BY AARON HANWAY
In all sciences, multiple theories and the proponents of those theories compete to best explain a phenomenon. This is no less the case than in psychology, and within psychology no more is this true than in the area of addiction. At a glance, the literature on addiction is split between multiple camps trying to explain the issue from their own narrow field: pharmacology, genetics, environment; each with its unique answers to the problem.
This article is a brief exploration of the disease model of addiction and close look at the group that helped promulgate this view point, Alcoholics Anonymous (AA).
The Disease Model of Addiction
No other theory in addiction seems to be more controversial than the disease model. As a concept, it has sparked wide debate spanning decades. At the heart of this debate is the question of morality and free-will: critics of the model state that it reduces the role of individual self-control and responsibility and other traditional values (Gori, 1996); proponents of the model state that it places addiction in the area of a health problem - people who need treatment, and away from a criminal problem - people who deserve punishment (What is the Disease Model of Addiction, 2017).
The American Medical Association officially classified addiction as a disease in 1956, stating that it aligned with their definition of a disease as an abnormal condition that is progressive, chronic and if untreated fatal (What is the Disease Model of Addiction, 2017). 60 years on from that decision, modern technology has allowed us to discover that addiction does have biological grounding. Galanter (2014) showed evidence to support addiction as an acquired dependency rooted within the brain’s neurology. In his research a wide variety of drugs inhibited dopamine receptors (our reward centres), reducing the natural highs a person can experience, which persisted for months after the detoxification and subsequently led to drug cravings. This is further supported by Volkow, Koob and McLellan (2016) who outlined that not only did the desensitization of the reward circuits increase dependency on the substance, but also weakened a person’s decision-making functions.
Moreover, neurological research looking at dopamine receptors may put addiction into the realm of a pre-existing condition. Kenny, Voren and Johnson (2013) showed that of the brain’s dopamine receptors, D2 receptors specifically, influence a person’s ability to forgo instant gratification, meaning those with high amounts of D2 receptors are more likely to display self-control than those with low. This means that those who are unfortunate enough to have low levels of D2 receptors, due to nothing more than their genetic make-up, have a much higher predisposition to addictive behaviour than those lucky enough to have high levels.
Although there is much more research into the neurological underpinnings of addiction, its critics state that such a model fails to acknowledge or explain how many people can take physiologically addictive substances and not seek to re-use (Gori, 1996). To further examine the validity of the disease model one must understand its history and the groups that promoted it.
The AA and Mutual Help Groups
Mutual Help Groups have been around for more than a millennia and consist of nothing more than solidarity movements of ordinary citizens, experiencing the same problem, providing mutual aid (Zafiridis and Lianas, 2011). The most prominent of mutual help groups for people experiencing addiction is Alcoholics Anonymous (AA) and more recently Narcotics Anonymous (NA) who developed and pioneered the 12-Step program to addiction.
AA was started officially on the 10th of June 1935 by two alcoholics Bill Wilson and Dr Bob Smith (Sharma and Branscum, 2010). It was loosely based on a Christian movement called the Oxford Group who started out as little more than a group of people meeting to discuss existential ideas (Davis and Jensen, 1998). Wilson’s and Smith’s purpose for AA was simple, to help a person obtain sobriety and make the spiritual transformation needed to create a sober life worth living.
AA and the Disease Model of Addiction
Contrary to popular belief, although many associate the disease model of addiction with the AA, the group neither originated or promulgated the model, however, it could be said that its members did play a role in spreading the concept and popularizing its understanding (McGovern and White, 2002). Nowhere in the AA’s “Big Book” (n.d.) is the term disease used. The closest it comes to identifying addiction with a disease is in calling it an illness, and throughout his work with the AA, its co-creator Bill Wilson described it as an “illness which only a spiritual concept will conquer”.
AA members viewed their addiction as multi-dimensional: physical, mental and spiritual. But, the notion of addiction as a disease served their 12-step program in helping someone realise that it was not something they had control over, and therefore were limited in their ability to manage it. This brought an individual closer one of AA’s central messages: only an appeal to a Greater or Higher power could help (McGrovern, 2002).
In truth, the notion of addiction as a disease had little to do with accurately representing the condition scientifically. AA members promoted the concept more as a way to elicit attention and concern for alcoholics: to see them not as morally reprehensible characters requiring punishment, but more of a sick people requiring treatment (Anderson, 1942).
Is AA effective?
The literature on the efficacy of AA, although extensive and over a long period of time, is split. Some studies suggest its efficacy is little to nothing, with the drop-out rate being 50 per cent (according to AA figures), while others have shown strong correlations between attendance and sobriety. Grossip, Stewart and Mardsen (2007) showed that 12-Step programs led to increasing rates of abstinence, and specifically with drinking behaviour a greater improvement over a cognitive behavioural approach. Although one must consider the direction of causality - is it that attendance at AA leads to increased rates of abstinence, or that abstinence leads to increased attendance at AA? If two variables correlate, one doesn't necessarily cause the other but could be linked by another deeper variable.
Getting to this deeper variable is where many place the efficacy of the AA. Proponents of the 12-step model criticise treatment models such a cognitive behaviour therapy on the basis that they are symptom-based models, which do not address the underlining causes of addiction, and that AA is not just a program for getting over your addiction, but a program that helps you gain meaning and purpose in your life. On this point, Davis and Jansen (1998) suggest that there is adequate evidence to suggest that AA members find something within the program that improves their lives not just in the short-term but overall. And it is here that AA may have something over some other treatments.
Addiction is a Spiritual Problem
In talking about addiction at TED X Dr Gabor Mate (2009) stated to understand addiction, one must view the positive side of the behaviour. You have to ask, what does the addict get from their addiction? A sense of peace, freedom from suffering, euphoria; then ask, why are these qualities lacking in their lives? Taking this viewpoint, addiction is not only a matter of physiology or environment (at least in part) but a much deeper issue. And it is here where many place the efficacy of AA. In appealing to a Higher or Greater power, AA members gain a new sense of purpose and meaning in which to build new lives (Montgomery, Miller and Tonigan 1995). Not only that but in moving through the steps, members gain a sense of belonging in a community with shared values and interest.
The great psychoanalyst Carl Jung has been credited with aiding Bill Wilson and Bob Smith with this realisation (McCabe, 2015). The two men corresponded with Carl Jung who explained to them that their problem was not with alcohol. Their dependency on alcohol was only a symptom of their real problem, a spiritual crisis. Carl Jung wrote extensively throughout his later years of the failings of modern science which for him did “not go beyond that frontier of human life which surrounds the commonplace and matter of fact, the merely average and normal. They afford, after all, no answer to the question of spiritual suffering and its innermost meaning" (Jung, Dell, & Baynes, 2009, pg. 229).
In sharing their stories and helping each other, the AA members learn much more than a set of steps to stop their behaviour, they experience connectivity, meaning and purpose. Themes that go deeper than their habit-forming behaviour. Themes that they can construct a new life from, setting a new course for their future (Zafridis, Lainas, 2011).
Final Thought
There is much research into the biological and neurological underpinnings of addiction, which are used to support the concept of addiction as a disease. However, when diving into the history, the concept of the disease model of addiction had little to do with accurately and scientifically representing the disorder. Groups such as the AA used the concept as a means to change the perception of addicts from that of people with moral failings, to people who were sick and needed support and treatment, while also bringing those suffering from addiction closer to their 12-step treatment, which for them only a spiritual awakening could ultimately solve.
In the end, it may matter little how one represents addiction. Despite the camps people put themselves in, everyone in the field can agree that people with chronic addictions are suffering and need support. That support may come from a biological solution or a behavioural solution, or a combination of both. But if we don't help them to address the deeper issues that led them to their addiction in the first place, if we don't help them find new new meaning and purpose, although we may be able to take away their addiction, what are we leaving them with? Which is what Bill Wilson's and Bob Smith's program tries to address: to not only take away peoples addiction, but leave them with a life worth living.