Eye on Science, Science Blog, Michael D. Lemonick, TIME

July 29, 2007 12:08

Sally Satel Responds on the Addiction-Disease Question

Posted by Michael Lemonick | Comments (25) | Permalink | Trackbacks (0) | Email This

A couple of days ago I ranted a bit on this article in Slate that argues addiction isn't a disease.

Many readers have commented, but now one of the authors of the original Slate article has weighed in. Here's her comment, in full:

Sally Satel responds: Below are the links to the SLATE article (note that the controversy is over the term "brain disease") and one to a expanded article on the same topic. http://www.slate.com/id/2171131/fr/flyout http://www.american.com/archive/2007/july-august-magazine-contents/the-human-factor-2 --Sally Satel MD

Not exactly a response, but quite useful. As she points out, the controversy is over the term "brain disease," and in both her Slate piece and the expanded version, it's clear that she doesn't oppose the term so much because it's wrong as because it's not useful.

Fair enough; since any mental behavior is by definition biological activity, you could arguably call any thought that deviated from the norm "pathological," and thus evidence of disease. Which we do, in fact, with schizophrenia or depression. But you have to draw a line somewhere, given that norms are somewhat arbitrary. Is a negative personality a disease state, or just a variant of normal personality? The Diagnostic and Statistical Manual, which psychiatrists use to answer those questions, is hardly a perfect guide: at one point, if I recall properly, homosexuality was considered a form of mental illness.

Satel argues that addiction isn't a disease because it involves a behavior that is at some level voluntary. I argue that it is a disease because the underlying brain state of an addict is different enough from that of a non-addict that the voluntary nature of the behavior is significantly compromised. Thus, when Satel argues that addicts have a choice about whether or not to use, I respond "yeah, that's easy for you to say."

Satel further argues that calling addiction a disease somehow relieves an addict of the responsibility to take action. In some cases, maybe so. But as Satel clearly knows, people in 12-step programs like AA manage to accept both concepts at once. Yes, it's a disease, and yes, you have to take some responsibility for your own recovery.

Is there a danger that some addicts use the disease label to avoid responsiblity? Sure, maybe. But active addicts are adept at using anything they can think of to keep from dealing with their addictions. Satel is sadly mistaken, in my opinion, if she thinks calling addiction a habit will make any difference at all. Conversely if calling it a disease leads to medications that can help addicts a little with their decision-making, I'm all for it.

Besides, addiction was stigmatized as simple bad behavior for about 10,000 years; it's been labeled a disease for the past half-century or so. Does Satel really think the treatment of addiction was better in the good old days?

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Reader Comments (25)

THOMAS BILLIS:

To call an addiction in any sense voluntary is to miss the point.What leads someone to the point of harming themselves as in addiction is the final step of giving into that addiction that you have no choice and is anything but voluntarily.They have to.Whether it is food or drugs or alcohol.Brain disease seems to fit it better.Cure the hostility in someones brain and you cure his addiction to fight.You can cure a disease.I beleive by labeling it correctly as a brain disease you will be able to help more people than by sticking them in jail where they get no help.If I am not mistaken in the more enlightened courtrooms in America they are treating it as a brain disease and leaning more toward a cure than incarceration.

Posted by THOMAS BILLIS | August 1, 2007 6:56 AM

Sue:

Addiction is NOT a disease, it is a CHOICE. I don't get to choose whether or not to get a cold, the flu, multiple sclerosis, cancer, anthrax, etc. And someone with a disease like this can't choose to "quit" it. So, to call drug addiction a "disease" is so incredibly demeaning to people who actually have a disease!

Posted by Sue | August 1, 2007 10:16 AM

speedy:

"Besides, addiction was stigmatized as simple bad behavior for about 10,000 years; it's been labeled a disease for the past half-century or so."

uh, no ... not exactly. on both counts.

the process of distillation (which yielded the production of stronger, more damaging & [arbuably] more addictive 'spirits') dates back only to the 12th century. man's harnessing of the natural fermentation process probably pre-dates written history. that said, a large number of ancient written artifacts that actually praise the intake of fermented beverages (over largely non-potable water sources) have been found -- the new testament miracle of jesus turning water into wine is probably the most well-known [if least understood] example of this. early civilizations relied on alcohol for their very survival.

the record simply doesn't substantiate a larger, societal condemnation of drunkenness as a personal moral failing -- never mind one that would pre-date written history by roughly 3,000 years as you nonchalantly claim.

as to your second point -- "it's [alcoholism/drug addiction]been labeled a disease for the past half-century or so" -- while the AMA's endorsement of the 'disease' model may only span 50 years, the concept is as old as the country itself (if not older). dr. benjamin rush (signer of the declaration of independence & surgeon general for washington's continental army) was among the first proponents of the 'mental illness' concept and he grouped the plight of the alcoholic under that larger rubric. the 'disease' concept persisted throughout the 18th & 19th century, adopted by the temperance unions, the washingtonian movement, and the salvation army. AA and NCA did not create the 'disease' concept from whole cloth post-WW II. in fact, AA (in the person of bill wilson) did its best to actually distance itself from an endorsement of using the word 'disease' to describe alcoholism. all of this is documented pretty handily in william white's "slaying the dragon: the history of addiction treatment & recovery in america". white, by the way, is a very vocal proponent of AA & the 12 step method.

all that said, let me explain why i went to such length to dispute what were probably meant to be read as two throw-away sentences. just saying something -- whether at an AA meeting or in a blog on Time's website -- does not necessarily make it so. you chide satel ("that's easy for you to say") for stating that alcoholic/addictive behavior is a choice, but then close your response with two remarks that are misleading and, i would argue, demonstrably wrong. those things are easy for you to say, but not so easy to actually prove.

since you've got the 'dr.' initials preceding your name and the real estate on Time's website, you can argue from authority. in the same way, you conflate the political efforts to legislate the 'disease' concept (which is based entirely on a material model of biological and behavioral symptoms) with AA's lay presentation of a three-part 'malady': an 'allergy' of the blood, 'obsession' of the mind, and 'disease' of the spirit.

they are not the same thing, not by a long shot.

one mans' personal (and admittedly cynical) opinion, but the 'disease' legislation effort is being driven by a pharmaceutical industry eager to open a new profit line. and for those who can't afford drugs and/or treatment, there's the 12 step movement that's been the standard-bearer of the 'disease' concept -- implicitly if not officially -- since 1939, right? whether the lion's share of people who try 12 step meetings repeatedly relapse, leave the groups outright to struggle on their own, or end up dead is neither here nor there. it's all 'anonymous' and no one's keeping score. besides, "it works if you work it" and "some must die so that others might live".

malarkey.

the 'disease' argument is a red herring. what this is about is america's two most cherished ideals: money and god. legislating the 'disease' concept means federal research money for science and tax incentives & profits for the pharmaceutical and 'treatment' industries. the afflicted with money (or insurance) can go that route as many times as they need and [hopefully] get better. for those without, there's god (as you understand him) and the 12 steps. oh, and anonymity -- which can be an awfully convenient tool for muddying the waters when it comes to measuring a method's overall efficacy and success rate.

cards on the table: i've struggled mightily with post-traumatic stress disorder accompanied by alcohol and drug abuse for 28 years. if i'm suffering with the disease of alcoholism (and i won't argue that's not the case), then it's co-morbid with the disease of critical thinking ... complicated by the malady of poverty and a lack of insurance. i still regularly attend AA meetings. while i'm sure that i need help when it comes to staying sober (an AA plus), i'm dubious about that help ultimately coming from a benevolent, intervening supernatural source (an implicit AA negative).

it's easy for you to "say" that AA offers an effective solution to the 'disease' of alcoholism, easy for 12 step proponents to "say" that atheists are accepted without reservation into the AA fellowship. but, outside of personal testimony, where are the numbers to prove those assertions?

today i'm a drunk without access to expensive medical care who's also found that my politely declining the 12 step model has severely restricted the number of helping hands extended to me within AA (virtually nil at most AA meetings). should the legislation pass tomorrow, i'll be a 'diseased' drunk in the same boat.

thanks for the advocacy. thanks for really "saying" something helpful.

Posted by speedy | August 1, 2007 1:46 PM

CMC:

I read your article with interest; I'm a 45-yr. old female "4th generation" alcoholic.

As your article stated, women fall quicker into the abyss of adiction--this was very true for me. I resisted alcoholic behavior until about four years ago, when personal issues had me sipping occasionally, then a bit more, then a bit more, and finally, well, you get the picture.

I voluntarily went to an in-patient rehab where I learned both sides of the disease/behavior argument. Knowing my family tree helped me accept the brain chemistry argument; knowing my addictive behavior choices helped me accept the 12-step behavioral modification methodology.

My husband always argued that addiction was NOT a disease concept until he read your article. It helped him to understand that there is a component of the disease we can only control by rigorous and committed behavior modification. I am also taking Campral, one of the medications that, when taken regularly, helps stop the cravings for alcohol.

But drugs alone won't stop my addiction. It's up to me. No one else. I have to put stopgap measures into my life so I don't drive to the liquor store (I was an isolation drinker to escape some life problems). To that end I've effectively handcuffed myself financially: I turn my paycheck over to my husband and rely on him to give me the money I need when I need it. Do I like doing this? No. But given that I'm in my early stages of recovery, this is a safety net for me. That's the behavior modification component. Only when I feel ready will I slowly take over more of my financial resources.

And yes, I did relapse once. And I put myself back into rehab (a very structured, austere rehab place, not like the celebrity ones).

I'd describe my relapse as like being on an Amtrak train in a long tunnel. During my relapse, I couldn't do anything but think about drinking, plan how to get my next bottle, plan how to hide my drinking pattern.

Trouble is, those that are sober around you know when you're drinking. My personality changes. I am my own worst tattletale when drinking.

So, while I can't speak to any of the science as an expert, as somone who only lived the addictive life for four years, I do know that I was an alcoholic before I ever picked up, and that I will be an alcoholic for the rest of my life.

It's up to ME to control my behavior, get rid of the "stinking thinking" and surround myself with sobriety. I thank God that I have a supportive family and husband. I thank God for AA meetings and other 12-step resources. I also am thankful for the counselors and psychaitrists that can diagnose and help treat the disease portion of addiction through medication and talk therapy.

As Speedy said above, we suffer from the disease of addiction co-morbid with the disease of critical thinking. As an alcoholic, I am all too aware of the enormous amount of personal work I must put into this in order to life a sober, happy life again.

Thanks for listening.

Posted by CMC | August 2, 2007 9:37 AM

speedy:

let me be clear:

- i view critical thinking as a strength, not a detriment. the AA/12 step lay notion of "stinking thinking" is naive at best and oppressive at worst. surrounding yourself with positive role models and an extended support group is actually the sign of a healthy thought process, as is asking for and accepting help from others.

- any one who actively seeks to put a stop to self-destructive behaviors (perpetuated as symptomatic of a disease or as the result of nurturing a bad habit), implicitly knows that there is a problem and that sustained personal efforts toward behavioral change are required in addressing it. that kind of commitment and struggle is hardly limited solely to practitioners of the 12 steps.

- the mental health parity act will do everything to enrich the coffers of insurance companies, pharmaceutical companies, and the treatment industry while leaving people suffering with mental health problems at the mercy of those interests. in a country where a large (and growing larger every day) percentage of the population is uninsured or under-insured, legislating 'disease' offers exactly nothing in the way of affordable or accessible care.

- spiritual/religious belief is a matter of personal preference & should not be requisite in treating a 'disease'. suggesting that the 'disease' model in the mental health parity act dovetails perfectly with the AA/12 step understanding of the 'disease' of alcoholism/addiction is being disingenuous: a 'brain disease' is not synonymous with 'an allergy of the blood' never mind the terms 'spiritual disease' or 'spiritual malady'.

- as a commenter to another post on this topic mentioned, the argument over the 'disease' attribution is largely semantic -- if not for the impending legislation. that's really at the heart of this debate, and that's what critics like satel are driving at. does the mental health parity act promise greater access to a wider variety of (and hopefully more effective) treatment modalities or does it simply increase profit margins for an already wealthy industry while also legislating behavior?

- where exactly is the science in the 12 steps, and where exactly is all the scientific data that suggests it's an effective treatment modality for 'disease'? if the author of the 'eye on science' blog on Time's website is going to [repeatedly] mention the practice as supporting evidence in the 'disease' debate, i think it's incumbent upon him to illustrate the method's scientific validity.

people helping one another in times of need is humanity at its absolute finest. people insisting that their fellows in need find god or a 'higher power' so that he/she/it may be called upon in times of crisis (or weakness) is a return to the dark ages.

Posted by speedy | August 3, 2007 1:27 AM

Paul du Buf:

More and more activities are been labelled as 'addictive' in both a negative and positive sense. Nike+ on its website allows you to identify yourself as one who is addicted to running and I was happy in doing so. This shift of meaning in what its means to be an addict is something that is evolving in our language and is more in line with the perspective that addiction is a choice and not a dis-ease. This is something I fully embrase as from my experience as a nurse working with people with addictions for the last 10 years, addiction can be beaten by education and an awareness and improvement of one's coping skills.

Posted by Paul du Buf | August 23, 2007 11:28 AM

Sharen:

It is interesting that a nurse working with 'people with addictions' doesn't understand what addiction is, or not. The medical model has more alcoholics, drug addicts and suicides than any other. An 'addicted' runner is an addict, has the same thought process and obsessive thinking.

If the only tool you have is a hammer - everything is a nail. Medicine never has and never will understand addiction.

--But you do? Is that what you're telling us?
M.L.

Posted by Sharen | August 30, 2007 6:50 AM

RozNor:

This is the best part of the article:

"...Thus, when Satel argues that addicts have a choice about whether or not to use, I respond 'yeah, that's easy for you to say...'"

Who EVER said it was EASY? What point does this make? It is a known that if someone really wants to stop engaging in active addiction they will go to whatever lengths they have to to not use again, be it rehab, recovery house, out-patient program, support group, counselor, therapist or all of the above. Any recovering addict I know will say this. It's a fact that a person CHOOSES to remain in active addiction.

Now, my father would rather be outdoors than stuck in a chair on a dialysis machine 4 hours per day, 3 days per week nursing his kidneys that are working at 15% capacity. Think there's a support group to stop his kidney failure?

Posted by RozNor | September 26, 2007 6:11 PM

Sam:

Another good articles which looks at whether or not addiction is a disease: http://www.myaddiction.com/education/articles/addiction_disease.html

Posted by Sam | November 13, 2007 1:35 AM

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