Addiction is not a Disease – there are alternatives to AA
The Truth About Addiction and Recovery
Why It Doesn’t Make Sense To Call Addiction A “Disease”
We frequently hear from people who say:
“I drink too much sometimes, but I don’t think I’m an alcoholic. And I don’t want to stand up and talk about myself in front of a group. Is there any other way I can change the way I drink?”
“I’m overweight, but I understand that people are born to be fat and there’s not much you can do about it. I know I’ve tried to lose weight a million times and failed. Does this mean I’m doomed to be overweight?”
“I saw an ad saying the only way to kick your addiction to nicotine is by going to a doctor. Is that really true? Don’t people ever quit smoking on their own?”
“My father was an alcoholic. Does that mean I’m likely to become an alcoholic myself? Should I play it safe and quit drinking altogether? A friend of mine joined a ‘Children of Alcoholics’ group, even though she’s never even been drunk. Should I join such a group? And what about my kids?”
“My son was caught smoking marijuana. Now I’m told that, unless I place him in an expensive residential treatment program, he could escalate his drug use and die. I don’t have the money for this but, of course, if I have to save his life I’ll mortgage the house!”
People are so much concerned about bad habits (which sometimes reach life-consuming proportions) that they’d like to do something about-drinking, smoking, overeating, taking drugs, gambling, overspending, or even compulsive romancing. We hear more and more that every one of these things is a disease, and that we must go to treatment centers or join twelve-step support groups like Alcoholics Anonymous in order to change any of these behaviors. Is there really no other way to change a powerful habit than to enter treatment for a disease? Do personal initiative, willpower, or just maturing and developing a more rewarding life have anything to do with people’s ability to overcome addictive habits?
As children, as spouses, as parents, as employers, as consumers, and as citizens we must struggle to understand and master the destructive potential of drugs, alcohol, and related addictions. The kinds of questions so many people face today include: What do we do if we discover our children are smoking marijuana, or worse? Should we put them in a treatment center that will teach them they are chemically dependent for life? How can we tell if co-workers, employees, and friends are secretly addicts or alcoholics? What is the most appropriate way to react to people who drink too much or do anything that harms themselves and others?
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Furthermore, as a society, how should we deal with these problems? Are our incessant wars on drugs really going to have the positive impact the generals in these wars always claim? Or is there some more sensible or direct way to reduce the damage people do to themselves through their uncontrollable habits? Rather than arrest drug users, can we treat addicts so that they stop using drugs? And if we expand the treatment for all the addictions we have seen—like shopping and smoking and overeating and sexual behavior—who will pay for all this treatment? Finally, does addiction diminish people’s judgment so that they can’t be held accountable for their behavior, or for crimes and financial excesses they commit while addicted?
What you will read here is not the same as what you see and hear in newspapers and magazines, on television, in addiction treatment centers, in twelve-step groups, and in most physicians’ and therapists’ offices or what your children are learning in school. For in its desperate search for a way out of the convulsions caused by drug abuse and addiction, our society has seized upon a simple, seductive, but false answer.
The simple but incorrect answer we constantly hear is expressed by the familiar statement, “Alcoholism is a disease.” In other words, we can treat away these problems in a medical setting. This viewpoint has proved so appealing that it has been adopted by professional organizations and government agencies as well as by groups like Alcoholics Anonymous. And now the “disease” label is applied not only to alcoholism, drug addiction, cigarette smoking, and overeating, but also to gambling, compulsive shopping, desperate romantic attachments, and even committing rape or killing one’s newborn child! A.A.’s image of “powerlessness over alcohol” is being extended to everything that people feel they are unable to resist or control.
But what lies behind the claim that alcoholism and other addictions are diseases? How accurate is it? What evidence supports it? Most important, what good does it do us to believe it? Will it really help you or someone you care about to overcome an addiction? We strongly believe that addiction is not a disease. What’s wrong with calling a tenacious and destructive habit a disease? Three things:
- It isn’t true.
- It doesn’t help most people (and even those it does help might succeed just as well in some less costly, less limiting way).
- It prevents us from doing things that really would help.
As you will see, there is no good reason to label yourself or people you know as forever marked by an addictive “disease.” Challenging this useless folklore is the first step toward understanding addiction and doing something about it.
Then we will present an alternative way of thinking about and dealing with addiction called the Life Process Program. The accompanying table previews the major differences between the Life Process Program and the disease model of addiction.
Myths Versus Realities
To highlight some of the surprising facts we will reveal, here are some common beliefs about various addictions:
- A person needs medical treatment or a program like Smokenders to quit smoking.
- Attending Alcoholics Anonymous meetings is the most effective way for alcoholics to stop drinking.
- Nearly all regular cocaine users become addicted.
- Very few people who have a drinking problem can ever drink in a normal, controlled manner.
- Drunk drivers who undergo treatment for alcoholism are less likely to repeat the offense than those who receive normal judicial penalties such as license suspension.
- Most people with an alcoholic parent become alcoholics themselves.
- Most people who are binge drinkers in their twenties go on to become alcoholics.
- Most of the American soldiers who were addicted to heroin in Vietnam remained addicted or became addicted again after they returned home.
- The fact that alcoholism runs in families means that it is an inherited disease.
- Fat children, because they have inherited their obesity, are more likely to be fat in later life than are people who become fat as adults.
Actually, the best scientific evidence available today indicates that none of these statements is true. Such specific misconceptions grow out of a foundation of false assumptions about the nature of addiction generally.
|Ten Assumptions that Distinguish the Life Process Program from the Disease Model
||LIFE PROCESS PROGRAM
- Addiction is inbred and biological.
- The solution is medical treatment and membership in spiritual groups such as A.A.
- Addiction is all-or-nothing; you are or you aren’t an addict.
- Addiction is permanent and you can relapse at any moment.
- Addicts are “in denial” and must be forced to acknowledge they have a disease.
- The recovering addict/alcoholic is the expert on addiction.
- Addiction is a “primary” disease.
- Your main associates must be other recovering addicts.
- You must accept the disease philosophy to recover.
- Surrendering to a higher power is the key to recovery.
- Addiction is a way of coping with yourself and your world.
- The solution requires self-awareness, new coping skills, and changing your environment.
- Addiction is a continuum; your behavior is more or less addicted.
- Addiction can be outgrown.
- You should identify problems and solutions in ways that work for you.
- Those without an addiction problem are the best models.
- Addiction stems from other life problems you have.
- You should associate with a normal range of people.
- Getting better is not a matter of believing a dogma.
- You must develop your own power to get better.
What Is the Disease Model of Addiction?
At first, it seems hard to understand what is meant by saying that something a person regularly does (such as· drinking alcohol) is a disease. Habitual, voluntary behavior of this sort does not resemble what we normally think of as a disease, like cancer or diabetes. What is more, A.A.—and even hospital programs for alcoholism—don’t actually treat any biological causes of alcoholism. After all the claims we have heard in the past decade about biological discoveries concerning alcoholism, not one of these findings has been translated into a usable treatment. Instead, the same group discussions and exhortations that have been used for the last fifty years are employed in hospital programs. Nor is any biological method used to determine whether someone is an alcoholic other than by assessing how much that person drinks and the consequences of this drinking. And if we have no special biological information about treating or identifying alcoholism, we surely know nothing about the biological causes of “diseases” such as compulsive gambling, shopping, and loving, which have nothing to do with drugs or alcohol.
There is, however, a standard way those who claim addiction is a disease describe addictive diseases. This description has been developed by groups such as Alcoholics Anonymous, by the medical profession, and by various popularizers of the idea that alcoholism is a disease. What they say is in every regard wrong. When they tell you that you have the “disease” of alcoholism, “chemical dependency,” obesity, compulsive shopping, or whatever, this is what they mean:
The basis of the disease is inbred and/or biological. There is no need to look for the causes of the disease in your personal problems, the people you spend time with, the situations you find yourself in, or your ethnic or cultural background. Addiction is bred into you from birth or early childhood. Your current experience of life has nothing to do with it; nothing you can do makes you either more or less likely to become addicted.
It involves complete loss of control over your behavior. Once involved in your addiction, you are utterly at its mercy. You cannot choose whether, or how much, to lose yourself in the involvement. No matter how costly it may be in a given situation, you will go all the way. You cannot make reasonable, responsible choices about something to which you are addicted.
Addictions are forever. An addictive disease is like diabetes—it stays with you as long as you live. The mysterious bodily or psychic deficiency that lies at the root of addiction can never be remedied, and you can never safely expose yourself to the substance to which you were addicted. Once an addict, always an addict.
It inevitably expands until it takes over and destroys your life. “Irreversible progression” is a hallmark of addictive diseases as they are conceived today. The addiction grows and grows until it devours you, like AIDS or cancer. No rewards, no punishments, not even the most momentous developments in your life can stay its course, unless you completely swear off the addictive substance or activity.
If you say you don’t have it, that’s when they really know you have it. According to this “Catch22” of the disease theory, anyone suspected of having an addictive disease who insists that he or she doesn’t have the disease is guilty of the added offense of “denial.” In this way, the “disease” label is like a web that traps a person more firmly the harder the person fights to get out of it.
It requires medical and/or “spiritual” treatment. Thinking you can cure your addiction through willpower, changes in your life circumstances, or personal growth is a delusion (like denial), according to disease-theory proponents. Addiction is a disease of the body that can be controlled only by never-ending medical treatments. It is also a disease of the soul requiring lifetime membership in a support group like Alcoholics Anonymous. Why supposed medical treatment consists mainly of going to group meetings and why people can’t develop their own spiritual approaches to life if they choose are questions disease theory adherents ignore.
Your kids are going to get it, too. Since addiction is an inherited disease, the children of addicts are considered at high risk for developing the same disease—no matter what you or they do or how careful you are. Logical deductions from this viewpoint are that you should have your kids tested for their genetic predisposition to alcoholism or addiction before they start school, or that you should simply teach them never to touch a drop of alcohol or expose themselves to whatever your addiction is. Obviously, this approach presents special difficulties in dealing with addictions to eating, shopping, and making love.
Where did these notions come from—notions that, when examined in the clear light of day, often seem quite bizarre and contrary to common experience? The disease theory takes a set of precepts that were made up by and about a small group of severe, long-term alcoholics in the 1930s and applies them inappropriately to people with a wide range of drinking and other life problems. The original members of Alcoholics Anonymous, realizing they would soon die if they did not give up alcohol, adopted wholesale the dogma of the nineteenth century temperance movement. The one major difference was that the A.A. members said drinking was a disease only for them, and not for everyone who drank—therefore not everyone needed to eschew “demon rum,” as temperance advocates had insisted.
The A.A. model has struck a responsive chord among Americans. Obviously, with the rejection of Prohibition, the United States had decided against a national policy that everyone should abstain from drinking. Yet American society continues even today to show a deep unease about alcohol and about intoxication, which many people seek even while fearing its disturbing effects. Given this national ambivalence, we have been drawn to the “old-time religion” of temperance, as represented by A.A., now cloaked in the modern language of medicine and the neurosciences. But, as this book will make clear, the operative assumptions about addiction have never arisen directly from biological sciences. Rather, they have been superimposed on scientific research, much of which directly contradicts the assumptions of the disease theory.
Why the Disease Model Is Wrong
Every major tenet of the “disease” view of addiction is refuted both by scientific research and by everyday observation. This is true even for alcoholism and drug addiction, let alone the many other behaviors that plainly have little to do with biology and medicine.
No biological or genetic mechanisms have been identified that account for addictive behavior. Even for alcoholism, as the following chapter will show, the evidence for genetic inheritance is unconvincing. By now, probably every well-informed reader has heard announcements that scientists have discovered a gene that causes alcoholism. In fact, as one of us wrote in The Atlantic, this is far from the case, and the study that prompted these claims has already been refuted by another study in the same journal. Moreover, if a gene were found to influence alcoholism, would the same gene cause drug addiction? Would it be related to smoking? Would it also cause compulsive gambling and overeating? If so, this would mean that everyone with any of these addictions has this genetic inheritance. Indeed, given the ubiquity of the problems described, the person without this inheritance would seem to be the notable exception.
How could an addiction like smoking be genetic? Why are some types of people more likely to smoke than others (about half of waitresses and car salesmen smoke, compared with about a tenth of lawyers and doctors)? And does believing that an addiction like smoking is genetic help the person quit (are all those smokers who quit not “genetically” addicted)? Returning to alcohol, are people really predestined biologically to become alcoholics and thus to become A.A. members? Think about the rock group Aerosmith: all five members of this group now belong to A.A., just as they once all drank and took drugs together. How unlikely a coincidence it is that five unrelated people with the alcoholic/addictive inheritance should run into one another and form a band!
The idea that genes make you become an alcoholic cannot possibly help us understand how people develop drinking problems over years, why they choose on so many occasions to go out drinking, how they become members of heavy-drinking groups, and how drinkers are so influenced by the circumstances of their lives. Genes may make a person unusually sensitive to the physiological effects of alcohol; a person can find drinking extremely relaxing or enjoyable; but this says nothing about how the person drinks over the course of a lifetime. After all, some people say, “I never have more than one or two drinks at a time, because alcohol goes straight to my head.”
As we document here and in the following chapter, we can actually predict the likelihood of people’s becoming addicted far more reliably from their nationality and social class, from the social groups they join, and from their beliefs and expectations about alcohol or drugs (or other activities), than from their biological makeup. Often, people who become addicted set themselves up by investing a substance or an experience with magical powers to transform their beings (“Getting drunk is great”; “When I drink I’m really at ease”; “Drinking makes me attractive to people of the opposite sex”). It is simply not within the chemical properties of alcohol or a drug, or the experience of an activity like shopping, to offer people what they want and seek from an addiction.
People find this in an addiction when they believe they can’t achieve the feelings they need in ordinary ways. Clearly, attitudes, values, and the opportunities available in a person’s environment have much to do with whether the person has a significant risk for a particular addiction.
People do not necessarily lose control of themselves whenever they are exposed to the object of their addiction. On the contrary, many practice their addictions quite selectively. For example, military and religious personnel are often deprived of tobacco during training or on retreats, and business people realize they can’t smoke in certain rooms. Orthodox Jews who smoke heavily abstain from smoking on the Sabbath, showing that their religious values mean more to them than nicotine does. Alcoholics in experiments routinely control their drinking when it is in their interest to do so—say, when they must leave a cozy room with television and companionship in order to get more to drink. These variations occur in real life just as they do in the laboratory—for example, when people avoid drugs or cigarettes when they are with people who won’t tolerate those habits. When something they really care about is jeopardized if they continue to drink, smoke, or whatever, most people will stop or cut down accordingly.
Addiction usually does not last a lifetime. “Once an addict, always an addict” is a pessimistic notion that is both wrong and harmful. It leaves people two choices: either you stay constantly addicted and miserable until you die; or you abstain for life while attending group meetings and viewing yourself as the perpetually “recovering” person. Sadly, a small number of people do die of their addictions; and another group succeeds in quitting drinking, drug taking, or whatever by maintaining the role of the recovering addict. But most people are more resilient and resourceful than that. Most people who have addictive habits moderate or eliminate these habits over the course of their lives. And they do it without having to say “I am an alcoholic” or “I am an overeater” or “I am a sex addict” as long as they live. Remember that, today, a majority of the adult Americans who have ever smoked have quit and nearly all did so without treatment.
Progression is not inevitable—it is the exception. If the majority of people give up addictive habits, then the idea of “inevitable progression” doesn’t hold water. Calling addiction a “progressive disease” comes from looking at the few who have progressed to severe addiction and tracing the path by which they got there. The progression of addictive problems only seems inevitable after the fact. For example, the great majority of college overdrinkers, even those who black out at fraternity parties, become moderate drinkers in middle age. When you consider that even most of the people who use narcotics and cocaine do not end up addicted, you can see that drug-and-alcohol use patterns are many and varied, even when a person uses a substance abusively for a time.
Treatment is no panacea. Contrary to all the advertising we hear, treatment for addictions is often no more effective than letting addiction and recovery take their natural course. The vast majority of people who have given up addictions (beginning with more than 90 percent of the forty-four million Americans who have quit smoking) have done so on their own. This does not mean that treatment for addictions cannot work—research has shown that some forms of treatment are effective. But the ones that are more effective are not the ones that have become popular in the United States.You can outgrow an addictive habit on your own or in therapy, but either way the principles of the Life Process Program are the same.
What about joining support groups such as Alcoholics Anonymous? Here, too, research reveals the opposite of what we have been led to believe. A.A is a valuable community resource for those who find support in a certain type of religiously oriented group ritual. But the best we can say about A.A is that it works for those for whom it works. Meanwhile, there are plenty for whom it doesn’t work. There is no scientific evidence that A.A. works better than other approaches when randomly selected alcoholics are assigned to A.A. or other treatments. In fact, the evidence is that the people who are now often compelled to attend A.A—after being arrested for drunk driving or being sent by a company Employee Assistance Program—do worse than those who are left on their own.
How can we reconcile this finding with the glowing testimonials we hear about A.A.? The people we see in A.A. are the ones who like it, find it helpful, and stick it out. But there are many others who don’t go to A.A. or who don’t like it and drop out. And as we show below, those who seriously try to stop drinking on their own are more likely to maintain their abstinence than those who attend A.A. In addition, since many more people try to quit on their own than through therapy or joining a group, the number of self-curers is triple or more the number of successful treatment or A.A cases. But such self-curers are not very visible, because they are individuals without an organized group to publicize their success.
These, then, are the key fallacies of the popularly held view of addiction. Even generally well-informed people may be astonished that we contradict such widely held beliefs. All of our refutations of conventional wisdom are carefully documented in the notes at the back of the book. But you don’t need to read scholarly articles and scientific reports to test the accuracy of what we say. Just check it out against your own experience and observation. Don’t you know anyone who used to drink excessively, at times uncontrollably, but who no longer drinks at all or now drinks in a normal, appropriate manner? Obviously, most people who used to drink excessively but who have now cut back (or even quit) do not attend meetings where they must rise and declare, “I am an alcoholic.” How many people of all ages do you know who quit smoking? How many of them did it by going through a medical program or joining a support group, and how many finally just decided to quit and made good on that resolve? What happened to all the people you knew who used illegal drugs in college, some quite heavily? How many of them are “chemically dependent” now? If we simply examine the cases of most of those we are close to personally, we will see how addictions usually do not follow the disease course.
Why the Disease Model Doesn’t Work— Why It Even Does More Harm than Good
The assumption that calling addiction a “disease” actually helps people crumbles when subjected to critical scrutiny. Some people feel comfortable thinking of their addiction as a disease and are able to function better on this basis for a time. But whatever short-term benefits medical, disease-oriented treatment produces are double-edged even for the individuals who claim it has helped them. Many of the most “successful” recipients of disease treatment might achieve a real breakthrough by learning to think about addiction differently. Meanwhile, for the majority of people, the disadvantages of the disease approach clearly outweigh the advantages from the start. The disadvantages of the disease approach are that it:
- attacks people’s feelings of personal control and can thus become a self-fulfilling prophecy;
- makes mountains out of molehills, since it fails to differentiate between the worst alcoholics and addicts and those with minor substance-use dependence;
- stigmatizes people—in their own minds—for life;
- interrupts normal maturation for the young, for whom this approach is completely inappropriate;
- holds up as models for drinking and drug use the people who have shown the least capacity to manage their lives;
- isolates alcoholism and addiction as problems from the rest of the alcoholic’s or addict’s life;
- limits people’s human contacts primarily to other recovering alcoholics or addicts, who only reinforce their preoccupation with drinking and drug use;
- dispenses a rigid program of therapy that is founded—in the words of the director of the government’s National Institute on Alcohol Abuse and Alcoholism (NIA.A.A)—“on hunch, not evidence, and not on science,” while attacking more effective therapies.
How can therapy that so many people believe in and swear by actually do more harm than good? To illustrate this point, consider the case of a famous psychiatrist who evaluated his hospital’s alcoholism program—one he felt was among the most outstanding in the world. This program first detoxified the alcoholic in the hospital, then mandated A.A. attendance, and finally actively followed patients’ progress with an outreach counseling program. When the psychiatrist running the program, Dr. George Vaillant, evaluated how well his patients were doing two years and eight years after treatment, however, he found they had fared about as well as comparable alcoholics who received no treatment at all!
How could Vaillant have been so wrong as to think his patients were doing phenomenally well, when actually they were doing no better than if he had left them alone completely? Naturally, he wanted to think it worked. But his research prevented his rose-colored views from distorting the actual results of his treatment. When he counted all his patients, not just his successes, when he scrutinized and verified what they were telling him in order to see exactly how well they were doing, and when he compared them with alcoholics out on their own instead of just assuming that all these people died without the help of treatment like his, Vaillant found that his expensive hospital treatment was close to useless.
Very few people in the treatment industry or in A.A. are as scrupulous as is Vaillant. When we hear from A.A. boosters, they tell us only about those who have stuck with the program and are currently sober. The same is true of treatment programs. They parade their best stars up front. We don’t hear about all their failures. Yet Vaillant, in a book that is cited as the major source of support for the benefits of treating alcoholics according to the disease model, concluded as follows: “If treatment as we currently understand it does not seem more effective than the natural healing processes, then we need to understand those healing processes better.” Indeed, Vaillant repeats another researcher’s conclusion that “it may be easier for improper treatment to retard recovery than for proper treatment to hasten it.”
What are the dangers of this kind of disease treatment? Here are explanations of the disadvantages listed at the beginning of this section:
It sets people up for failure. All disease treatments emphasize how much out of control “patients” are, and what a delusion it is for them to feel they can exert any control over their addictions. Is it possible that such a message can do more harm than good? William Miller and Reid Hester, reviewing all the comparative studies on treatment for alcoholism, made a surprising finding: in the only two studies in which alcoholics were randomly assigned either to A.A., to other forms of treatment, or to no treatment, those assigned to A.A. did no better or actually suffered more relapse than those who received other treatment or who weren’t treated at all! Intrigued by this outcome, one of us wrote George Vaillant and asked him whether subjects he studied who abstained without entering formal treatment did better if they joined A.A. Again, A.A. members were less likely to maintain their abstinence.
Why would people be more likely to relapse if they entered A.A. than if they quit drinking on their own? There are several reasons. For one, people who enter A.A. are told they cannot succeed on their own. Therefore, if they should stop attending A.A., many are convinced that they will soon resume alcoholic drinking.
A.A. and disease treatments are especially defeatist in dealing with relapse. Accepting the disease-oriented philosophy of inevitable loss of control thus makes it more likely that the alcoholic will binge if he or she ever has a drink. Yet, Vaillant found, nearly all alcoholics will drink again at some time.
It makes matters worse than they are. Can attending A.A. or going into addiction treatment really cause people to develop some of their alcoholism symptoms? In his book Becoming Alcoholic, sociologist David Rudy reports on the time he spent observing A.A. meetings. Rudy found that most people had to learn their role as alcoholics. An important “rite of passage” is the first time members tell their story for the group, beginning by acknowledging, “I am an alcoholic.” In Rudy’s words, the alcoholic’s tale “is made up of two parts: a story about how bad it was before A.A. and a story about how good it is now.” This presentation is warmly greeted by the member’s sponsor in A.A., and the entire membership responds with enthusiastic acceptance of the convert.
When alcoholics introduce their experiences and symptoms in or treatment, the group or therapist homogenizes them through interpretation and clarification. For example, most people who enter have not had blackouts, which are more typical of long-term alcoholics than of the younger drinkers now flooding into treatment and A.A. But blackouts are taken as the badge of alcoholism, and according to Rudy, “members learn the importance of blackouts as a behavior that verifies their alcoholism, and an indeterminable number of members who may not have had blackouts report them.” Rudy continues:
When newcomers to A.A. claim that they cannot remember if they had any blackouts or not, other members use this claim as evidence of the event in question. As one member put it to a newcomer: “The reason you can’t remember is because alcohol fogs your brain. If it fogs your brain now after not drinking for a few days it must have fogged your brain before. See, you must have had blackouts then.”
A large part of alcoholism and drug treatment in America consists of group meetings where alcoholics or addicts “confront” one another and their problems. Newcomers who don’t report the correct symptoms are treated with knowing condescension or are actively hazed—sometimes quite abusively—until they “get” and repeat the party line. When Dwight Gooden entered the alcoholism-andcocaine program at the Smithers Alcoholism Center, he described being assailed by his fellow residents there during the constant group-therapy sessions. “My stories weren’t as good as theirs. . . . They said, ‘C’mon, man, you’re lying.’ They didn’t believe me. . . . I cried a lot before I went to bed at night.”
After he left the Betty Ford Center, Chevy Chase reported that he had often been angry at the counselors, who heckled the residents mercilessly, constantly denigrating them and claiming they had been living worthless lives. Does all this sound like good therapy technique? It is simple common sense that belief in your personal value and your own strength is superior to having these things denigrated for getting your life under control.
It stigmatizes people for life. The disease model puts a label on you that you can never outgrow. Once diseased, always diseased. The effects of this defeatist view are especially tragic—and unjust—in the case of people to whom the “disease” label is most inappropriately applied in the first place: teenage binge drinkers, most drunk drivers, “adult children of alcoholics,” recreational drug users discovered through drug tests, and—in areas not involving drugs or alcohol—overweight adolescents or “hyperactive” or “learning-disabled” children.
It brutalizes and brainwashes the young. The largest single age group of people undergoing hospital treatment today for chemical dependency, eating disorders, depression, and so forth is adolescents. A.A. members are also much younger today, on average, than when the fellowship was founded by a group of men with serious, lifelong drinking problems. Nonetheless, virtually none of these young people meet clinical standards of alcoholism or drug addiction. Indeed, numerous cases have been identified in which young people have been hospitalized for smoking marijuana or even for being suspected of using drugs. When one such case was revealed on national television, an unusually forthright consultant for the National Association for Alcoholism Treatment Programs confessed, “I’m afraid this happens far more than people in the field want to admit; it’s something of a scandal.”
Meanwhile, A.A. and Alateen (for teenage children of alcoholics) groups now pervade high-school and college campuses. What is the impact of treatment that forces teenagers to take on the identity of addicts or alcoholics or children of alcoholics?
Young people are warned that their substance abuse is a permanent trait, even though we have seen that a large majority will outgrow substance-abuse problems as they mature. Presenting this message to the young can only prolong or exacerbate their substance abuse, since it denies their own capacity for change and forces them to believe that any substance use for the rest of their lives will lead them back to excess, addiction, and drunkenness.
Young treatment grads who constantly relapse and return to treatment are the norm, as in the cases of Carrie Hamilton, Erinn Cosby, Drew Barrymore, and other young “patients” whose stories are less well publicized. Of course, the relapses are then attributed to their “disease” and to their failure to heed the treatment’s warning to abstain forever.
These programs fairly frequently involve emotional abuse. Such “treatments” for children include “refusing to allow them to wear street clothes, keeping them in isolation for prolonged periods, or forcing them to wear self-derogatory signs, engage in other humiliation rituals . . . , or submit to intense and prolonged group confrontation” all of which, psychologists believe, “may destroy the youngsters’ already fragile self-esteem.” When we describe these experiences, treatment specialists often argue in response, “Well, what if the kids would end up dead if we didn’t do this to them?” In other words, to object to these programs is likened to promoting intoxication leading to death. Certainly, it is crucial to prevent children from harming themselves, and it can be worthwhile to remove children from a problem home, whether through a residential program or a visit to a sympathetic relative. But brainwashing, emotional blackmail, denigration, and psychological torture never work, except to make people so unsure of who they are or what they value that they will temporarily consent to the demands of those in charge.
Worst of all, therapies that were devised for the most incorrigible children—though they don’t benefit even these unfortunate kids have been spreading down the ladder to more and more children whose behavior represents typical adolescent exploration and insubordination. Parents are then confronted over whether they want to “save” their kids or allow them to die, as though the latter were the normal outcome of adolescence. The threat of their children’s dying is then used as emotional blackmail to make parents accept the sacrifices necessary to place their children in expensive residential treatment programs.
It presents the alcoholic or addict as someone to emulate. Prominent graduates of treatment programs, like Drew Barrymore, Betty Ford, Kitty Dukakis, and a host of athletes now lecture to others about chemical dependency. If alcoholics and drug abusers suffer from a disease and are now recovering, then they can educate others about the disease and even about how young people should live and behave. If, on the other hand, we think of them as people who are tremendously poor at self-management, then it is indeed stupid for the rest of us, who have not been seriously addicted, to ask them for advice and information. Someone like former football star Bob Hayes explains that he took and sold drugs as a result of an inherited disease. One reviewer’s reaction to Hayes’s book, Run, Bullet, Run, could stand for any and all of these confessional tracts: “Aside from a brief closing statement on personal responsibility, he self-servingly portrays himself as a victim throughout the book.”
Alcoholics and addicts like Hayes regularly come into schools to relay their tortured drinking experiences and to reiterate that alcohol is a dangerous drug. But nearly every child in these schools will drink. It is as though the schools wished to undermine children’s sense of self-control and to attack their chances of becoming normal drinkers, which in most cases their “nonexpert” parents are. In treatment itself, “recovering” addicts and alcoholics counsel the drug or alcohol abuser—who usually has not drunk as destructively and hurt himself or herself as much as the counselors! In all types of twelve-step groups, the most severely debilitated person tends to become the leader and model for others, so that the most out-of-control shopping addict tells others about the nature of their problems. Who should be counseling whom? In the case of drug abuse, a number of reviews have found that informational and scare lectures by recovering addicts produce the worst results of all prevention programs. These programs have never yet been found to reduce drug use; on the contrary, several studies have found increased drug use in their aftermath.
It ignores the rest of the person’s problems in favor of blaming them all on the addiction. When someone like Carrie Hamilton lectures about her youthful drug abuse and delinquency (often alongside her mother, Carol Burnett), she makes drug abuse and family failures sound like mysterious, unavoidable illnesses that some people and their parents “have.” Of course, this excuses her and her mother from dealing with painful problems they would prefer to avoid. But by adopting the disease identity as her protection through the rest of her life, the youthful convert guarantees that she cannot grow beyond the limitations of her adolescent family life. Can people hope for more than this?
When treatment views alcoholics as being victims of a different body chemistry that forces them to become alcoholics, the treatment process ignores the person’s life problems and the functions drinking serves for the alcoholic. For example, in family therapy where the alcoholic’s drinking is addressed as simply the result of a disease, the therapist and the family are not able to understand that some people use alcohol to air feelings they cannot express when sober. Ignoring dynamics like these leaves the drinker unable to cope with the things that led him or her to need to drink—such as doubts about self-worth, a difficult relationship with a spouse, roles (such as homosexuality) that create conflict for the person, and so on. If the labeling of alcoholism as a disease provides welcome relief from the shame of overdrinking. it also prevents people from confronting the emotional tasks they need to accomplish to attain personal wholeness.
It traps people in a world inhabited by fellow disease-sufferers. Many “recovering” people report that they feel comfortable only with others in exactly the same plight. They find they can’t create intimacy outside of treatment and that they are driven constantly to talk about their alcoholism or addiction. This is a frequent hang-up for recovering alcoholics who attend A.A. meetings so religiously that they can’t maintain a life outside of the group. The phenomenon of compulsive therapy attendance has made many people ask us, “Is there such a thing as addiction to treatment?” Indeed there is, when people rely on a twelve step group or therapy to the point where it disables them from conducting outside relationships and activities.
One of us has treated a number of A.A. members or treatment graduates who now fear they can’t deal with normal society. One man, who was regularly asked to head his local A.A. group, had dated a series of women he met at A.A. Unfortunately, all of these relationships had ended in bitterness and mutual recriminations. But when he tried to date outside the group, he discovered that nonalcoholic women found him overbearing and compulsive. “I don’t want to be limited for the rest of my life to dealing with alkies—I’d like to think I can advance beyond that, “ he plaintively told us. This man felt that dealing exclusively with alcoholics was debilitating him, and yet he couldn’t escape A.A.
It excludes other approaches, many of which are more successful. Even if one accepts that many A.A. members are happy and successful, it is simply absurd to discourage people from trying to recover without A.A. The National Council on Alcoholism and Drug Dependence (NCADD) frequently announces statistics about the continually rising costs of alcoholism and the increasing number of alcoholics in our society. But, then, the NCADD is capable only of calling for more of the standard approach to treating alcoholism that has accompanied these increases, while discouraging all alternative approaches. Why should things improve all of a sudden if we simply do more of the same? The A.A. approach to America’s drinking problems has shown conclusively that it cannot make a decisive difference for most active problem drinkers, since there are very few alcoholics who aren’t already aware of—or who haven’t already attended—A.A.
Meanwhile, greater numbers of Americans are being forced to enter private treatment centers and A.A. as a result of court orders, Employee Assistance Programs, or school counseling programs. Despite the almost universal belief that compelling people to attend standard treatment programs is helpful, these programs regularly demonstrate they are no more effective than self-initiated programs for curing addictions. Psychologists William Miller and Reid Hester, reviewing all the comparative studies on treatment for alcoholism, made a surprising finding: “virtually all of them [the standard treatments] lacked adequate scientific evidence of effectiveness.” At the same time, they discovered, the “treatment approaches most clearly supported as effective . . . were very rarely used in American treatment programs.” What don’t really work in the long run are the conversion-experience type treatments; what do work are therapies that teach people skills at self-management and coping.
Nonetheless, most American treatment personnel seem hell-bent on eliminating any other treatment for alcoholism besides twelve-step programs. In the United States, discredited disease-treatment programs—ones that NIAAA Director Enoch Gordis believes may be “frequently useless and wasteful and sometimes dangerous” —proliferate and spread into whole new areas of behavior. This issue is important because the United States spends more money on health care than any other country—and the percentage of our gross national product that we spend on health care is growing faster than that in any other country. The fastest-growing component of the health-care system is substance abuse and related mental-health treatments. According to a hospital trade publication, “psychiatric, chemical dependency and rehabilitative hospital care—all largely unregulated by government payment mechanisms—are booming.”
This is one reason so many companies are being forced to cut insurance benefits or are asking employees to pay a greater share. What if your insurance rates were raised to pay for a fellow employee who was undergoing a repeat treatment for cocaine addiction, since he had relapsed one or more times? How would you feel about sharing the bill for a colleague who entered an expensive hospital eating-disorders clinic? Do you think that smokers who want to quit should enter treatment programs and be excused from work, with pay, while they concentrate on quitting? And, especially, how would you react if you had quit smoking on your own? It is morally and economically necessary for us to evaluate the effectiveness of alcoholism and other addiction treatments. For we are wasting limited health-care resources to place people in expensive treatments—treatments that have not shown they do more than inexpensive, straightforward skills counseling or than people accomplish on their own—often more reliably!
Kitty Dukakis: “Chemical Dependency” Reduced to Absurdity
Kitty Dukakis became the paradigm of the addicted person of the 1990s. Kitty Dukakis has been eager all along to accept the “disease” and “chemically dependent” labels. Advertisements for her autobiography, Now You Know, trumpet the opening line of the book, “I’m Kitty Dukakis and I’m a drug addict and an alcoholic.” Mrs. Dukakis seemingly has been either addicted or in treatment throughout her adult life. Shortly before she joined her husband in his 1988 presidential campaign, she revealed that she had been treated for a twenty-six-year reliance on diet pills, which she began before she married Michael Dukakis. Soon after her husband’s defeat in the election, she began to drink herself unconscious and underwent a series of treatments for her alcoholism and for a variety of emotional problems.
That treatment did not succeed. Mrs. Dukakis only began getting drunk after the election, for which she first entered the Edgehill Newport hospital. But soon after this treatment experience, she began having explosive relapses in which she drank rubbing alcohol, nail polish remover, hair spray, and other commercial products containing alcohol. Moreover, she discovered during the course of writing her book that she suffers from another disease— manic-depressive disorder—and as a result she ends the book with the revelation that she is receiving lithium treatment. Previously, Mrs. Dukakis had been prescribed Prozac, a drug featured on the cover of Newsweek in 1990 as a new miracle in the treatment of depression, to no avail.
Mrs. Dukakis appears, in the book and on television, a forlorn being. Indeed, syndicated columnist Ellen Goodman, who had known Mrs. Dukakis, wrote a column entitled “Do Our Drug Treatment Programs Label Patients as Losers?” Ms. Goodman wondered aloud how labeling oneself as sick and without hope is helpful. “What happens when those who wrestle with problems of self-esteem are required to wear such a label? . . . Today, Kitty Dukakis describes herself by diagnosis. Drug addict. Alcoholic. Manic-depressive.” Ms. Goodman ended her column by wishing that Kitty Dukakis might see the brighter qualities that others have seen in her, and which seem entirely to have disappeared thanks to her various diagnoses and cures.
It seems clear that excessive drinking is only the tip of Mrs. Dukakis’s problems, and that medical treatment will never get to the bottom of them. Labeling Kitty Dukakis as a “sick” person who needs medical treatment is a palliative for her uncomfortable marital and personal problems. Reviewers have commented about how insensitive and unaware of her problems Michael Dukakis appeared to be, yet Kitty never reflects on the limitations of her spouse or their relationship. Somehow, her never-ending disease-oriented treatment fails to raise crucial issues for Mrs. Dukakis about a life and marriage she seems to have found intolerable. Will Kitty Dukakis be writing another book in which she reveals she has discovered she is suffering from one more dis-ease—that of codependence?
With Kitty Dukakis as a prominent model of the addict/alcoholic, those who look to her life for answers are being fed yet another self-defeating solution. To call Kitty Dukakis’s and her audiences’ problems diseases is to evade reality, much as Mrs. Dukakis used diet pills and alcohol to do. Whether the pain Mrs. Dukakis and others feel is temporary or persistent, relatively mild or relatively severe, it does not need to rule the rest of their lives. Kitty Dukakis and the rest of us are more than our misery and problems. Moreover, what troubles her and those like her are life problems, not diseases. And when we have reduced them to life size, we can begin to deal with them reasonably and hopefully.
The Experience of Addiction
The question is: “If addiction isn’t a disease, then what is it?” An addiction is a habitual response and a source of gratification or security. It is a way of coping with internal feelings and external pressures that provides the addict with predictable gratifications, but that has concomitant costs. Eventually these costs may outweigh the subjective benefits the addiction offers the individual. Nonetheless, people continue their addictions as long as they believe the addictions continue to do something for them. It is important to place addictive habits in their proper context, as part of people’s lives, their personalities, their relationships, their environments, their perspectives. The effort to change an addiction will generally affect all these other facets of a person’s life as well.
An addiction may involve any attachment or sensation that grows to such proportions that it damages a person’s life. Addictions, no matter to what, follow certain common patterns. We first made clear in Love and Addiction that addiction— the single-minded grasping of a magic-seeming object or involvement; the loss of control, perspective, and priorities—is not limited to drug and alcohol addictions. When a person becomes addicted, it is not to a chemical but to an experience. Anything that a person finds sufficiently consuming and that seems to remedy deficiencies in the person’s life can serve as an addiction. The addictive potential of a substance or other involvement lies primarily in the meaning it has for a person.
A person is vulnerable to addiction when that person feels a lack of satisfaction in life, an absence of intimacy or strong connections to other people, a lack of self-confidence or compelling interests, or a loss of hope. Periods such as adolescence, military service, and times of isolation or grief may for a time make people especially susceptible to an addiction. Under some circumstances, a harmful involvement can become so important to a person that addiction is very likely, as heroin addiction was for many in Vietnam. Situations in which people are deprived of family and the usual community supports; where they are denied rewarding or constructive activities; where they are afraid, uncomfortable, and under stress; and where they are out of control of their lives— these are situations especially likely to create addiction. The relationship between hopelessness, lack of opportunity, and persistent addiction is, of course, a template for lives in America’s ghettos. Recognizing the connection between these situational factors and addiction will explain why our wars on drugs, including the latest, never succeed.
The “hook” of the addiction—the thing that keeps people coming back to it—is that it gives people feelings and gratifying sensations that they are not able to get in other ways. It may block out sensations of pain, uncertainty, or discomfort. It may create powerfully distracting sensations that focus and absorb attention. It may enable a person to forget, or feel “okay” about, insurmountable problems. It may provide artificial, temporary feelings of security or calm, of self-worth or accomplishment, of power or control, of intimacy or belonging. These benefits explain why a person keeps coming back to the addictive experience—an addiction accomplishes something for that person, or the person anticipates that it will do so, however illusory these benefits may actually be.
Addiction, drug abuse, alcoholism, obesity, and smoking all involve and are fueled by value choices. Think of people whose lives are “together”—who enjoy strong emotional bonds with others, productive work, satisfying feelings of competence and of fun, and a sense of responsibility toward others. Will they become addicted to drugs or alcohol because of some physiological susceptibility and allow the addiction to undo the fabric of their lives? For you personally, can you imagine getting so drunk that you would abuse your infant child? It just doesn’t happen that way. If you have better things to do and value other things more than escape into intoxication, then you won’t make intoxication the center of your life. And if you are addicted, you can best overcome it by creating or re-creating those personal strengths and values.
Whatever the subjective benefits of an addiction or the values that drive an addiction, the person pays a price for an addictive involvement. Addictions make people less aware of and less able to respond to other people, events, and activities. Thus, the addictive experience reinforces and exacerbates the problems the person wanted so badly to get away from in the first place. In the person’s inner, subjective experience, the addiction may make things seem better. But in the real world, it only makes things worse. With the worst addictions, jobs and relationships fall away; health deteriorates; debts increase; opportunities disappear; the business of life is neglected.
The person is increasingly “out of touch” with nourishing contacts and essential responsibilities. This growing disengagement from the realities of life sets the person up for the trauma of withdrawal. When the addictive experience is removed, the person is deprived of what has become his or her primary source of comfort and reassurance. Simultaneously, the person “crash-lands” back onto an inhospitable world, a world from which the person has been using the addiction to escape. Compared with these existential torments, the purely physical dislocations of withdrawal are, even for most heroin addicts, not particularly debilitating. After all, nearly everyone who receives powerful narcotics in the hospital gives them up after returning home or when the illness is over. Consider also that drug addicts and alcoholics indicate that the most unbearable drug withdrawal is from cigarettes. And if one puts all withdrawal on a scale, probably the worst of all occurs in the case of failed love relationships.
The experience of withdrawal, like that of addiction, is shaped by the way a person interprets it. In therapeutic communities like Daytop Village in New York, addicts are not excused from their normal duties when they undergo withdrawal; as a result, withdrawing addicts—even those who have had several withdrawal episodes previously—continue mopping floors and carrying out other duties. Cultural beliefs also play a crucial role in addiction—for example, beliefs that are widely propagated about the power of a drug to enslave a person and the difficulty of escaping it actually contribute to the difficulties of withdrawal. Equally important are the person’s readiness to confront withdrawal and belief that he or she can manage it. If you are convinced that withdrawal will be intolerably painful and that you cannot withstand it, or if you don’t have sufficiently powerful reasons to confront withdrawal experiences, you won’t be prepared to withdraw from your addiction.The addict who feels incapable of existing without a drug can never successfully withdraw, and doesn’t want to try.
Ironically, one of the beliefs that most contribute to the susceptibility to addiction is the belief in the power of addiction itself. Believing that drugs are stronger than you are means you will become addicted more easily and stay addicted longer. But if you recognize that drugs and alcohol never take away your own responsibilities and capacity to control your destiny—even if you have alcoholic relatives or have had addictive problems in the past—you always stand a better chance of avoiding addiction or dealing with it successfully.
Although the schematic description above is useful for understanding what addiction is and how it comes about, we need not think of all our troublesome habits or fixations in such dire terms. In fact, when we overdramatize our addictions, we may do ourselves an injustice and make change more difficult. An addiction may be more or less severe—and a person may be more or less able to give it up— depending on the circumstances of the person’s life. Addiction is more likely in stressful times, times when gratifications are slim, times when a person is less together or secure. Likewise, one type of excess may be more stubbornly entrenched in a person’s routine, or more closely linked to a person’s self-doubt and insecurity, than another.
Addiction occurs along a continuum—there is no easy test to tell you whether you have an addiction or just a bad habit. For example, by some estimates, half of all Americans are overweight. Are they all addicted overeaters? Many people encounter significant health risks because of the way they eat (recall that heart disease is America’s major killer). Are these the addicts? Some people are preoccupied day and night with their eating; they are suffused with guilt over eating too much, yet they are unable to change their eating habits. Surely, these are the addicts, we think. A still more limited group of people encounter major health problems through their overweight, severely restricting their lives, but are unable to modify their eating habits.
At the furthest extreme of addiction are the minuscule number of people who become so fat they are completely immobile—people we sometimes see on television who may not even be able to fit through their doorways. If we call only these people—people who have given up all effort to control their eating—true addicts, we end up with a fraction of a percentage of addicted overeaters, and books wouldn’t need to be written for millions of people who fear they have food addictions. Moreover, for this minuscule group, concepts such as “denial” hardly seem to have meaning—does the twelve-hundred-pound man who hasn’t left his house in years really need to be told that he has an addictive eating problem?
For most people, the exercise of drawing the line that divides “addicted” from “normal” is not very helpful. We need to remember that nearly all people cut back and forth across these categories at different points in their lives and in different situations. Although letting your urges overcome you to gain total control of your life is a relatively rare phenomenon, everyone has addictive urges and sometimes gives in to them. Addiction characterizes some aspect of everyone’s life—this is one reason why it is so ridiculous to think of it as a disease. Thin people whom we envy for their self-control will tell us there are some treats they can’t keep in the house because otherwise they would eat them all at once. Remember that people whom we admire for having had the strength to quit smoking used to search ashtrays desperately looking for a butt when they ran out of cigarettes!
What we most need to know is not how bad off or how genuinely addicted we are but, rather, how people learn to resist successfully the addictive or unhealthy urges that come with being human. How do they construct full lives, develop alternatives to addiction, learn the strength to stop after having started or, when necessary, not to start at all? Let us start, then, with alcoholism, the addiction most commonly referred to as a disease. There must be—there is—a better way to understand and redirect the paths people take into and out of problem drinking.
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