Why the 'Disease Model' Fails to Convince Americans That Addiction Is a Health Issue

In America, the D-word in the context of addiction has come to mean something much different from the word "disease" used for any other condition -- something that unfortunately is more moral than medical.
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By Maia Szalavitz

These days, everyone from Obama's "drug czar" Michael Botticelli to former Republican presidential candidate Chris Christie strenuously emphasizes that addiction is a disease, not a sin.

Such proclamations have been earnestly made for over two centuries now, starting with physician and Declaration of Independence signer Benjamin Rush in the early 1800s. Indeed, the American Medical Association declared alcoholism a disease in 1956 and did the same for other drug addictions in 1989.

But these declarations have a hollow ring to them: They wouldn't need to be remade constantly if the idea were truly accepted. No one goes around issuing statements about how "cancer is a disease" or "AIDS is a disease" or even "schizophrenia is a disease," because it's pretty obvious that they are.

From my perspective, addiction is clearly a health and medical problem -- no different from depression or attention deficit/ hyperactivity disorder (ADHD), both of which are influenced by biological, social, cultural and developmental factors. However, in America, the D-word in the context of addiction has come to mean something much different from the word "disease" used for any other condition -- something that unfortunately is more moral than medical.

So why don't Americans really buy the idea that addiction is no different from "diseases" (if we choose to use that word) like depression?

I think there are two fundamental problems that undermine the way arguments about treating addiction as a health issue are made: The first involves the criminalization of drug possession; the second, the 12-step model of treatment.

"No one goes around issuing statements about how 'cancer is a disease' or 'AIDS is a disease' ... because it's pretty obvious that they are."

Neither of these issues actually has anything to do with whether or not addiction is a medical condition -- but both deeply undermine the case for medicalization. Indeed, I think that disease model supporters have often, inadvertently, been their own worst enemies.

Lack of acceptance of the disease model can be seen everywhere -- from the "let them die" (and worse) comments on articles about people with addiction, to the War on Drugs, to the segregation of addiction treatment from mainstream healthcare. Although there isn't much polling on the question, the research that has been done suggests that despite all the proclamations, many, if not most, people still don't see addiction as genuinely medical.

A 2006 study, for instance, which looked at alcoholism, found that 65 percent of 630 people polled in a general population sample said that the condition was due to "bad character." Only 47 percent saw it as a problem of brain chemistry and/or genetics. (People were allowed to endorse more than one cause).

And research published in 2014 found strong moral stigma associated with addiction: 90 percent of respondents, for example, would not want someone with addiction to marry into their family, and 78 percent did not want to work alongside addicted people. Those rates are far higher than those who would similarly reject people with mental illness.

So what's behind the ongoing prejudice? Let's return to those two main factors that I believe are responsible.

The first is criminalization. There is no other illness that can get you arrested simply for displaying symptoms; but it is impossible to be addicted to illegal drugs without breaking the law. This matters here because one of the key purposes of criminalization is to create moral stigma: The idea is that this behavior is so bad, we will put you in prison with murderers, rapists and others whose actions are terrible enough that society must isolate and cage them to protect itself and punish the evildoers.

As a result, criminalization itself undermines the disease model. We don't treat anyone else who has a "disease" with punitive incarceration simply for being affected. While our jails have unfortunately become warehouses for people with mental illness, if you have psychiatric problems and are not at risk of harming anyone or violating other laws (and this is the case for the majority of us who have such diagnoses), the police do not have cause to arrest you. If you are addicted to drugs, however, you must possess them in order to take them.

Also, when the public portrayal of addiction is almost always in the context of crime, it's hard to take medical claims seriously. Images of arrests, handcuffs, prisons, jail cells, courts and police officers standing in front of large quantities of drugs undermine medicalization by promoting the idea that drug use is itself criminal and that therefore, drug users are sinful by nature. In addition, criminalization in and of itself creates greater connections between people with addictions and illegal or immoral behavior: The high prices caused by prohibition, the marginalization of people with criminal records, and the fact that it is necessary to hide illegal activity all combine to make it difficult for even the most ethical people who are addicted to avoid deception and criminality.

"In no other condition do we see allowing patients to suffer the worst possible symptoms -- AKA 'hitting bottom' -- as appropriate, let alone effective care."

What's more, there is no other disease for which a judge can dictate which medications are allowed or banned: If you have cancer, the standard of care entitles you to the therapy that is linked with the greatest survival rate, even if you are in prison (whether you actually get it or not, of course, is another question). But if you have addiction, the only treatment known to reduce mortality by 70 percent or more -- maintenance with methadone or buprenorphine -- can be denied to you either by a drug court judge, or by a jail or prison.

Further, in no other condition do we see allowing patients to suffer the worst possible symptoms -- AKA "hitting bottom" -- as appropriate, let alone effective care. And in no other disorder is denying access to symptom-relief seen as acceptable medicine.

With addiction, however, jails, prisons and even hospitals routinely deny access to medical care that could relieve suffering because of the misguided idea that suffering itself will help solve the problem. Some programs even deliberately inflict emotional pain and humiliation.

This brings us to the second main reason Americans resist the current disease model: the ubiquitous influence of 12-step programs.

From the 1980s to the 2000s, 90 percent of U.S. addiction treatment was based on getting patients to buy the ideas of 12-step programs and become members; now that is apparently down to 80 percent, but the approach is still overwhelmingly dominant. Indeed, the position is so entrenched in the addiction treatment establishment that the American Society of Addiction Medicine actually defines addiction as a disease with "characteristic bio-psycho-socio-spiritual manifestations."

The "spiritual" part is something no other medical specialty feels compelled to mention in its official documents.

While 12-step programs claim to be "spiritual, not religious," they aren't like any other mainstream medical or psychological treatment. Do oncologists ask cancer patients to find a Higher Power? Do psychiatrists suggest that people with depression must to take "a searching and fearless moral inventory"? Do any other patients routinely get told by the medical professionals that their problem involves "defects of character"

While this language -- taken directly from 12-step programs -- remains a fundamental part of treatment, why would anyone believe it is a medical issue, rather than a problem only bad people have?

Indeed, if you sought any other type of medical care and were informed that the best treatment is meeting others with your condition, praying, confession and restitution, you'd likely rapidly conclude that you were seeing a quack -- or at the very least, had wandered outside of mainstream medicine.

In addictions, however, this profoundly moralizing treatment is mainstream. And that leaves many disease model folks arguing out of both sides of their mouths.

"It's a disease like any other," they insist -- while touting a treatment that would be considered faith-healing in general medicine and psychiatry, one that also implies moral failure. As a result, it's no surprise that the public, seeing the prominence of the 12-step approach, thinks the word "disease" belongs in scare quotes for addiction, and hides a wink and a nod because the "treatment" is really either incarceration or God.

None of this is to say that some people don't find the Steps helpful -- it's just that they really aren't an argument for the disease model.

"You can't simultaneously criminalize addiction and destigmatize it."

If addiction is a disease, the treatment should be evidence-based and led by doctors, not patients -- sure, there are spiritual support groups for people with cancer and depression, but these do not replace chemotherapy or appropriate use of antidepressants. If I get brain surgery, I am not entitled, 90-days-to-one-year later, with no education beyond my own experience, to perform it on someone else.

If we really want people to see addiction as the health problem that it is, we can't have treatment in which most -- or really any -- of the content is aimed at getting people to uncritically accept the Steps. And we also can't criminalize drug possession and allow the courts to dictate what medical care is acceptable, in ways that they aren't allowed to do for any other disorder.

Both the dominance of 12-step-based rehabs and counseling and the integration of the current treatment system with the criminal justice system undermine claims that addiction is a disease.

You can't simultaneously criminalize addiction and destigmatize it. Nor can you call it medical at the same time as you treat it like a moral issue -- at least if you want to convince anyone that you actually believe what you say. To move forward, we need to separate self-help and social support from medical care. We need to get punishment and prayer out of treatment.

Then we can create a health model of addiction that genuinely informs effective treatment and policy, rather than undermining them.


Maia Szalavitz is a columnist for The Influence. She has written for Time, The New York Times, Scientific American Mind, the Washington Post and many other publications. She has also authored six books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). Her latest book is Unbroken Brain: a Revolutionary New Way of Understanding Addiction. Her last column for The Influence was "The Rehab Industry Needs to Clean Up Its Act. Here's How." You can follow her on Twitter: @maiasz

This post originally appeared on The Influence.


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