For decades the medical profession has largely treated addiction as as a chronic brain disease. The US government’s National Institute on Drug Abuse characterises addicts as compulsive drug seekers and users who continue taking drugs despite harmful and unwanted consequences. “It is considered a brain disease,” the institute says, “because drugs change the brain; they change its structure and how it works.”
Dr Marc Lewis, a developmental neuroscientist – perhaps most famous for detailing his own years of drug addiction and abuse in Memoirs of an Addicted Brain – strongly refutes this conventional disease model of addiction. His new book, The Biology of Desire: Why Addiction is not a Disease, argues that considering addiction as a disease is not only wrong, but also harmful. Rather, he argues, addiction is a behavioural problem that requires willpower and motivation to change.
Lewis’s theory has divided the medical profession and those suffering from addiction. He has been lauded by some for putting the theories challenging the disease model together into one book; others have labelled his ideas dangerous, and him a zealot.
Guardian Australia sat down with Lewis before his appearance at Melbournewriters festival on Sunday and the festival of dangerous ideas in Sydney to talk about the controversy, as well as his theories on how addiction can be treated and overcome.
Through your years as an addict, were you questioning the idea that addiction was a disease you were suffering from? Or is this book purely a result of your later studies and expertise in this area?
Well my training was as a developmental psychologist, so I studied child development, cognitive development, emotional development, and personal development. So I really had a strong developmental framework for thinking about all human psychological phenomena.
When I started thinking about addiction in my first book, it was more or less descriptive. So, ‘This is what happens to your brain when you become addicted,’ and, ‘This is what drugs do to your brain.’ But in this latest book, I wanted to really try to explain addiction, and it just came crashing down that this was a developmental phenomenon. You grow into addiction. It takes place in a sequence or a progression through repeated trials, through repeated exposure, repeated actions, and through practice.
So it wasn’t until you started writing about what addiction is that you really began to think describing it as a disease didn’t make sense to you?
When I was doing drugs, I wasn’t thinking about it in any kind of analytical way, well except, you know, trying to analyse, ‘Why the hell am I doing this to myself?’ But no, I think in writing The Biology of Desire … put it this way. It never occurred to me that addiction was anything other than a developmental phenomenon. The whole idea that addiction is a disease never made sense to me either personally, scientifically, nor through my discourse with other people who are addicted.
Have people been supportive of your arguments that addiction is a behavioural problem, but not a medical one?
It’s been mixed. There’s certainly been negativity. I just had a review in the Washington Post where I was called a “zealot”.
But 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.’ It’s a very strange argument, to have to think of yourself as having a disease because that’s the only way you can live with yourself and deal with the addiction. And then I feel badly, because I don’t want to harm these people or take away something that they need conceptually or motivationally.
There is this idea that the addiction label is the only thing that is going to save them and stop them from being blamed and denigrated as addicts by society. They feel that if it is a disease, they don’t have to feel that burden or shame, because it’s not their fault. It’s hard to pull the rug out from under that without causing some upset.
Is there anyone for whom addiction is a disease? Are there a small portion of people who are unable to stop taking these drugs, who are wired to be reliant no matter what kind of treatments or motivation they have? Or do you believe that for anyone, addiction should not be labelled a disease?
That’s a really good question. I guess that’s why I’ve been called a zealot in the last day or so. I guess there is a point where the devastation of addiction, combined with the situation of people’s lives – whether through poverty or crime and social isolation – and when those factors hook up they get really hard to stop, really, really hard to stop.
I was in Vancouver a couple of weeks ago at a supervised injecting room, so these were the most down and out people, really long-term street people. Most of them had grown up in foster homes, they had no property, no money. They didn’t connect with the world like most normal people, they lived on the street and their whole lives were organised around getting the next fix.
Given the way their lives are structured I think its very, very hard for them to stop. Does that make it a disease? Well, no, I don’t think it does. I think that makes it a social problem that’s terribly entrenched. It has to do with dislocation, alientation, poverty and all these sort of factors and a lack of care by the larger society for people who are suffering. When you put all those factors on the table, then you don’t have to use the disease label to explain why some people can get really deeply stuck in addiction.
OK, but there are also high-functioning, middle-class and wealthy people with jobs and social support who would describe themselves as addicts, and for whom those social factors you talk about don’t resonate. Despite having all the resources in the world available to them, they feel they can’t stop.
Well I think those people have a better chance of quitting. They have family, they can afford therapy, they can talk to people. But of course no, I don’t want to say people who are riding high in society can not become very deeply addicted. So what’s left then in the formula? Probably the fact that addiction includes a very strong compulsive property, so when people have been addicted to something for some period of time, the psychological process moves from impulse to compulsion.
And that also involves in part, brain changes. The parts of the brain that become activated when craving is triggered by cues changes. So there’s something going on that makes it hard to stop for very good neurological reasons. So then, do you want to call addiction a disease? Well, maybe, then you’re getting close I think, because you could call it a pathology I guess. Because obsessive compulsive disorder, that’s a pathology right? So yeah, I think there is a point at which the line betweens those definitions starts to blur.
So it sounds like it comes to a point where perhaps addiction does fall into disease territory then?
[Pauses]. I wouldn’t say disease. I would call it disorder. Or even the adjective, “pathological”. But I just don’t like those words because there’re all part of this particular framework, and that’s the dominate framework in the US and parts of Europe, that this is in fact a chronic brain disease. It’s hard to talk about it as if sometimes it’s a disease or sometimes it’s not. Then the argument starts to get kind of mushy. But when you are in the grips of compulsion, yeah, there is a process going on that of course isn’t healthy and requires a certain amount of cognitive and emotional and probably therapeutic work to get out of. So yeah, OK, I’ll grant you that you could call that, certainly, a disorder.
Why does it matter? Disease, disorder, behavioural problem? Does it affect the way we might think about treating those suffering from an addiction?
It sure does. The whole campaign to see addiction as a disease is that it works against people’s sense of empowerment. If you have a disease, you’re a patient. If you’re a patient, you have to take instructions from your doctor and do what you’re told. So people line up for rehabilitation centres and often have to wait for a long period of time, long after they’ve lost the motivational rush to actually quit.
Then if you do get into rehab, you’re putting yourself in somebody else’s hands and you’re going with the program. But the best way to combat addiction is through setting different goals for yourself and setting your own goals. “I want this for my life, I don’t want that, I want to change.” That kind of self-perspective change and self-development of future goals and orientation is critical.
That’s been an argument against rehabilitation, that it doesn’t always set people up to meet personal goals and readjust to society.
That’s right. It really hinges on the idea of who is setting the goals here. Who is telling you what to do? Are you telling yourself what to do, or are you being told? If you’re being told what to do, you fall into a position of helplessness or disempowerment, which makes it hard to develop this head of steam, this effortful strength and self-control and willpower. I mean really, a lot of it is about willpower to master this thing, to take it in hand and change it. The best way to combat addiction is by setting goals for yourself.
Different types of rehab programs are needed for different types of drugs, for example it might take someone longer to get off ice than say, heroin, and therefore programs should be tailored to recognise that. But given what you’re saying, would the model of treatment be relatively the same across all drugs, because it’s more about willpower and setting goals than the type of drug being abused?
A good question. I don’t think so. Even though it has those goals in common, people are very different and there are many ways to quit. Some people will need to focus more on cognitive tricks to self-program to modify their behaviour, others will need to change their environment to make sure they don’t drive home past the liqour store, and for other people it’s much more of a motivational thrust, more mindfulness and meditation. For others, it’s about deeply connecting intimately and honestly with loved ones. Those are really different ways of getting better, even though what they all have in common is that theme of empowerment of self-motivation.
I can see why people with an addiction resist this way of thinking. No one likes to think of themselves of having a lack of willpower, or being to blame. Some members of the medical establishment are resistant to this idea too. Why do you think that is?
I think it’s partly ownership, it’s partly they way they’ve been trained to operate. I don’t hate doctors, there are wonderful doctors. But doctors are trained to look at things in terms of categories, diagnoses, which have a certain set of possibilities for treatment or certain sequence of things to try. It’s a really strongly inbred way of looking at very serious problems. And it’s hard for them to shake it.
Right, but we need some kind of diagnostic framework. Are you criticising the medical profession for needing to label patients? Because don’t we need to label people to some extent in order to narrow down treatments?
Sure we do. I’ve had a number of medical issues in the last few years and I’m damn glad my doctors have had a diagnosis and a treatment strategy. So yes, doctors do need to function like that. But it’s just I don’t think addiction is a medical problem. It has a medical side to it. So doctors should be involved in an adjunct capacity, particularly with drugs that produce withdrawal systems when you stop taking them. So doctors should help people with the medical problems associated with addiction, but addiction itself is not a medical affliction.
So what would you say to those who read your book, have an addiction, and have taken in what you have to say and want to know what to do?
I’ve had dozens of emails specifically to ask that. People saying, “My son is addicted to heroin,” or “I’ve been addicted for many years.” I say that well, there are many different ways for people to kick their habit and it is important to think about where that habit comes from and social factors. The person’s developmental stage is important, for example addiction is a different beast for someone in their 20s compared to in their 40s. Some people outgrow addiction and spontaneous recovery is just another way of saying people stop when it gets too much. They can’t handle it, and that often taken place when emerging through their 20s and into their 30s and wanting to start taking responsibility for their life in a different way. Treatment depends entirely on who I think they are, and what they are going through.
• Marc Lewis: Learning Addiction; Sydney, Sunday 6 September, 2pm, Playhouse Theatre