Considerable research has been conducted attempting to explain the causes of addiction in particular the arguments for both the medical and moral models of explaining addiction. The clear difference between these models are the causes they attribute to drug and alcohol abuse and the role of free will. A critical review of the literature for and against addiction as a personal choice versus a disease model one concludes that discourses on addiction and applied treatment are often influenced by what is funding them. It excludes the complex interplay of the social and environmental history of the individual, their brain chemistry and development and the link to the drugs and behaviours associated with addictions.
The moral model emerged in the first half of the nineteenth century and was perpetrated by temperance campaigners and religious zealots suggesting that alcohol was directly responsible for the problems of society. Literature suggests the moral choice debate began as society begun to frown upon the previously normalised drinking practices of pre industrialisation. Work ethic became a valued term with those not aspiring to this social ideal through excessive drinking or substance abuse deemed deviant. Theorists suggest alcoholism was born from industrialisation and the subsequent movement away from family and social values, however, since these early beginnings more sophisticated discourses on addiction as a personal choice have come about.
The disease model grew from early studies on a select group of AA members and their alcohol dependence. Literature now defines the disease model of addiction as an affliction of the brain resulting in uncontrollable and chronic use, despite negative outcomes for the individual and those around them. Erickson (2011) distinguishes the difference between addiction and chemical dependence and identifies the later as a disease where the changes in the structure and functioning of the brain leaves the person defenceless against the throws of addiction. The disease model of addiction was seen as an attempt to move away from the value laden language inherent in the personal choice model . Addiction as a disease appreciates the vulnerability and fragility of the individual working to reduce the stigma and shame of addiction.
Extensive literature supports the compelling argument toward a disease model of addiction, early research identified the progression and fatal nature of addiction in its subjects yet the limited pool of subjects and unscientific methods of research worked to discredit it in many circles. White, White and Loveland (2002) portrayed addiction as a chronic disease that can only be only be stopped through sobriety while Volkow, Koob and McNellan (2016) stress how advances made in the brain disease model have positively influenced treatment, public policy and preventative measures.
It is widely documented that AA, NA and other 12 step fellowships integrate this model and purport the only way to overcome addiction is to remain abstinent as to not activate the disease lying dormant beneath the surface (Goldstein, 2001). In response however Peele (1995) cites extensive studies that illustrate drug and alcohol abuse peaks in adolescents and early adulthood then declines over time. Furthermore a distinct lack of studies that determine a direct link between neural adaptions resulting from drug use and a preference or compulsion for drugs of addiction is concerning
Chemical dependence is included in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and indicates strong support of the disease model of addiction. Research by Watkins (2010) discredits the diagnostic tools themselves and challenges the subjective context in which pathological labels are applied, along with the concerning connection between the medical practitioners responsible for these diagnostic manuals and the pharmaceutical companies. Though this model of disease is clearly reinforced in the public domain critics of the disease model object foremost to the medicalisation and the lack of self determination inherent within it.
Literature surrounding the disease model is not definitive and distinguishes different extensions of the disease model, the modern arm of this model looks at the genetic cause for addiction. Physician and addiction specialist Mate (2009) discredits both the moral and disease models of addiction due to their failure to consider the discourses on human development and environmental and social impacts associated with addiction and brain development. Interestingly, Leyton (2013) a supporter of the disease model, identifies in his studies the course of the disease has rooted in the genetic, biological and environmental, stating that addiction is just one manifestation of the disease.
Advocates for addiction as a choice links the individuals moral value set directly to their environment and believes that through the medicalisation and pathologising of addiction we ignore, minimise and deny the social moralistic components and disempower individuals. It can be surmised this is a more self empowering view than that of the early religious and temperance movements however critics argue the focus on autonomy, individualism and self sufficiency fails to adopt the relational concept of development. Heyman (2009) and Shaler (2000) express they are not simply implying lack of moral value or judgment but rather the presence of voluntary mechanisms that are driving the addiction.
Studies by Hart (2014) in which drug addicts were presented with their drug of choice along with an alternative reinforcer such as money or vouchers found that given the choice the addict would take the incentive over the drug. Hart concluded from his studies that addiction is a choice when presented with more favourable alternatives however, its credibility has been questioned as to the studies length and the view that anyone can reframe from an action for short term gain but long term reprieve from severe drug addiction is different. Nonetheless extensive research supports these finding and posits that to make good choices requires the presence of meaningful alternatives, and the choice toward these alternatives has a snowball effect such as obtaining jobs, relationships and social standing. Though this model is viewed as individualist in some regard it has correlations to the trauma informed approaches made popular by Mate (2009) and Van Der Kolk (2013) that focus on the environmental influences.
Conceptualising addiction as either a disease or personal choice has direct implications for treatment, education, funding and the way in which society reacts to the issue. Addiction as a medical concern defined by the disease model has on one hand enhanced the scope for individuals to seek treatment and access healthcare services, but on the other hand has geared funding and research toward pharmaceutical interventions at the expense of others. Further literature suggests it as a form of social control.
Conversely if addiction is viewed solely as a personal choice, funding may become obsolete and more punitive measures preferred. Clearly not all choice advocates are suggesting the simplistic view of purely making a choice, but argue by adopting a disease model we are abdicating ourselves of any free will to explore and choose another way of relating to addiction. Heyman’s (2009) argument that addiction is a self harming action influenced directly by the context of its environment opens up the possibility to look at the attitudes of society, economic inequalities and social policy that address the issue systemically rather than individually.
Research has raised concern regarding the dangers of medicalising addiction, particularly when viewed solely as a gene mutation or neurological defect only able to be supported by the medical model and abstinence. Mate (2009) and Van der Kolk (2013) argues the culprit of addiction is not the illicit substance and its affects on a diseased individual but rather the impact of early childhood trauma and adverse life experiences on the developing brain. While the trauma approach and its biological underpinnings is similar to the disease model, one important component differs, the individual is not powerless over their disease but can change these pathways of the brain, through emotional connection, environmental influences and neuroplasticity.
While both sides of the argument hold merit the disease model is a profitable entity firmly committed to changing life through medicalisation and chemistry. It fails to explore the possibility of individuals being the agent for changing their own physiology and emotional stability. Further areas for review would be the limitations of these models applied across varying cultural and social settings. As a point it may be that addiction is contributed to by our own societal responses to ordinary behaviours and responses that left alone would shift over time, but our approach only serves to pathologise and victimise individuals creating an adverse relationship to drugs and alcohol.
By Kylie Beattie
Kylie is an experienced psychotherapist having provided in-house clinical support to clients of Byron Private since inception, and having previously worked at the The Australian Addiction and Trauma Treatment Centre, Byron Bay. Kylie holds qualifications in psychotherapy and has conducted extensive studies in Family Systemic Constellation work, a cornerstone element of therapy for clients of Byron Private. Kylie began her own journey in recovery over 15 years ago from disordered eating and addiction and understands first hand the miracle and wonder of recovery.