Alcohol & Drug Abuse – just what are we responsible for?
This blog will explore the roles that the 'Brain Disease Model of Addiction' (BDMA) and the principles of 'Choice' and 'Responsibility' should play in a.) identifying the cause of addiction to alcohol or drugs and b.) the treatment of it. In order to do so, I will initially provide a brief theoretical background of both arguments before moving on to analyse some of the research which identifies a proposed 'hybrid' solution that incorporates both the BDMA and principles of 'choice' and 'responsibility'.
The research carried out includes the review of academic papers and surveys of practitioners, counsellors and addicts in treatment. Additionally, the report will also include evidence from my own experience as a recovering alcoholic. It is intended that my views are non-biased and important to add that they have been included after having engaged with hundreds of people who are in recovery from alcohol or drug abuse, as well as a lesser number, who were actively consuming alcohol or drugs to such a dangerous level that they could be deemed as addicted. Therefore, rather than this be interpreted as a 'personal view' it is hoped that it is instead seen as non-biased empirical evidence.
According to the Brain Disease Model of Addiction (BDMA), addiction to alcohol is a,
"…chronic condition, the symptoms of which reflect persistent changes in neural functioning produced by long-term alcohol use. (Meurk et al., 2016, p.34). Repeated alcohol use changes brain functioning in ways that are not easily reversed (Leshner, 1997: Volkow & Li, 2005 as cited by Meurk et al., 2016, p.34) and whilst its use is initially voluntary, chronic alcohol use flicks a neurochemical 'switch' in the reward and executive control systems of the brain that makes it very difficult for addicted persons to stop using it" (Meurk et al., 2016, p.34). It sees the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities and causes an increase in the strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and negative emotions when these cravings are not sated and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse (Volkow et al., 2016, p.363).
The argument against the BDMA is that addiction to alcohol is a motivated choice. Here,
"…alcohol use is at all times something individuals do voluntarily, usually when life is going badly or to avoid coping with problems in living (Schaler, 2000 as cited by Russell et al., 2011, p.151). When these problems in living are resolved, individuals normally find that the addiction resolves with them, while other individuals mature out of their addiction in time (Peele, Brodsky, & Arnold, 1991 as cited by Russell et al., 2011, p.151) or learn to control their consumption (Heather & Robertson, 1989 as cited by Russell et al., 2011, p.151). With regard to the issue of control, choice proponents argue that not only do alcohol users never lose control over their alcohol use but that the best way to curb problem use is to make and implement better decisions, which does not require them to seek medical treatment. They argue that alcohol users are always free to choose to stop and that users' difficulty in effecting change should not be mistaken for a lack of freedom to do so" (Russell et al., 2011, p.151).
As can be seen, there is a stark contrast between both models and therefore it is understandable that supporters of each theory tend to strongly disagree with the other. However, "a common criticism of the disease–choice debate is that absolute truths about addiction are irrelevant so long as people do 'recover'" (Russell et al., 2011, p.162) and so with that in mind, it is hoped that the following analysis will build on that sentiment and demonstrate the positive role that both can play.
The critical analysis in this report focuses on the argument that basing a person's treatment from alcohol addiction on the BDMA provides them with, what may be seen as, an 'excuse' should they relapse and that it also affords them little or no control over their treatment and ongoing recovery.
Meurk et al. carried out 44 interviews with users who were receiving treatment for alcohol (or drug) addiction and asked for their thoughts on the BDMA. Whilst it should be pointed out there were some negative responses to it, for the purposes of this report I have used the following transcripts:
Interviewee One: "Well I'm happy if it is a disease because it helps me. Takes that pressure off – I'm a fuck up. [. . .] Ah I can say it's not just me and it's a disease. It's not just me being a screw up that is by drinking all the time, so yeah that made me feel better. [. . .] [if it's a disease] then at least I know all right there's a problem there and it can be fixed hopefully".
Interviewee Two: "I think that it's – I think describing it as a disease gives an alcoholic or a drug addict some kind of modesty because a lot of people will just look at you and go oh, you're just a drunk, you're an alcoholic, we're not here to help you, but if it's looked on as a disease, then there's help for diseases. People want to help cure cancer, they want to help cure AIDS, they want to help cure an alcoholic or a drug addict. So, I think it's good". (Meurk et al., 2016, p.39).
As can be seen, both of the interviewees felt somewhat positive towards the BDMA however, the following person gave an insight in to what dangers the BDMA could mean for those in recovery:
Facilitator: "You've said that you do think that addiction is a disease, do you think that describing addiction in that way is useful?".
Interviewee: "Yes and no. Yes to the point of understanding it, it definitely is. For me, I'm convinced that – yeah, I've done my darndest to bury this and coming from the point of it's a discipline thing and I just don't pick up the first drink and all of this. There's attributes which maybe I'm not aware of which trigger it [. . .] The no is that part of me feels that that could give me permission, which is a scary thing, and I see that in other addicts and alcoholics where they go, well it's a disease I'm like this, so this is it anyway, so sort of give up the fight. Then there's the thing of it's not something I should fight, it's something I should accept and just try and do the next right thing about it". (Meurk et al., 2016, p.39).
The latter part of this comment is crucial, when an addict themselves is telling you that the BDMA could give them "permission" to drink alcohol, it makes it difficult for advocates of the BDMA to respond to this particular point with much credibility. The same point was also raised in the following survey of counsellors; however, it is here that one can potentially find a proposed solution.
Members of the National Association of Alcoholism and Drug Abuse Counsellors took part in a survey that looked at their view of the role of personal responsibility in addictions treatment and, following on from the concerns raised above, they highlighted that,
"…if addiction is thought of as a disease, which one is not responsible for developing, and neuroscience evidence is taken to indicate that, when one has the disease, one's ability to evaluate various courses of action is corrupted, this evidence may be taken to undermine the view that clients are personally responsible for addiction at all, development or recovery" (Steenbergh et al., 2012, p.422).
Whilst this statement clearly highlights the same point about personal responsibility in recovery being undermined, it also produces a split and breaks the whole process into two by suggesting there is no responsibility for the development of the addiction yet that may not be appropriate for the recovery part of the addiction process. This identification led the counsellors to implement,
"…therapeutic approaches that generally avoid assigning personal responsibility for developing an addiction yet they each emphasise personal responsibility for recovery (Steenbergh et al., 2012, p.422). This is an important distinction because, even if addiction is thought of as a disease, recovery may nevertheless be thought of as a choice" (Steenbergh et al., 2012, p.423).
The authors also point to a study that was conducted by doctoral-level addiction counsellors that ranked 'increasing client's acceptance of responsibility for change' as the, "most effective component of addiction therapy out of 35 different factors" (Morgenstern & McCrady, 1992 as cited by Steenbergh et al., 2012, p.422). This 'compensatory view', described by Brickman (1982), "places limited emphasis on personal choices in the development of an addiction while accentuating clients' responsibility for recovery from their addiction" (as cited by Steenbergh et al., 2012, p.426) and can be simplified into the following:
- Addiction = no user responsibility
- Recovery = responsibility of user
The Counsellors that took part in the survey above also encouraged the use of self-help or mutual help groups, suggesting that they complemented the counsellors' notion of the addict being responsible for their recovery and that they do not take away their choice, control or power. Steenbergh et al. summarised this by highlighting that,
"The idea that individuals are personally responsible rational agents is heavily emphasised, and assumed, in prominent psychosocial approaches to recovery from addictive behaviours. According to Alcoholics Anonymous, although addiction is viewed as an illness of body and spirit that one is not responsible for developing, one is held responsible for the work of recovery" (2012, p.422).
I agree with what the data from the two surveys indicated: that those addicted to alcohol are not responsible for their addiction, yet they are responsible for their recovery. The empirical evidence I have gained since 2013 corresponds with this principle, as does a previous addiction career spanning almost eighteen years and is a key ethos of Making Changes – we work on taking responsibility for our past actions and owning them, but we do not continually beat ourselves up about our problematic use or addiction. Instead, we break it down and understand it, we get to know it so that in our future, where we change – we become responsible for our recovery and how we live our life. The individuality of each person's approach to Making Changes is empowering and will give you a confidence that you will probably not have felt for some time, if ever.
Furthermore, it is hoped that critics of both the BDMA and 'Choice' arguments can begin to think more creatively about what options might be best for the addicted user as, "we need a concept of addiction that both acknowledges people's sense of agency and the hard-ships they encounter in controlling their use" (Snoek & Matthews, 2017, p.2). This is instead of an 'all-BDMA' or 'all-choice' approach, as addiction is far too complex to be so black and white.
One such example of innovative thinking can be seen in the theory of neurodiversity as mentioned by Szalavitz, who, in relation to the disease model, talks about,
"…a comparison to cases of ADHD, dyslexia and autism. Developmental differences can lead to differences in ability, and disability advocates have argued these are not diseases if they are built out of different wirings in the brain. What we have here is neurodiversity. Addicted persons have a blame-less impairment, yet they retain an ability to change" (2017 as cited by Snoek & Matthews, 2017, p.3).
The final point is that more definitive research needs to take place in order to gain a deeper, more accurate understanding of recovery methods by involving those, such as myself, who have been through it, at a high research and scientific level. As Gazzaniga points out, there can be no doubt that addiction studies benefit from what can be learned from neuroscience, however,
"the neuroscientific study of addictions might also benefit from considering what can be learned from the practical experience of addiction counsellors and individuals struggling with addiction" (2010 as cited by Steenbergh et al., 2012, p.427).
As I always make a point of saying to clients – labels that are associated with what we go through are not important when it comes to completing the programme of Making Changes. People can get very hung up on definitions and in my academic experience in this field, lots of time, effort and funding is wasted with not much end results – it is my strong opinion that what matters more are the individuals who suffer and identifying ways that they can get better. This is why I spent my time developing this programme rather than spending it writing research papers.
- Alcoholics Anonymous World Services Inc. (2001). Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism. 4th Ed. New York City.
- Committee on Addictions of the Group for the Advancement of Psychiatry. (2002) 'Responsibility and Choice in Addiction'. Psychiatric Services, 53(6), 707-713.
- Meurk, C., Morphett, K., Carter, A., Weier, M., Lucke, J. & Hall, W. (2016) 'Scepticism and hope in a complex predicament: People with addictions deliberate about neuroscience'. International Journal of Drug Policy, 32, 34-43.
- Russell, C., Davies, J.B. & Hunter, S.C. (2011) 'Predictors of addiction treatment providers' beliefs in the disease and choice models of addiction'. Journal of Substance Abuse Treatment, 40, 150-164.
- Steenbergh, T.A., Runyan, J.D., Daugherty, D.A. & Winger, J.G. (2012) 'Neuroscience exposure and perceptions of client responsibility among addiction counsellors'. Journal of Substance Abuse Treatment, 42, 421-428.
- Volkow, N.D., Koob, G. & McLellan, T. (2016) 'Neurobiological Advances from the Brain Disease Model of Addiction'. The New England Journal of Medicine, 374(4), 363-371.