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5 Things the Disease Model Gets Wrong About Addiction

Denying an addict's will is a poor path to personal responsibility.

“Use every man after his desert and who shall ‘scape whipping?”

There’s a narrative that comes up whenever addiction is discussed publicly nowadays: the narrative in which the disease of addiction essentially replaces a person’s free will.

The barroom-wisdom version of it is the old line, “First the man takes a drink. Then the drink takes a drink. Then the drink takes the man.” A fairly heartbreaking version of it comes in this interview with author (and father of an addict) David Sheff: “Once I started realizing that my son was not making choices, I went from being angry and judgmental to being able to look at him with compassion: He’s sick; he needs help. It also allowed me to figure out what I needed to do: He’s sick; he needs to be treated.”

This narrative is, to put it mildly, not uncontested. Lots of addicts don’t agree with this description of our problem. Lots of non-addicts also disagree, typically more virulently (but I guess I’m biased), and insist that addicts are doing it on purpose: That’s a narrative I seem to see more on the right than on the left, though these are personal enough matters that ideological categories get blurry. The whole debate over how fully you want to reify the disease metaphor (which is what it is—that’s not bad, metaphors are a normal and poetic part of human understanding) gets tangled up in related debates about Alcoholics Anonymous, metaphors of surrender, treatment and/as/vs. punishment, and the promotion of personal responsibility.

There are five things wrong with an overemphasis on disease at the expense of free will—but the reaction against the disease metaphor often merely serves to strengthen it. First, the five things:

It doesn’t (always) accomplish the purpose of provoking compassion. I know the thinking, She really can’t help herself, can often make us gentler. She’s not doing it on purpose; it isn’t her fault; it’s the same as if she had cancer or epilepsy or schizophrenia. But that last example should make it clear that “it’s a disease” is no guarantor of kind treatment. Disease carries its own stigma, and the disease model of addiction can easily coexist with the conditions of power vs. helplessness and shame that make abuse easy. In fact…

It can become an excuse for control. If our will has been totally replaced by disease, whereas yours is still sturdy—is there anything you can’t force us to do? Defining someone as an addict, in the strongest version of the disease model, reduces her to the moral status of an infant: someone to be protected, sure, but definitely not to be trusted or allowed to choose. You don’t have to listen to someone who says her rehab is abusive, because that’s the disease talking.

And this is why the expansion of the language of addiction has served the expansion of the nanny state. Oreos are just as addictive as crack! Cigarettes are obviously addictive. So let’s ban and tax them, for the good of the less-rational among us.

It assumes that “addiction” is all one thing. “Addiction” is a modern umbrella term which transforms a host of wildly disparate experiences into an identity group. My alcoholism isn’t necessarily going to have much in common with that of, for example, someone with a long family history of addiction (perhaps suggesting a stronger biological component), someone with a concurrent mental illness like depression or bipolar disorder, or someone who responds really well to drug therapies to fight cravings, but responds not at all to spiritual approaches to recovery. It’s not really (or at least not primarily) about the substance we choose: I relate much more to crack addicts talking about how they found God than to fellow alcoholics talking about self-actualization.

There’s a weirdly double-edged argument, which can be either a case against AA or a case against the disease model: “For what other medical condition does 90 percent of the treatment consist of meetings and prayer?” My own answer is that some people’s addiction is a lot more like a disease than others’.

It assumes way too much self-knowledge, let alone knowledge of others’ psyches. When I was drinking my will really was damaged. The scriptural metaphor of slavery, bondage of the will, resonates with me more than metaphors of disease, but they’re getting at the same sense of helpless compulsion. I made and broke all kinds of plans and resolutions and promises. My imagination was distorted: I literally couldn’t imagine a future without drinking.

I am convinced that there were times, within this compulsion and constriction, when I was capable of choice. Sometimes I chose heaven—often tiny little choices which seemed pointless at the time, like the choice to read a book about addiction even though I was stressed and scared, or sincere prayers which were quickly swamped by rationalization, exhaustion, and fear—and a lot of times I chose the other place. But even in my own past, I doubt I could accurately gauge the depth of my own freedom in any individual moment. How can I hope to gauge it for others?

This is the point that both sides of the disease/choice divide get wrong. Of course your will is constrained. Your background, what you were taught (explicitly or implicitly) growing up, your brain chemistry, your mental health—a whole host of factors out of your control, unchosen and not always even noticed, constrain your choices. But within that landscape of constraint we often do choose. We make huge leaps or crawl tiny, painful inches up or down. You’re not trapped in your brain or your past—at least, not always. But even from the inside, you can’t always see the moments when you’re free.

And it’s even harder to tell from the outside. Someone making slow, switchbacky progress toward recovery often looks just like someone choosing addiction. (We say the same things, too. David Carr’s phenomenal memoir The Night of the Gun hits this point hard: “Part of the problem with authentic recovery is that you are stuck with the same rhetorical set that you had when you were chronically relapsing. This time, I’m really about something. No, this time.“) You don’t know what internal obstacles another person faces. Or, in that attributed-to-everyone line, “Be kind with everyone you meet, for everyone is fighting a great battle.”

To put it as bluntly as possible, you can think laziness and selfishness exist without thinking you know when another person is just being lazy and selfish. And if you’ve ever misjudged another person’s character, or had your own humiliating failures treated as if you just weren’t trying, you know that.

And so finally, the biggest problem of all:

It isn’t mercy. If someone genuinely did not choose to do wrong then compassion for that person isn’t mercy—it’s justice. And conversely, if you can only have compassion on someone if you believe she did not choose her misdeeds, then you’ve defined mercy out of existence. You’re not forgiving—you’re saying there was never anything to forgive.

And I think this narrative, in which addiction destroys the will, exists precisely because we don’t trust others to have mercy on us or on those we love. A lot of people get jumpy when conservatives start talking about “personal responsibility” not because they think it’s awesome to be a self-centered overgrown infant, but because they think “personal responsibility” is code for a) conflating all forms of personal failure—mistakes, bad luck, a bad hand dealt at birth, inability to overcome massive societal injustice, misunderstandings, petty idiocy, and grave sin; and then b) punishing personal failure with contempt and cruelty.

Adam Smith had this cute little tagline, which I admit I am taking out of context, “Mercy to the guilty is cruelty to the innocent.” Now first of all, mercy to the guilty is the only kind of mercy there is, see above for details. But we might also add, “Cruelty to the guilty creates pressure to declare everybody innocent.”