Why can’t the disease and learning models just get along?!

Will a developmental-learning model of addiction (e.g., Maia Szalavitz, Gabor Maté , Stanton Peele, and me) ever make peace with the disease model? That would be a happy ending! Nora Volkow and I could eat muffins together…or maybe have a glass of wine. We could establish a space for sharing data and ideas, working together toward an explanation that incorporates the best of both worlds.

Yet I don’t think it’s in the cards. Not because the disease model is so far off base scientifically. In fact, where the brain in concerned, the distinction between learning and pathology isn’t always obvious, as epitomized by ADHD, autism, bipolar disorder, even schizophrenia. There’s got to be some allowance for overlap — doesn’t there?

It’s not that the disease model is so wrong, it’s that the baggage it carries may never fit in the same home as the learning model. Here’s what I mean:

Society’s understanding of addiction can be seen as advancing through three stages.victoria

First, beginning in the Victorian era, addicts were considered morally flawed and indulgent. We could call that the “sin” model. Consequently, the appropriate response to addiction was to punish the addict through scorn, isolation, and maybe even jail time. Through shame and retribution, the addict might, with luck, go back to being good.

The second stage was the era of the disease model, beginning in the middle of the 20th century. The change was driven by the emphasis on helplessness in Alcoholics Anonymous, beginning in the 30s, and the evolution of residential treatment centers that stressed obedience to therapeutic regimes, beginning medicalin the 50s. Finally, the proliferation of neuroscience in the 80s and 90s put a seal on the package by pointing to a diseased organ, namely the brain. Now specific neural changes could be pinpointed as the source of addiction, and the disease model ruled the roost.

According to the disease model, the appropriate solution to addiction was medicine. Specifically, addicts were to be urged to follow the advice handed down by medical practitioners. Rather than confess to being immoral, addicts were advised to confess to being incapable. The only hope to control addiction was to accept a regime imposed by an authority. In other words, to subdue a problem located on the inside, you needed to take orders from the outside. It is this baggage that seems destined to clash with the mindset of a third, more progressive view of addiction.

The third stage in our understanding of addiction is the learning model: a developmental sequence of events that gives rise to habitual patterns of thinking and feeling. This view of addiction admits the potency of social factors, like isolation and dislocation, as catalogued by Bruce Alexander. It makes sense of the impact of adversity in early development, as emphasized by Gabor Maté and Maia Szalavitz. And it allows for the influence of societal and cultural issues, as portrayed by Carl Hart and Johann Hari.

According to a developmental-learning definition, the appropriate response to addiction is neither shame and isolation nor submission to a therapeutic regime. Rather, it is further growth. The solution to addiction can’t be a medical regime that returns the addict to some previous level of normality. Nor can it be disempowerment, intended to counter built-in character flaws. Rather, people emerge from addiction through ongoing development. In this light, addiction can be viewed as a stage of individual development, and it must therefore be addressed through different folksindividual efforts based on individual perspectives, goals, and capacities. A developmental-learning model of addiction suggests that positive change must be pursued from within.

The final two stages in our understanding of addiction, the disease model and the learning model, have both achieved some of their plausibility on the basis of brain research. But the role of neuroscience in these two stages of conceptualization could not be more different. Neuroscience helped shore up the normativitydisease model by identifying deviations from what is considered standard neural architecture, a project we could call “neuronormativity.” Remember: the target was a cure. In contrast, the developmental-learning model of addiction embodies an emerging understanding of neuroplasticity. This replaces the search for normality with an emphasis on the brain’s capacity to change.

Thus, both models borrow something from the brain—a detailed breakdown of measurable biological events. But they are fundamentally different in orientation, and they perceive the brain in such very different ways that it’s hard to imagine how they might be reconciled. It’s the same problem that’s appeared in the tension between developmental psychology and mainstream psychiatry over many decades. The brain is either a normative thing that can go wrong and then be repaired, or it is an open system that can develop along diverse trajectories, integrating the meaning of experience according to its own expertise.

Addiction is one of those trajectories, but then so is progress beyond addiction.

 

NOTE TO READERS: I do try to respond to most of the comments in the comment section following each post, unless there is already a dialogue going and/or I have little or nothing to add.  But I can’t always keep up with the volume of comments (volume = GOOD!) I’ll have an easier time responding, and so will others, if you keep your comments relatively succinct. Try for two or three paragraphs, max. Longer “essays” can be very thoughtful and informative, but they take time to consider and respond to intelligently. That’s the trade-off.

73 thoughts on “Why can’t the disease and learning models just get along?!

  1. Tim February 18, 2016 at 5:07 am #

    Provocative and interesting. Myself I can accept both disease and learning models because I don’t think of “disease” in scientific sense but more in a metaphorical sense. Having struggled mightily with addictive behaviours in my life I know it felt like a disease I could not get a handle on. In my own experience the 12 Step Model was the tool I used to start to break out of addiction. So having had that powerful existential experience of using this tool born out of a “disease framework/paradigm” It would feel hypocritical or inconsistent to totally abandon it. But my own journey has taken me to a place now where the learning model also makes sense. I love the paradoxes of this Reality. Where for example Light can be both particle and wave. For some God is personal but at the same time impersonal. Sometimes it seems things are both things at the same time.

    • Janet February 18, 2016 at 1:14 pm #

      Tim, I like this. Often the 12 Step is the first available tool. Refinements can come along. I’m so glad this happened for you. And as the word gets out, others will know that the learning model is alive and well and waiting for them.

    • Jo February 19, 2016 at 8:28 am #

      Well said Tim..
      For me, the 12 step model gave me the tools I needed to grow.. To learn.. To live

      • Carlton February 19, 2016 at 8:54 am #

        Freedom, or relief from an addiction is the direction the all the current programs for addiction are pointing.

        The difference is in beliefs.

        What an overarching model of addiction can allow and account for, is the differences in these beliefs, the differences in the current models, and provide the general public with a universal and relatable understanding of what addiction is.

  2. Marc February 18, 2016 at 5:27 am #

    It’s funny, Tim, that the second I finished reading your comment a couple of evangelical Christian guys (7th Day Adventist?) rang the doorbell. When I told them I was Jewish AND couldn’t read Dutch AND I’m a scientist they finally gave up. Very friendly though. Talk about God being both personal and impersonal!

    But your point is well taken, and wave/particle duality might be a good analogy.

    • dan February 24, 2016 at 9:36 am #

      Ha, I don’t drink alcohol because I know that I can’t drink in safety. I’ve been stuck in in a cell more times than a mitochondria. Always for silly things (thankfully) but SSShhh ! don’t tell anyone, I sneak off to Holland every now and then and get stoned and eat lovely falafel for a few days and come home again. I don’t use at home because I associate home with being wasted all the time and it is important to understand the power of setting. I also speak Dutch and was thinking about this cheeky secret that I have when I read your reply. I go to Aa meetings but that is for alcohol and I don’t believe in the disease model but I believe in the power of learned behaviour and alcohol’s ability to skew my thinking, it never was my first choice of drug anyway but the most available.

  3. Lew Gervais February 18, 2016 at 6:46 am #

    This article was stimulating to say the least. I came out of a heroin addiction in December of 1972. I never went to a 12 step meeting, I never read anything about addiction but I knew I was in trouble. At that time I was working with munitions in the Air Force and shooting up heroin four or five times a day. After my last overdose I ended up in the military hospital, and that is when I knew I was in trouble. Shortly after that I experienced a conversion experience with Christ that put me in a totally different trajectory. I not only learned how to live without using drugs; I learned to live…period.I have now been sober for 43 years. My life has change, my thinking has changed, and so has my brain functions. I have been working in the addiction field for over three decades and I see many addicts attempting to work the 12 steps who just keep going around the same mountain of relapse…detox…recovery, and then back to relapse repeating the cycle over and over again. I have never been on that merry go round because I am convinced that I have changed by God’s help and I am no longer addicted to drugs today.I continue to move away from addiction as I help addicts.

    • Janet February 18, 2016 at 1:30 pm #

      As I heard an addict say once in a twelve step meeting: “God can be anything you want it to be. As long as it isn’t yourself.” When we find something bigger than ourselves, bigger than the isolating false siren call of addiction, recovery can begin. How beautiful, Lew, that you were lifted from the emptiness of addiction into a world of faith, healing, and helping others. Whatever one’s personal beliefs… this is the face of love and connection to something greater.

    • Judy Wright February 21, 2016 at 3:33 am #

      DITTOS! Lew: “Shortly after that I experienced a conversion experience with Christ that put me in a totally different trajectory. I not only learned how to live without using drugs; I learned to live…period.”

      I’ve been living without drugs and alcohol for 36 years and our Lord and Savior receives all the glory! When all the inevitable negative consequences of drinking everyday became too much to bear, I entered a three-week hospital “treatment” program which consisted of vitamin B and orange juice every morning, and hours and hours of “talk-therapy”, group “therapy” 12-step indoctrination and arts and crafts. I volunteered to take antabuse as insurance against relapse … totally motivated by fear … fear of relapse and fear of physical reaction to the drug.

      I was/am RECOVERED ONCE AND FOR ALL TIME by my Lord and Savior, Jesus Christ. Once I replaced myself on the pedestal of my life with Jesus, I freely acknowledged that I was powerless to change. There’s no shame in being a bond slave to God, and His beloved child at the same time. He is the power and there is no greater freedom than a relationship with Him. And the relationship continues for all eternity. Imagine! Peace of soul and joy of heart forever and ever!

      Jesus asked: “What does a profit a man to gain the whole world and lose his soul?”

      Thank you, Lew, for your comment! You blessed my day!

      • Lew Gervais February 21, 2016 at 3:38 pm #

        Thank you for the kind words Judy. For decades now I have been teaching that there is a level of freedom that we can all reach that is beyond recovery. but like you, I doubt it can be reached without a vibrant growing relationship with Christ. It is the freedom to live free of the fear of relapse…free from attending meetings and working recovery every day to keep from relapsing, free to live without our former addiction haunting us or tripping us up. I have been living in this kind of freedom for over four decades and I am not working a recovery program to maintain my sobriety. I taught that addiction was a chronic brain disease for many years but it never settled right in my heart of hearts. This is why I like Marc Lewis’ approach to recovery. There is only one other person that teaches what I have experienced in my recovery and that is Mike Quarles. In his book “Helping others overcome addictions” He struggled with alcoholism for many years even while he was a pastor. He would preach a sermon on Sunday morning and in a blackout later that afternoon. He had an encounter with the living God that ended his addiction. He has been sober for over 25 years now where he could not make one week before. We are not alone.

        • Marc February 22, 2016 at 3:40 am #

          Thanks for your contributions, Lew and Judy, I usually ignore the “spiritual” element, partly because it’s rather hard to talk about and partly because it gets mixed up with religion, which is not the same as spirituality — see Sam Harris’s excellent discussion of the difference in Waking Uphttps://www.samharris.org/waking-up Anyway, the fundamental experience of a spiritual transformation is certainly important for many people.

          I wonder if you can rephrase some of these ideas without making it seem as though you have to be Christian to make use of them.

          Thanks, Janet, for helping with this!

          • matt February 22, 2016 at 6:08 am #

            Hey Marc

            It is interesting how many people think of religion and spirituality as the same thing. I try to liken it to the difference between restaurants and food. You can go to any restaurant for the ambiance, decor, cleanliness, prices, etc. But all of them have food. Food is everywhere. All human beings need food, wherever they can find it.

            • Marc February 22, 2016 at 7:09 am #

              Hi Matt. Fancy meeting you here. I like this analogy….except for maybe one detail: most restaurants won’t sentence you to hell for choosing to eat elsewhere…At least not publicly…;-)

              • Carlton February 22, 2016 at 8:04 am #

                Having a spirit is as much a part of being human as having a head or torso.

                Being aware of ones spirit, and relating to it, varies a great deal.

                Some people feel more aware and comfortable relating to their spiritual life via the many religions available, and some in an individual, private way, and some in other ways.

                The efforts to regain freedom from an addiction can unintentionally lend itself to becoming aware of the spiritual sense of oneself.

                This can change a persons perceptions, and ultimately change the feelings they has about the dependence on an addiction.

                This may be why some people don’t seem to be concerned about relapsing at some point.

                This sounds cryptic, but am keeping the reply brief for this Blog.

                • Marc February 25, 2016 at 3:01 am #

                  Thanks, Carlton. Brief is good. But I agree with you that overcoming addiction can bring one’s spiritual side to the foreground….and that’s a cool side-effect, so to speak, of recovery.

                  Interesting that this is sort of the opposite of the AA position (and that of other religious or quasi-religious approaches)…..Their assumption is that spirituality comes first and recovery comes next. First you find God and then you get the help you need to sober up. It can indeed be the other way around.

                  • Carlton February 29, 2016 at 12:54 pm #

                    Hi Marc, This point may be more accurate and clearer without using any religious or spiritual terms and meanings:

                    There is a long list of difficulties and struggles that seem to ultimately end up helping a person unfold, and can even contribute to a persons understanding and appreciation of life.

                    But Addiction has a stigma of being a life-long albatross… an ever lurking malady of some sort.

                    But in the bigger picture of addiction and recovery, this may not be true for everyone.

                    When accounts from the people that have recovered is examined on a larger scale, the addiction and recovery experience might be added to this common and recognizable list of difficulties and struggles mentioned above.

                    This could be beneficial for a number of reasons, such as;

                    It could bolster peoples hope that currently cannot imagine living without the addiction.

                    It may also throw new light on the unsettling mystery currently surrounding addiction and recovery.

                    It could pave the way to a better understanding by Public at large even
                    allow people to relate to their fellow humans that are currently struggling with addiction.

                  • Reagan April 6, 2016 at 8:58 pm #

                    Marc,

                    Overcoming addiction can indeed be a catalyst for bringing one to the spiritual path as I have discovered during my own journey through addiction. White knuckling-cold turkey is how I went and something did occur that has caused me to seek further and deeper than I would have done previously. Yes, the approaches within the twelve step programs seems a little reverse to me when I do attend them. And I have found myself to be looking elsewhere for answers.

                • Reagan April 6, 2016 at 9:06 pm #

                  Carlton,

                  It is interesting that you spoke about the spiritual aspect once regaining freedom from ones addiction and how, “… some people don’t seem to be concerned about relapsing at some point.” I interact with people that metaphorically look over their shoulder constantly waiting for relapse to come for them and I just cannot understand that. I cannot live that way if I am going to move forward and regain my own freedom from addiction. Living in fear is what kept me in active addiction and it is my belief that if I constantly perceive my own struggle with addiction with anger, hatred and resentment than I will also be one of those constantly looking over my shoulder. The spiritual side of oneself as you mention is more moving and compelling to me then regurgitated stories of the past that I will continue to re-live. Thanks

              • matt February 22, 2016 at 3:34 pm #

                Maybe you haven’t been to enough restaurants 🙂

                Whether subject– object, witness mind –ego, internal vs external loci of control, there has to be something to consolidate the bicarbishmarble of experience we call a self. As Harris puts it, “to get a clearer understanding of the way things really are.”

          • Lewis Gervais February 22, 2016 at 8:38 pm #

            Marc, I will attempt to rephrase my post using an analogy. I like picture stories because they give me a visual that I can hold on to. My picture of recovery is this: A person finds himself in a wide river and he can hear a waterfall as he is floating downstream. He has two options, He can tread water to stay alive and eventually he will find himself over the waterfall and drown in the pit of his addiction. His second option is to swim upstream as fast as he can. For seven years I tried both of those options. When I did finally ask my
            Creator for His help and gave up trying to fix myself and surrendered to Him here is what He did. He picked me up and placed ame in a canoe, then He gave me a paddle and told me to paddle like hell. At that moment one of my problems had been solved. I no longer had to tread water in order to breathe. But now I still had to paddle or I would have ended up at the bottom of the falls. So I paddled hard in my early recovery for about two years. Today, I still don’t have to worry about drowning and I don’t have to worry about the falls because they are miles downstream, however I still slowly paddle to keep myself heading upstream. I could never have done it without my Creator;s help. I would certainly have drowned in my condition. So today I help people find their canoe. Some people would rather swim than paddle so I tell those people to find some 12 step meetings to attend and hope the best for them. When they want a canoe and a paddle I will help them find it. Until that time they just have to keep treading water or swimming.

            • Marc February 24, 2016 at 4:48 am #

              Thanks for that, Lew. I hope that will be helpful for some of my readers.

              For those of us who don’t believe in a personal God, I guess things are going to be tough. Which is too bad, since there are a lot of us out here.

              Still, for people who do have a relationship with (their) God in the way you describe, I think your analogy is clear and compelling, and I’m very much in favour of whatever works!

          • Jeff February 22, 2016 at 11:11 pm #

            Marc,

            For me personally your approach, scientific knowledge, book, vulnerability, and lack of emphasis on spirituality is exactly what I needed to finally quit on my own a few years ago.

            I know we all need to find what works for each of us. For me it wasn’t the disease model and it definitely was not relying on a higher power.

            Thank you for all you do.

            • Marc February 24, 2016 at 4:50 am #

              Thank you, sir! I think a lot of us are in the same boat….boat analogies seem to be big at the moment. Seriously, I appreciate what you’re saying.

          • Carlton February 23, 2016 at 7:35 am #

            It is the similarities, not the differences of peoples experiences with addiction and recovery that indicates that a model with a much broader, larger arc than the current models, probably exists

            • Marc February 24, 2016 at 4:51 am #

              …Or should exist.

          • Terry February 23, 2016 at 9:43 pm #

            spirituality has a significant place in addiction in my view – addicts seek a different identity not being happy with their own or the spirit within and recovery for want of a better term requires some degree of self acceptance and re-connection with self and spirit – what is the neuroscience take on where the spirit resides given reference to various structures within the cortex involved in addictions – does the soul live in the cortex or limbic system too ??? or can’t science find it yet ??

            • Marc February 24, 2016 at 4:58 am #

              Terry, neuroscientists can’t find a brain region that corresponds to your feelings for your mother, never mind a God region. Trying to connect the notion of spirituality with brain science is really challenging. But interesting.

              I think I’d put it like this: somehow the brain creates a holistic sense of oneself in the world which, when perceived directly, we call consciousness. That consciousness is incredibly precious. Whether it connects with a larger consciousness or not, it is a wonderful thing to find and stay with as much as possible. There are strong indications from quantum theory that everything in the universe is connected in ways we can’t pin down….maybe because we were all room-mates around the time of the Big Bang. Moreover, it may be that consciousness is necessary for particles to exist in one place at one time (I didn’t make that up: it’s quantum mechanics 101) ie. for reality to exist at all. And if that’s so, maybe our brains are fantastically important arbiters of a larger reality. A nice thought.

              • Terry February 24, 2016 at 4:05 pm #

                Mark – that’s why your an author as well as a scientist – you have a way of explaining things, and i must say beautifully. yes i am a sceptic as far as God goes but as for collective consciousnesses that’s another story. i asked the question tongue in cheek but i do find it worthy given the new science emerging in regards to unconscious behaviors – the soul may be like addictions and found in various places which work together to influence the human. i found hard work and new habits managed my addiction not God. appreciate your response.

                • Marc February 25, 2016 at 1:00 am #

                  I thought it might be tongue in cheek….In fact I started my reply with “You must be kidding” or something, then deleted it because I wasn’t sure and didn’t want to be dismissive.

                  Well, thanks for your nice words.

                  Reading the newspaper convinces me that, if there is a god-like presence in the universe, it’s not in the business of guiding what goes on around here.

                  • Terry February 25, 2016 at 4:04 pm #

                    Ha, almost got a bite. Thanks. if God does exist it has no sense of humor given the misery that still exist for humans. Buddha got it right – life is hard. From an addicts view i could not reconcile the hardship alcoholism led me to with the notion of a loving savior I was then required to place my life into the hands of. Changed addicts do a lot of hard work to change. a higher power cannot be trusted or relapse would never occur.

  4. John Becker February 18, 2016 at 8:07 am #

    Thank-you for this excellent post today. Resonating with your ideas, Marc, I would say that for me the disease model is not so much the wrong answer as the wrong question. And that reminds me: did you know that the words cure and curate come from the same root?

    • Marc February 18, 2016 at 8:41 am #

      Thanks for that, John. A perfect high-wire act — I see the trapeze artists in graceful flight. And no, I didn’t know that.

  5. Guy Lamunyon February 18, 2016 at 8:38 am #

    The model with the best rate of recovery wins?

    But wait, recovery outcomes are universally low.

    Outcomes are more important than theories!

    • Carlton February 22, 2016 at 10:56 am #

      A model that does not undermine the various beliefs about what addiction is, or is not, could also throw new light on addiction, and on what is currently called recovery too.

  6. cheryl February 18, 2016 at 9:19 am #

    Wow, I love how specifically you nailed the stages of society’s understanding of addiction. Best I have ever seen. Thanks!!! I agree with where you think it should be going.

  7. Michael February 18, 2016 at 10:19 am #

    Hi Marc,

    Seems what when down with me since I left a 23 year pharmaceutical addition to benzos and oxycodone/hydro (chronic pain until I burned it out in the gym) fits your theory. (By the way, read both your books; thank you. They helped greatly as did all addiction resources I inhaled). I put down neuro-change time (after 2 years clean, my brain chilled out) while building on myself in growth oriented ways; spiritually, mindfully, with nature, music, art and exercise daily in my sweet spot). Now 5 years later, never really think of those pills; just think of how shitty I felt “chasing” doctors and pharmacies, BS’ing pain levels, my drug seeking salesmanship and being sick at least a week a month.

    Can’t say for sure my approach would work for most, but I’m not diseased, for certain.

    Peace and the best for 2016,
    Michael ~ NYS

    • Janet February 18, 2016 at 1:20 pm #

      Indeed you are not diseased. You were in a spiral of diminishing returns. Now, it sounds as if you are nurturing your naturally well self and expanding in every good direction. Many heartfelt congratulations. It takes a great deal of courage.

  8. Paul Regier February 18, 2016 at 11:32 am #

    A wonderful idea that is not mutually exclusive with the disease model.

    I love the idea of addiction being a part of development, and while I think this is a great concept (and more psychological in nature), it ignores key elements necessary for moving passed addiction. True, there are neurobiological processes that will be new/developed as a result of addiction. It’s a thing that remains in the past no matter what. It’s a part of someone’s life. This learning model concept will help people deal with addiction and move on (and it has, based on comments here and previously, which is fantastic). Cortical areas and memory structures will form new connections around the idea of once having addiction. Cues may hold different meanings while potentially eliciting nostalgic drug memories. However, there are normative processes in the brain that will reset during abstinence or reduction of drug/alcohol use. Otherwise, how do we explain the homeostatic mechanisms driving tolerance and withdrawal? How do we explain extinction? So, yes, I am an advocate of these two concepts working together, and I think they do. Anyway, great piece. Cheers, -Paul

    • Marc February 24, 2016 at 5:18 am #

      Thanks, Paul. I think we agree on the basics, but I’m not sure about the homeostatic mechanisms you mention. First of all, there is no homeostatic resetting when people give up gambling or porn…so any formulation that only applies to substance addiction is, to me, limited. Second, the idea of a reset can also be overinclusive… there’s a reset when we go off beta blockers. So a physiological reset is not the same thing as change from nonnormative to normative habits. Third, homeostasis is a nice idea, but it doesn’t seem to jibe with ideas about developmental change and neuroplasticity. The brain no doubt finds new set points as we develop….there is no way in which it can go backward to some previous stable state.

  9. Marc Kern Ph.D. February 18, 2016 at 1:37 pm #

    We at Alternatives see addiction like a marbled rye bread. I find it interesting that the medical establishment has been debating the cause of addiction for hundreds of years. Some feel it’s biological. Others swear it’s psychological.

    Which side is right?

    Actually, both sides are correct. Every addiction contains elements of the biological, as well as the psychological. In my opinion, it’s not a matter of one or the other. Instead, we should be asking how much of an individual’s addiction is biological, and how much is psychological? Then we will be addressing all facets of an addiction.

    M. Jellinek, the founder of the disease concept of alcoholism, felt there were five types of alcoholics. This reminds me of something I saw on a Jerry Seinfeld show about a loaf of marbled rye bread.

    The ratio of dark pumpernickel to light rye varies within the loaf, depending on where you slice it. The same is true for the ratio between the biological and psychological components of addiction.

    For example, I’ve worked with addicted individuals who have experienced trauma and psychological despair. In that case, the addiction is more psychological than biological in origin. On the other hand, I’ve worked with clients suffering from ADHD and chemical imbalances. In this instance, the nature of the addiction is more biological than psychological.

    It’s important to realize addiction is never static. In many ways, it’s a moving target. No matter how an addiction begins, it becomes more biological with each passing day, as it rewires the physical structure of the brain. However, if addiction were strictly biological, we’d have shots, pills, and surgical procedures to cure or correct it. But we don’t. Not even after hundreds of years.

    If we are to treat addiction successfully, we must understand that both biological and psychological elements are present. Addressing both gives us the ability to help more people enjoy long-term recovery. And that’s what it’s all about, isn’t it?

    http://addictionalternatives.com/addiction-and-a-loaf-of-marbled-rye-bread/

    • Marc February 24, 2016 at 5:43 am #

      Hi Marc, I like the marbled bread analogy, but I think you have to pick your terms differently. Things aren’t either biological or psychological EVER. All psychological states arise from brain processes. Depression and trauma involve changes in neuromodulator balance as much as does ADHD. And anything that has anything to do with learning and development involves changing synaptic pathways.

      Perhaps the two layers or components, which show up differently at different time slices, have more to do with substance dependency vs. psychological habit/addiction. Even these are hard to parse, but there are phases when withdrawal symptoms are the villain and other, overlapping phases when loss and emptiness are the driving forces.

      • matt February 28, 2016 at 3:46 pm #

        …an interesting factoid around this. In detoxes people often exclaim that it is so hard to stop because it’s a physical addiction. Yet most are surprised to admit that even when they are very sick in physical withdrawal, when they make the decision to use…they call the dealer and he has the stuff, or they have the pint of vodka on the car seat next to them…they feel better immediately. It seems there is some overlap between the physiological and psychological in this case, albeit anecdotally. The anticipation, just knowing it’s gonna happen is enough…

        • Marc March 1, 2016 at 9:33 am #

          Interesting point, Matt. I think that has everything to do with the feeling of safety, which is indeed a psychological bond, not a physical one. Knowing you are not alone, your needed fix is by your side, relieves a very specific emotion: panic. Relief, by the way, brings with it a throng of endogenous opioids.

          • matt March 1, 2016 at 1:14 pm #

            …and sometimes just making the decision to use can bring that relief. The trick is to train your brain to feel some relief when we make the decision not to use.

  10. William Abbott February 18, 2016 at 2:32 pm #

    The real problem here as I see it is with the word disease itself– all definitions of which there are many use the word ” abnormal” which immediately conjures self defeating stigma and stereotype .. and further just what is normal anyway and who is to decide which is which ?

    And of course disease is sickness which must be treated- of course by people who know more about the abnormal’s problem than they do . All detracting from self management… this said by an MD who now knows better

    Perhaps better start with the notion that it is a perfectly understandable and yes expected consequence in some people in the evolution and development of the homo sapiens brain . One learns addictive thinking and behaviors from repetition and dysfunctional , maladaptive consequences ensue. All this is supported by current and exploding neuroscience ..correctly interpreted instead of the way the disease model lovers describe

  11. Heather February 18, 2016 at 4:27 pm #

    People accept the model that appeals to them and helps them. I have a friend who found the courage to seek help for her addiction, because the disease model took the stigma away for her. Even though I disagreed, i would not take that away from her. Personally, I found the disease model left me feeling hopeless and defeated, whereas the learned behaviour model leaves me feeling empowered.

    • Terry February 18, 2016 at 5:46 pm #

      addiction is a bitsa condition – a bit of this, a bit of that – a biopsychosociocultural model is what we call it when working with indigenous men – too often though the spiritual element, the identity deficit, the disconnection with self is not discussed. this is not religion but about the lost soul that many addicts relate to. a disease of the soul is not about neurobiology nor is it learned ??

      • Mark in Oz February 18, 2016 at 10:54 pm #

        Perhaps the soul is not at ease (hence the substance use). Soul at dis-ease.

        And as Marc suggests the soul and experience of the person can evolve though that as things in their life change.

  12. Annette February 19, 2016 at 11:12 am #

    Thanks Marc, very insightful. I live in the UK and was a high functioning alcoholic for 40+ years. Me and my husband’s drinking spilt over to our son, causing many issues and fights. I tried Al-Anon 5 years ago, but couldn’t see any benefit in sitting there after 10 years stating: “My name is xxx and I’m an addict.” The helplessness in that room made me feel ill, like Heather. (Good people, but I still felt like running outside, screaming.) Had 2 lots of counselling and anti-depressants: nothing really worked

    Read Gabor Mate’s book, and your “Memoir of an Addicted Brain” and lots of books about compassion and neuroplasticity. I joined an alcoholics’ recovery website, http://www.hellosundaymorning.org. Blogging there every day for the past 9 months, meditating, being grateful and helping others, doing yoga and cutting back on drinking, I am now completely teetotal. As my brain adapts to much healthier thoughts and habits, there is 0 attraction in returning to the ‘old days’.

    Today, I have no depression and am the fittest and healthiest I’ve been for 20 years. We can and DO change, it just requires lots of self-belief, a healthy respect for the sacred (whatever we call it) and daily application. And lots of alcohol free alternatives to grog!

    • Sonya February 19, 2016 at 12:29 pm #

      Good to read your comment here Annette. Thanks for directing me to this site and post…Sonj.

  13. Frederica February 19, 2016 at 11:48 am #

    Dear Mark,
    Thank you for your insightful post. I stopped drinking 2 and a bit years ago with the support of the folks on http://www.hellosundaymorning.com
    The reason I decided to go down that route is that I watched my ex-husband become increasingly ‘addicted’ to AA when he stopped drinking 12 years ago. I know that it was an individual choice for him, but it concerned me that the fellowship appeared to be more important to him than personal growth, This trait seemed to be one that many of his fellows shared,and as an educator, I felt that there must be another way.
    Through HSM, I have learnt that I don’t have to walk around with ‘alcoholic’ stamped on my forehead forever more. I had a problem with drink, I have dealt with it and its causes, and I am moving on as a more aware and productive member of society.
    I see addiction like being pregnant…it’s not a state that you have to dwell in forever!
    With all best wishes
    Frederica

    • Annette February 19, 2016 at 2:35 pm #

      Thanks Frederica. In our small town, I know the folks who run AA and Al-Anon and I saw that there’s a bit of a ‘cult’ going on. Staying stuck is so darn depressing. Choosing a wise, self-development approach is so much healthier. <3

    • Marc February 24, 2016 at 5:52 am #

      Hi Frederica, I’ve never heard the analogy with pregnancy! I’ll have to add that to my stock phrases. But, point taken. Notice that the concept of being an alcoholic forever is tightly linked with the disease model. If you have a chronic disease, then of course you have it forever. See Matt’s comment below.

      But as to the “addictive” aspect of AA, it’s sort of like the concept of “secondary gain” in depression — a phrase that may have gone out of fashion…. or maybe now it’s more relevant to ADHD. For some people, the idea of being part of a small group of sufferers is a convenient way to maintain a concrete sense of self, maintain a regimen of self-care, and even elicit support and/or sympathy from others. It’s not intrinsically evil, but, as you say, there are better ways forward.

  14. Judy Wright February 21, 2016 at 3:36 am #

    Excellent article! Thank you!

  15. matt February 21, 2016 at 9:53 am #

    I think the disease model is a distraction and disincentive to recovery. It’s held by most people… at least those in detoxes. It can keep people stuck.

    A developmental model of behavior change used in most treatment settings is Prochaska and DiClemente’s Stages of Change, originally developed to describe how people stop smoking. In my experience, I have only seen it used in treatment venues to describe the process people go through moving from addiction to recovery. But it is just a description of change– neither toward nor away from addiction. When I was in treatment, the stages were of little use to me. But when I started to get some time, they helped me maintain my sobriety. I noticed the process of change, as I moved toward relapse. It helped to keep me sober, which is where the struggle is for most of us. 12 years after “Changing For Good” was published, DiClemente wrote an exhaustive tome “Addiction and Change” about how the change can go either way– toward or away from addiction. It helped me notice when I was engaging in thinking and behavior that endangered my sobriety, and I caught myself. Yet I have never heard any reference to the second book. What’s up with that?

    Shooting hoops or shooting dope, people learn how to do this stuff.

    • Marc February 24, 2016 at 5:46 am #

      Thanks for bringing up DiClemente, Matt. I haven’t read either book, but obviously I should.

    • Frederica February 24, 2016 at 6:19 am #

      Hi Marc,
      Thank you for pointing me back to the secondary gain model. I remember learning about it at Uni, but had forgotten the name of. I use it daily when working with children with AHDH/ASD and other less well defined mental health difficulties…my catch phrases being ‘and how did that help you?’ Trying to elcit some logical thought from them. Just because you were told you are naughty, there is no need to keep on repeating and reinforcing the label that other people have given you. Some of my guys now look at me and smile and say..yep, I was looking for ‘bad’ attention !
      I will think a lot more about this in the next few days and apply it to myself, as although I do not think that it is very helpful to chew over the causes of addiction, I do think it is helpful to unpick old behaviours to try not to repeat them in the future

  16. Richard February 21, 2016 at 1:58 pm #

    Hi Marc,

    Great post as always

    I will attempt to keep this brief !

    I know your are not necessarily a fan of residential treatment but I’m interested in your (and your community of readers) view on what should constitute effective drug rehabilation and how best to utilise a learning model

    The reason is ask, is that myself and a few colleagues are looking to design a treatment program here in London that can really be effective and move away from the old school, one size fits all, diagnostic 12 Step approach, I guess similar to CMC in New York, who seem to have an interesting program

    So, in short, seeing as I’m sure you’re inundated with requests, I was hoping to get a few sound bites from you as to what the ideal treatment model should include ? Be it specific excercises, approaches or simple words of advice

    Anyway, be great to begin a dialogue, and of course, if you’re ever in London, to come and chat to our clients

    Richard

    • matt February 21, 2016 at 4:43 pm #

      The short answer: actively involve the the person with the issue in their treatment plan. Don’t even use the word treatment. It is a team effort. It will be effective when everyone on the team is involved. One possibility is to model it after the Open Dialogue approach.

      Smaller open discussion meetings, where everyone is actively involved come around every once in a while. We need to pay better attention other than remarking “What great meeting that was.”

      • matt February 21, 2016 at 4:47 pm #

        Sorry. Open Dialogue approach that is having success in Finland.

        • Richard February 21, 2016 at 4:49 pm #

          Thanks Matt – sounds important, will check it out

      • Carlton February 21, 2016 at 9:20 pm #

        Crosstalk, or open dialogue in a group, allows a person to catch fragments or glimpses of themselves in other people talking.

        This can help a person help themselves regain their freedom from an addiction.

    • Marc February 22, 2016 at 3:22 am #

      Hi Richard, This strikes me as a long, involved conversation. I don’t have a recipe that I can send you, just some ideas that I’ve arrived at over time. I’ll be in London in mid-July to give a talk. I supposed we could arrange a visit to discuss this. Meanwhile, others are already providing you with useful suggestions…which is just great.

      Chapter 9 in my recent book also goes into several recommendations for a philosophy of treatment, if not details on how to apply them.

      And for the record, my main beef with residential treatment is simply that it usually doesn’t work and it often costs too much (at least in the US). In principle, it’s great. The problem is obviously transferring the new skills, perspectives, mood variables and all the rest back to one’s home environment!

      • Richard February 22, 2016 at 12:18 pm #

        Hi Marc

        That sounds good
        Do you have details of the talk in London etc ?

        Richard

        • Marc February 24, 2016 at 5:32 am #

          I will be at something called the Royal Institution….right around the middle of July. Sorry but I don’t have a date yet.

  17. matt February 21, 2016 at 11:53 pm #

    Hey Carlton

    I couldn’t agree more. An open discussion format has multiple benefits, information sharing, peer support, etc. This is different. The Open Dialogue Model involves the entire community of care around the person with the issue in a process of shared decision making, feeling heard, and supporting self-efficacy. in less clinical settings, like the person’s home. It was developed in Finland. It was originally developed to treat psychosis with huge success. Check out the YouTube videos. It’s very hard to characterize in a brief description. It may be in the future for recovery.
    https://www.youtube.com/watch?v=vRjk4_ybCqU

  18. Gary February 22, 2016 at 7:40 am #

    I’m not really sure that it matters much rather one refers to a “Disease Model” or “Developmental Learned Model” as long as a person gets help. One size doesn’t fit all, however, if perhaps it’s a matter of being “right” then the person who feels they are absolutely right has killed their creativity. Whenever you think you’re right there is no room for other possibilities and the thinking tends to become narrow. It may be a matter of communication and one’s ability to relate to a narrative that makes sense regardless of any definitive model.

    With respect to any debate regarding various models keeping it clear, concise and simply may be the more effective approach. What causes a problem, is a problem, so! looking and observing in that context allows for one to see what is taking place without being distracted or perhaps conditioned to any model whatsoever.

    I tend to take a position that thinking and “brains” can actually get in the way and even impede treatment be it from client or clinician.

    What’s been helpful, in my experience, is appreciating the clients’ map of the world and helping to reshape the scaffold and/or narrative that encourages change from within. I really don’t believe recovery or “Discovery” is a science, model or even an approach of any kind. People constantly disrupt their addiction by quitting without any education or programs perhaps due to their health, cost or any other reason that is valid in their minds. This is why some smokers’ quit Cold Turkey, not necessarily that they found a “way” as much as they have a “reason”. Once a person have a valid reason just about any way could help because that person may have exhausted every possible excuse etc…,

    • Carlton February 24, 2016 at 11:28 pm #

      Gary,
      you wrote:

      “I really don’t believe recovery or “Discovery” is a science, model or even an approach of any kind. People constantly disrupt their addiction by quitting without any education or programs perhaps due to their health, cost or any other reason that is valid in their minds. This is why some smokers’ quit Cold Turkey, not necessarily that they found a “way” as much as they have a “reason”. Once a person have a valid reason just about any way could help because that person may have exhausted every possible excuse etc…,”

      To add to your observation, during the recovery struggle, the thought that strength, skill, mindfulness, etc were going to be constantly necessary to keep the addiction at bay, was Sisyphus-ian, and an impossible task for someone like myself.

      It became apparent that something else was occurring when people that used to be active members of recovery program, would eventually leave.

      Trying to get a new meeting called “Former members as Guest speakers” just would not take hold.

      It is very hard to articulate about something that was so critical to your sense of being when it no longer is, for a number of reasons.

      A persons period of Addiction it is not something people generally want to spend time on, let alone expound on it, especially when there are many others that do, and remain and help others in recovery programs.

      But these peoples accounts that are not heard, may illuminate things about addiction that currently does not get heard.

      Research is naturally on people that are addicted, but insights would come from research on people that no longer feel addicted, and are not relying on strength, skill, or things of that nature.

      I feel research in this unexamined area will reveal and confirm a new model
      of Addiction that will account for all the various individual stories and experiences, rather than being in contrast to each other.

  19. CM1 February 24, 2016 at 5:20 am #

    Hi Marc,

    I don’t always comment but follow the posts avidly. I wonder what would a more inclusive less dogmatic non pathologising critique look like and more importantly what would “Help” look like could it possibly have as consideration an existential phenomenological driven relational Enquiry? As the great Emmy Van Deurzen asserts these issues are issues of “Being” that is being in a world where we are doomed to choose and where even non choice is itself a choice. How do we gently wake up to the choices we have despite our limitations. We exist to choose we either choose in line with our heartfelt values or we give our choice for others to define our realities for us. I wonder what we would call addiction if we had to think of it in terms of “non existence”. I hope we are getting more courageous in waking up to our one and only existences?

    As for “God” I am more of an agnostic I just could not call it one way or the other I remain curious and open.

    Thanks again love and peace to all✌️

    • Marc February 24, 2016 at 5:57 am #

      Thanks for commenting, CM1. I guess the closes thing I can think of are the mindfulness approaches to addiction…they start of with concrete practices, like meditation, urge-surfing, etc. But then people presumably become more aware of the ebb and flow of their own consciousness…. and that’s when those existential issues can become objects of reflection…rather than just abstractions.

      Waking up “gently”….very useful and evocative image.

  20. Gary February 25, 2016 at 7:09 am #

    In terms of “waking up” each person may have to seriously consider that they are first and foremost their own authority, which, is the start of waking up. “Recovery” is the discovery that change is an inside job and embracing this fact one gains the courage and strength to reach out. However, “thought” and “thinking” are extremely limited and can actually impede one’s ability to reach out. This process can, at times, help or hinder. Long before a person decides, if at all, to get help they probably “thought” about it for quite some time and thinking can get a bit pathological to a degree that the person may feel even more helpless or hopeless. Perhaps a person needs to take a break from the “mind” or “thinking” altogether in order to appreciate a real sense of effortlessness breathing and calm. Healing ourselves comes out of the effortless quiet where there is a natural numinous intelligence. Perhaps it is a way of “getting out of our mind” instead of operating on a level that requires more effort. Sometimes the method, model or approach actually gets in the way of real recovery and impedes ones’ ability to discover the power of effortlessness. In many ways, we are still trying to “fix” the problem. Unless we (clinician/client etc…,) start with a “clean-slate” how can we even begin without the distraction of knowledge, pre-conditioning methods, anecdotes or other approaches that actually impede healing.

    • Carlton February 25, 2016 at 9:02 am #

      People that think, feel, believe and accept that something outside of themselves is involved in their situation, (such as a higher power or a disease) are ALSO listening to themselves, and have “woken up” to this understanding for themselves.

      Additional recovery programs are now available for people that have woken up to a different understanding for themselves.

    • matt February 27, 2016 at 6:50 am #

      I think this is a good characterization of what happens in recovery. We are all unique collocations of mind, body and experience, so everybody’s “recovery” is going to look different. How do we instill the life skills necessary to negotiate that change? How does what is “within” navigate what it encounters outside? What tools do we need for the job? Models to policies to programs to practice. The addicted person is at least twice removed from finding what s/he needs to do the job..

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