I have been a recovering alcoholic for almost nine years. A lot has happened during that time: I’ve watched as the failures of the war on drugs have made themselves clear; as the prevalence of opiate addiction in white, middle-class neighborhoods has swelled; as the problem of addiction has taken on a more prominent place in public discourse.
Over the course of my sobriety, I’ve also watched as fights over what causes addiction have become louder and more volatile: Is it a disease? A learning disability? How much of a role does genetics play? In these arguments, it’s easy to lose sight of one important truth: Every theory we have about what causes addiction is imperfect. No one treatment will work for all addicts — and I have seen friends lose their recovery, and sometimes their lives, because they were led to believe otherwise.
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For much of the history of modern medicine, addiction was considered a moral failing, a refusal to exercise willpower (a theory that fit nicely with the Puritanical values of centuries past). The notion of addiction as a disease didn’t gain significant traction in the U.S. until the 1950s, when researcher E.M. Jellinek published his book The Disease Concept of Alcoholism. By the 1990s, the disease model of addiction was the dominant addiction narrative, supported by the National Institute on Drug Abuse. At the same time, 12-step recovery programs like Alcoholics Anonymous, built around the belief that addiction is a chronic disease, rose in popularity to become the dominant style of treatment.
The disease model, like all singular theories about addiction, is far from universal. It suggests that while remission is possible, a person can never be fully “cured” of the disease. This is not always the case: In one 2011 study in the journal Addiction, for example, roughly half of all people who were diagnosed with alcoholism or other addictions in their teens and 20s no longer met the diagnostic criteria after a period of several years. And 12-step treatments don’t work for everybody, either: Some features of these programs, like antiquated language and a focus on a higher power, can turn off some people who would otherwise seek them out.
These problems with the disease theory have led some addiction researchers to continue to search for new models and treatments. In recent years, they’ve come up with a handful of compelling alternatives: that addiction stems from childhood trauma, or that it develops as a learning disorder, or it’s the result of the brain’s normal neurological process gone awry. (This list is by no means exhaustive, but it encompasses many of the most popular ideas.)
All of the above theories have significant evidence supporting them — but, as with the disease model, none of them can be universally applied to every addict. That doesn’t necessarily undermine their validity, though. Addiction is perhaps best understood as many different pieces of a puzzle: The nature of those pieces will differ from person to person, and the picture they form will be as unique as the individual herself. To say that various theories of addiction are inherently in conflict with one another, and that only one can be “right,” is a dangerous fallacy, one that serves only to prevent people from exploring alternative treatments.
And yet experts often downplay the complicated, highly individual nature of addiction to cling steadfastly to their own theory. For example, in his book The Biology of Desire: Why Addiction Is Not a Disease, neuroscientist Marc Lewis writes that the disease theory is “harmful, first of all, to the addicts themselves,” arguing: “Most of the addicts I’ve talked to would rather think of themselves as free–-not cured, not in remission.” But in an interview in The Guardian a few months after his book’s release, Lewis discussed the reaction to his anti-disease-model stance, telling the paper, “What really moves me is the addicts who get in touch and say, ‘Don’t take this away from me. If you take away the disease label, then basically I won’t be able to get better, if you don’t let me understand myself as having a disease.’” Those people are likely among the many who fight their cravings for a substance by thinking of addiction as a dormant state that can be reactivated: “I can’t use this safely, when I do, my brain tells me I want more and more and I can’t stop.”
When directly faced with evidence to the contrary, in other words, Lewis still claims that the disease theory is harmful and disempowering to people struggling with addiction. This may be true for some; it may also be helpful and empowering to others, and we have to allow space for both of these perspectives.
Even the word addict has become a controversial term in relation to disease theory. Lewis is correct that some people who struggle with substance-use disorders won’t feel comfortable with permanently labeling themselves addicts. But if we look at addiction through multiple models, being an “addict” doesn’t have to convey the lifelong condition the disease model implies. It can simply be a descriptor of a person’s current behavior, fitting easily into Lewis’s neurobiological theory, which allows for a total recovery: You were an addict, and now you’re not. People like myself, who feel it’s a useful descriptor as to why they don’t drink or use, are free to identify with the term. As with the theories themselves, there is room for the language of addiction to be more flexible than we make it out to be.
Some addiction experts do promote a more holistic, multiple-theory perspective of addiction. Physician Gabor Maté, a longtime advocate for a more compassionate treatment of addicts, is one of them. In his book In the Realm of Hungry Ghosts: Close Encounters With Addiction, Maté wrote, “It’s impossible to understand addiction fully from any one perspective, no matter how accurate. Addiction is a complex condition … [it] has biological, chemical, neurological, psychological, political, economic, and spiritual underpinnings.” This is the kind of open-minded, tolerant attitude that’s essential to developing comprehensive treatments for addiction.
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Anyone who has struggled with addiction or a substance-use disorder can attest to the daily pain, confusion, and despair that it causes. As an active alcoholic, I was desperate to understand why it was so painful for me to live without drinking my way through each day. Most people don’t need alcohol to make it from one day to the next, but to me it was as necessary as water — the physical signs of withdrawal, when I tried to stop, made that clear. The confusion, anger, and pain of living this reality nearly took my life.
When someone offered me an explanation for the internal battle I was fighting — one that didn’t involve me being a weak-willed loser — it was a lifeline. I was shown evidence of how my brain changed with chronic alcohol abuse, how those changes made it harder and harder for me to stop drinking. It didn’t matter to me if that was called a disease or a developmental disorder, an illness or a “condition.” What mattered was that there was a lens — multiple, actually — through which I could understand the mystery that had been ruining my life. Over the years, with the help of professionals and peer support, I have gone through several different types of treatment, learned more about the components of my addiction, and developed ways of keeping a constant craving for alcohol at bay.
I am lucky. Too many people are dying every day. Anyone who is truly invested in reducing the number of people suffering from addiction should be eager to explore new frameworks; medical professionals, courts, and others working with people struggling with a substance-use disorder have a responsibility to explain the full range of models. And instead of pitting theories against one another, addiction experts should be focused on learning how to best tailor treatment combinations to each individual, knowing that what fails for one might work for another. After all, if we limited treatment to programs or methodologies with a 100 percent success rate, we’d have nothing to offer.
