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The "Disease" Model

I get a bit hung up on words from time to time. I often ask my clients to clarify a word or idea so that I can have as close to an exact understanding of their experience as possible. I have noticed that many communication breakdowns occur through how people interpret the meaning of words. Certain words tend to bring up complicated emotions and meanings for different people.  I have been thinking a lot lately about the “disease” model of addiction, specifically the “disease” part.

The disease model asserts that certain individuals have an unfortunate genetic predisposition towards becoming addicted to a substance or behavior, which can obviously lead to numerous health and social maladies. Legitimate, empirical research has demonstrated that a genetic predisposition does exist in addiction through twin studies and the abundance of dopamine receptors we carry; the fewer you have, the more likely you turn to addiction to feel better.

I am not refuting the term “disease model” in any way. I think it has done wonders in destigmatizing substance use and has helped countless souls seek out treatment from medical and recovery based providers with the goal of “curing” the disease. “Disease” is a highly emotionally charged word and its antithesis is “cure”. Disease is a word that mobilizes action in that people tend to seek a cure when they have been told they have a disease as opposed to a moral failing or psychological issue. The use of this one word highlights the power and conflicts around the words we choose and the various meanings that emerge.

There are a lot of seemingly very bright people heavily invested discrediting the disease model. Individuals that struggle with addiction have been known to engage in some unsavory and anti-social behaviors in service of the addiction. It is challenging for family members, providers, and policymakers to view these behaviors through the lens of a “disease” and put aside their initial negative emotional responses to what we so eloquently call in the treatment industry, “addict behaviors”. I do not find the goal of discrediting the disease model of addiction to be particularly helpful since it feels like trying to define the word “disease” is more of a semantic pursuit rather than anything that can expand our understanding of addiction and how to treat it. In fact, I think it further stigmatizes and shames the person struggling with addiction.

In my experience, the physiological damage and alterations addiction causes is very much a disease that requires specialized medical care. However, developing an addiction follows the similar course of any mental health disorder. Addiction utilizes our brain and body’s natural operational systems against the self, much like anxiety, depression, PTSD, etc. And yes, there is a strong genetic component with those concerns as well. The difference is that addiction treatment embraces the term “disease” while policy makers, providers, and researchers have long struggled with the exact manner of defining mental health issues. Some are in favor of calling depression and anxiety a “disorder” or an “illness”, while other camps attempt to normalize and destigmatize this phenomenon as routine human experiences we simply need to be more open about.  My manner of reconciling this contradiction is to view any mental health issue as a combination of genetics, life experience, and normal psychological functioning culminating in a personal experience that impairs health and functioning.

There are seemingly a lot of seemingly very bright people heavily invested in discrediting the treatment industry. Having worked in it, that is understandable; there are some truly abhorrent and unethical practices going on. That is a topic is for another time. I do however think the treatment industry, through sheer competition and scrutiny, has been forced into doing a better job of tending to the psychological and emotional factors behind addiction. In that process, nurturing self-awareness, excavating trauma, and taking an inventory of personality dynamics have made a comeback in opposition to the misguided fatalism of the disease model.

Genetics aside, there are a whole host of psychological factors fueling addiction. Successful recovery models need to address these forces. At the core of many addictions is dysfunctional affect regulation. Affect regulation is a fancy way of describing how we experience and control our emotional states. EVERY SINGLE client with addiction I have worked with has struggled with problematic emotions like anger, boredom, sadness, anxiety, and shame. Substances and behavioral addictions (process addictions) are effective in that they offer the individual temporary relief from these states but at a gradual and insidious long-term cost.

In addiction, our brain’s standard functions begin to work against us. The brains develop neural networks linking emotion, desire, movement, thoughts, and memory into habitual patterns, especially in the case of rewarding behaviors like an addiction. We develop scripts for how to handle just about every situation. Novel experiences can be stressful since we have yet to develop a script for our behavior. Once we engage in a behavior and our brains learn successful strategies for the situation, a neural network or script emerges that the person unconsciously relies on in the future. The more often we complete a chain of rewarding behaviors, the more automated and difficult to break it becomes. Eventually, the original emotions that prompted the substance use fade into the background as a stark physiological dependence develops (the disease) solidifying the addiction. The addiction eventually creates a new baseline physiology that is at constant risk of dipping into painful withdrawal symptoms without the substance. Usually, this is when the addicted individual’s life begins to catch fire around him or her.

It pains me to say it but our personalities are largely out of our control and based on an accumulation of interactions with the closest people in our environments interacting with our pre-determined temperament. We tend to internalize our caregiver’s personality traits for better or for worst. I see it in my own life as my father’s behaviors are now seemingly my own without any say on my part! This dynamic can set the stage for addiction if healthy affect regulation was not modeled in the family or worse yet if trauma was experienced. The child growing up in these environments has a difficult challenge of not allowing these behaviors to become blueprints for the architecture of their emerging personalities. Children that experience trauma are especially vulnerable and do not have the maturity to recognize the dysfunction within their environments; they simply internalize and develop their scripts about themselves and their world.   

My way of reconciling the term “disease model” is to view addiction as a psychological, emotional, and relational phenomenon rooted in how one manages emotional states that eventually turns into a set of physical signs and symptoms that can require medical treatment or at the least behavioral health intervention. More severe presentations of any mental health-related concern or addictive behavior can eventually fit the criteria for a disease due to physiological implications that can disrupt or flat out destroy one’s functioning.  

Epigenetics has taught us that we all have a variety of genes that can diminish one’s quality of life, but it is our environment that ultimately activates and reinforces them. Overcoming addiction and breaking the generational transmission of addiction is not simply about getting sober and spending your remaining days cataloging and avoiding triggers. Learning how to get in touch with, accept, and skillfully manage difficult emotional states is where true transformation is born. This transformation can then extend outward to partners and children thus creating an environment that values healthy emotional expression and coping, thus breaking the chain of addiction.

It is human nature to want to escape that which hurts. That tendency can sometimes lead to more hurt. Is addiction a “disease”? Eventually, but it starts with unexpressed or unheard emotional pain.

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