In future Briefings, I will look at treatment of substance use problems and addiction. However, before doing this, I thought it best to look at some of the main theories of addiction, and some of the factors that are thought to contribute to addictive behaviour. This will help us better understand the rationale behind certain therapeutic interventions.
Readers who are particularly interested in theories of addiction must read the excellent new book by Robert West, in which he assesses a large number of previous theories and then develops a new theory of addiction that brings together diverse elements from current models.
The disease model of alcoholism and drug addiction assumes that they are chronic, progressive illnesses (or diseases), similar to other chronic diseases such as Type II diabetes and cardiovascular disease. Addiction is considered to fit the definition of a medical ailment, involving an abnormality of structure in, or function of, the brain that results in behavioural impairment.
At the heart of this model or theory is that addiction is characterised by a person’s inability to reliably control his use of alcohol or drugs, and an uncontrollable craving or compulsion to drink alcohol or take drugs.
The loss of control can be manifested during either a short or long time span. A person may begin what they believe will be a short drinking session, but after one or two drinks find it impossible to stop drinking. Over a longer time period, they may make the decision to definitely stop drinking, but after an interim period (maybe days) resume drinking.
Craving was defined by Jellinek, a key player in the development of the disease model, as an “urgent and overpowering desire.” It can be viewed as a feeling that compels the person to do whatever it takes to obtain the object of the addiction, even when there are potential harmful consequences.
The disease model of alcoholism and addiction is central to the philosophy of Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and the 12-step Minnesota Model.
This approach assumes that the impaired control and craving are irreversible. There is no cure for alcoholism and drug addiction; they can only be arrested. The alcoholic or addict must maintain a total and lifelong abstinence from all mind-altering drugs, except nicotine and caffeine.
In addition to their physical effects, alcoholism and addiction are considered to impact on the cognitive, emotional, social and spiritual functioning of those affected. Like other diseases, there is a natural progression, so there continues to be a deterioration in overall functioning until a “bottoming out”, unless a person enters treatment or receives the right sort of support (e.g. AA/NA).
The AA view is that alcoholism and addiction are also characterised by “denial”, or resistance to accept the essence of addiction – the failure of one’s own will power and the loss of one’s own self control.
The 12 steps of AA/NA and the Minnesota model are a suggested pathway for ongoing recovery. The essence of this recovery pathway is a changed lifestyle (habits and attitudes) and a gradual spiritual renewal. The person must accept that his own willpower is insufficient to conquer addiction – he must receive the help of others who have been there – and must avoid taking that first drink.
Some people find the concept of alcoholism or addiction as a disease helpful for understanding their condition and the path to recovery they can take.
They find consolation in the fact that they have a condition that can be understood in terms of the same model as diabetes or heart disease. They can feel less guilty about their condition, and they can join a programme that offers a clear personal goal (abstinence), a pathway for ongoing recovery (the 12 steps), and a life-time of support (via AA).
There is much (often heated) debate about the disease model and the implications that it has for therapeutic interventions. In brief (and I could spend an article on the pros and cons), it is argued that there is no single constellation of alcohol related problems that could be described as alcoholism (there are a range of problems), there is no evidence that addiction and its core elements are irreversible, and progression of the problem is not inevitable.
Opponents of the model also point out that the disease model can lead to people avoiding self-responsibility, believing that the disease must be attended to by experts, rather than the changes come from within (albeit with help from others). Opponents also point out that being labelled as an alcoholic or addict for a life-time, and spending a lot of time with other alcoholics and addicts, does not help the person attain a fully balanced lifestyle and re-integration back into society.
What is apparent, is that some people can be helped by this theory and the AA approach, whilst others will not find it suitable.
Recommended reading:
Robert West (2006) Theory of Addiction. Blackwell Publishing.
Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.
