in that direction and you get to bipolar disorder, schizophrenia, and wait a minute! Now it really does look like a disease. Where do you draw the line?
There’s the anti-psychiatry movement that was pretty big in the ’80s and ’90s that said, “Well, we don’t really want to call any of these things diseases because we don’t have a right to talk about how anyone’s mind works as being right or wrong.” That was an important pushback against the power of the psychiatric community, which wanted to get a box and cage people, saying, “Well, if you’re feeling this way, we’ll give you these drugs and make you feel better.” Now that we’ve gone through that, we still consider people who are really crazy and have voices telling them to do bad things, we can conceive of that as an illness, whereas the kind of depression your friend felt after his wife left him just isn’t. I think drawing the line is really difficult in that spectrum. In truth, everything that we feel, the way our minds work, all our modalities of thought and impulse and consciousness and attention, they’re all biologically rooted. Every moment has to do with ongoing neurochemical changes and trajectories. In a way, if you were standing inside your brain instead of outside, you’d say it’s all just cellular stuff happening, and there’s never any line. On the other hand, some people’s brains are working so differently that their behavior is what’s putting them over that line, and we have to put that in a category if its own and say, “This is different. This is not okay.”
I don’t know if I’m answering your question. I was depressed for a while, and my depression is what led me to my addiction. That was in my late teenage and young adult years. Depression is pretty nasty, but I never felt that it was an illness of any sort. A lot of my friends have battled with depression of different sorts. Let’s face it: Life is pretty fucked up in all kinds of ways. It’s full of loss and frustration and disappointment. I was trained as a clinical psychologist also, and I became used to that way of thinking about things: looking something up and saying x equals y. I guess psychiatry takes it in one direction. It’s a branch of medicine, so you make a list of symptoms and give it a category and figure out what drugs are best suited to make it go away. Meanwhile, psychologists are more interested in functional issues — not giving it a label so much as how it came about, how it might be adapted, and how it might continue to change with ongoing development. I think that’s, in many ways, a more human, effective and productive way of thinking about people’s thoughts and emotions and getting along in the world — and I extend that to addiction.