Addiction: To the End at the Bottom
Is addiction a brain disease or something else?
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“Picture yourself standing on a porch in 1976 after the weather breaks, smelling the metal screen of the storm door while the air is warm outside. It’s a Sunday and your mother has made you put on nice pants. The Philadelphia Bulletin has sponsored a spelling bee for middle school students, and one Jean Brennan, BA in linguistics from Georgetown, eighth-grade teacher, has entered you in it because on First Fridays before Mass there is a spelling bee, and you have been able to spell “antediluvian” and “schizophrenia” without even knowing their meanings.
In front of the screen door that Sunday you dissociate. You imagine yourself on the steps of the Bulletin building in Philadelphia, as if you could transport yourself there through time and space without any interaction with the man you know will be hostile because he is not the type of “father” who knows how to be dedicated to his kid enough to take him to a spelling bee. You don’t know at the time that this is not fathering at all; it is sabotage because you might be successful and leave.
Your mother calls the bar once, twice, then downplays it to hide her rage. She walks away so you don’t see her face, as you keep yours facing the street where he never shows, looking at the diver’s watch your uncle gave you, thinking you’ve blown it.
The Monday after the missed spelling bee, your teacher asks you how it went, and you take the blame on yourself for not showing up.
When he gets home, he never apologizes or even acknowledges that he was supposed to have taken you. You can’t remind him because the smoldering rancour could turn to rage.”
This is a memory Dino D’Agata shares about growing up with an alcoholic father.1 He paints a landscape pock-marked with pain that will be familiar to anyone who has a family member struggle with an addiction: the emotional storms, the lapsed commitments, the secrets.
What we don’t see here, and in so many other stories, are the malfunctioning brain circuits, the depleted or excessive neurotransmitters, or the flaring regions of brain tissue. The brain disease model of addiction has given clinicians a way of thinking about and intervening on the problem of addiction at the biological level. But it’s not enough. What so many stories like D’Agata’s reveal is that addiction is neither one problem nor is it solely biological.
To write this way might revive fears of the moral model of addiction. Throughout history, people were cast from society, blamed for being useless drunks and sinful opium addicts. The path to redemption, if there was one, led only through a Christian church, a thought that became intolerable in a pluralistic society. Certainly the way D’Agata tells the story of his early life with his father pulls for a moral assessment. How the story ends pulls for a different moral assessment. Reading it, I find the brain disease model of addiction woefully inadequate. It cannot capture both the problems of addiction and a holistic response to D’Agata’s father.
“I think what this gets is the question of not just is the model useful, but who is it useful for? Who is it serving and who is not serving? … I embrace the science of addiction. Of course, I embrace the power of the tools we have, which includes some medication interventions for certain addictions. But the model has limitations that are inconsistent with the emphasis on engagement, on shared humanity, and on the power of that connection to being a healer that I have found enriches my life as a physician, and that I think is so helpful to people who are struggling and suffering and who come to us for what we have to offer.”
This is Stefan Kertesz, a general internist who is board-certified in addiction medicine, speaking with Saul Wiener on their podcast. The disease model of addiction has allowed medicine to put handles on what seems to be a wicked problem. I’m right there with Kertesz and Wiener: I’ve seen medication for substance use disorders (primarily opioid use disorder) turn lives around. It’s remarkable.
But buprenorphine won’t make someone apologize. Methadone won’t fix a marriage. Naltrexone won’t resurrect the person killed by a drunk driver. These medications are helpful tools, but they’re not cures, nor can they absolve wrong-doing. The gap is dark and deep that the disease model can’t bridge.
The Moral of Addiction Stories
The problem of addiction can lead us down a strange trail. Maybe we can just peek through the trees but spare ourselves a prolonged hike. We start by asking, “What is a disease?” This seems fairly straightforward for something like, say, pneumonia, in which an infection causes bodily dysfunction, discomfort, and a threat to life. So, too, with cancer or heart disease, even if their pathophysiology is more complex and not fully understood.
The story with psychiatric disorders, including addiction, is more complex still. The Diagnostic and Statistical Manual, used for the diagnosis of mental disorders, sets aside declarations about etiology and focuses on observable behaviors. This means judgments about goodness are baked into something like the criteria for alcohol use disorder from the DSM-5:
Alcohol is often taken in larger amounts or over a longer period than was intended.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
The list goes on. Each of these statements has a hidden judgment about what is good or bad. For example, the first criterion assumes that someone can form an intention to act in a certain way (that is, to bring about a state of affairs they think is good) and then fail to do what they intended. Does this occur because the alcohol is forcibly given to the person? No. The “alcohol is taken.” Part of having alcohol use disorder is having one’s intentions frustrated by one’s own hand and this is, by implication, not good.
Likewise, ongoing alcohol use results in a failure to meet one’s obligations. Instead, it causes all manner of social problems. It may be an objective fact that alcohol prevented you from completing an assignment at school or work, but it’s a normative judgment that this should have gone differently or that you should avoid it in the future. People might disagree with your negative assessment of what happened, retorting, “I never liked that job anyway. I’m not sick!”
Though we could linger among these questions about the essence of disease, I only want to glance at them to show how bedeviling they can be when we consider them in light of addiction. Sally Satel and Scott Lilienfeld observe that, “Changing a behavior like addiction requires addicts to work hard to change their patterns of thought and behavior. In contrast, antibiotic cures for pneumonia work even if the patient is in a coma.” While any disease influences one’s agency (e.g., cancer may make someone too fatigued to work), addiction is a disorder of agency. Its uniqueness calls for a unique response.
If addiction is unique among diseases, it’s common within the human experience. Brendan Dill and Richard Holton argue that addiction is an exacerbated form of a problem we all face. Each person has an “incentive salience system” which helps us learn to want things based on their association with past rewards:
“…the features of addictive desire that pose self-control problems are features of incentive salience desires in general, and thus are shared by a wide range of non-addictive desires as well. Just as the motivational force of an addict’s incentive salience desire for heroin persists despite her judgment that she should not take it, the motivational force of an ordinary agent’s incentive salience desire for a cake will persist despite her judgment that she ought to have something more healthy instead. Whether the agent’s judgment or craving prevails is a matter of self-control.”
Dill and Holton comb through the literature on decision-making to highlight how strategies for improving our odds in carrying out an action apply just as well to someone grappling with an addiction as anyone else. The difference is one of magnitude, not kind:
“The incentive salience desires that render the addict’s actions so wildly out of sync with her values are present in non-addicts as well, though in less extreme form. And thus the non-addict will also sometimes act in ways she does not endorse, driven by desires that motivate independently of her conception of the good. The non-addict can resist these desires by exerting self-control; but the addict can do this too. The task of self-control is far more difficult for the addict - which is why it is often unreasonable to blame addicts for giving in to temptation even when we might blame a non-addict for doing so. But self-control is possible for addicts, especially with strong incentives and assistance from others. Indeed, this is just what recovery from addiction is: the addictive desire does not go away, but the recovering addict learns to control her behavior in spite of it.”
Dill and Holton briefly signal an important point: people, whether they’re addicted or not, may have a reason that mitigates blame for their action. Consider a stark example: you can’t blame a person with severe dementia for hitting their caregiver. They aren’t morally culpable because their agency is so diminished. Addiction can help us acknowledge that, sometimes, people aren’t entirely in control of their behavior. But the brain disease model, in an attempt to avoid blame, risks obliterating the moral nature of life in general, with its multifarious desires and temptations.
Blame matters. We need it to signal a morally culpable problem that contributes to internal and relational discord so we can form an appropriate response. One such response might be punishment (to hopefully remediate behavior and to possibly isolate a dangerous person from others). Beyond or instead of punishment, though, blame opens up other paths like restorative justice, forgiveness, insight to contend with vices (of which addiction may only be a visible symptom) and other forms of moral work. These are unavailable if we can’t blame others or ourselves.
Not even the most severe forms of addiction can rival dementia and some other neuropsychiatric disorders in how they impair agency. To what extent can “disease” mitigate the blame we might assign to D’Agata’s father for failing to pick him up for his spelling bee? I doubt we could ever know. Far from making the moral valence of addiction vanish, though, this challenge calls on the family and society to figure that out. It’s probably something with which we need to grapple on a case-by-case basis.
In the midst of that work, we discover that blame is only one of the inhabitants of the moral world. The moral model isn’t just about shame and exclusion, but about agency, character, and community. Hanna Pickard argues:
“One lesson that clearly can be learned from clinical contexts is this: we do not help service users with disorders of agency by denying their agency and absolving them from responsibility. In so far as we aim to help service users improve or recover, their agency and responsibility should be upheld. Moreover, apart from this aim, agency and responsibility are goods. As Angela Smith elegantly points out: ‘being held responsible is as much a privilege as it is a burden. It signals that we are a full participant in the moral community.’ In other words, in holding service users with disorders of agency responsible, we treat them as one of us - as belonging with us, as equals.”
This dilemma surfaces a hidden tension in addiction. It’s not be between the brain disease model and the moral model. It’s between whether we’ll regard people with addictions as moral agents or moral patients. We respect people with addiction as moral agents if we hold them responsible for their behavior and help support their agency. We treat them as moral patients if we consider them as foci of moral regard but not in a way that acknowledges their own capacity to act in morally relevant ways. Animals, very young children, trees - these are all moral patients in different ways without themselves being moral agents.2
It’s not bad to be a moral patient. For animals, very young children, trees, and many other creatures, that’s all they can be. But to deny a moral agent their agency is to do them wrong, just like it would be wrong to deny a moral patient their own status.
Consider D’Agata’s father again, now dead:
“When my life is over, I won’t be judged for the education I got or the success I made of myself. I’ll be judged by how, in the long run, I loved this man who was given to me as a father. His ridiculing of my piano lessons, the Beethoven I played, the Debussy he found stuffed shirt out of his jealousy and resentment at not having had a childhood—though I could judge it later as part of his sickness—wasn’t the point. The point was, though I was his son, I had an eternal creature on my hands. What kind of mercy did I manage until now, long after his death?”
This is the testimony of a man who has come to terms with the fact that he couldn’t control his father’s choices. Children whose parents struggle with addiction sometimes learn this lesson. Many stories of addiction portray, if only peripherally, the hard work families and friends must do around a person with addiction. D’Agata, not his father, was the one who had to learn patience, courage, self-control, and the like. His father threw everyone around him into a crucible. It imposed on them needs for virtue and many opportunities for vice. If we claim that everyone around the person with addiction must bear responsibility for growth but the person themselves is only a victim of their addiction, that exiles the addicted person from the community of moral agents. D’Agata’s father faced the same opportunities and temptations from his own relationships.
If D’Agata leaned entirely on the brain disease model of addiction (which I suspect he didn’t), he may have become more isolated from his father. There would have been no context to call his father to account, to ask for an apology, to extend forgiveness. There would have been only the seething, twisting mass of brain circuitry that bears no blame but afflicts so much pain. You might as well try to seek an apology from a hurricane or reconcile with a wildfire.
Likewise, a person with an addiction might struggle with how to reconcile themselves to their own behavior. If this is just corrupted hardware in their head, then who are they really? In what sense can they take ownership over their lives if their lives are so tightly biologically determined as to allow a disease to erase moral agency?
Some people turn to 12 Step programs like Alcoholics Anonymous. There’s plenty of evidence to support that, but I’ve also met folks who tell me AA isn’t for them. Some get hung up on the “higher power” language, but others struggle with how morally laden the entire program is. They find the externalizing frame of the disease model to help them cope with this problem. When I’m busy, I shrug: “To each their own.” But when I step back to consider the broader social implications of abandoning addiction to the brain disease model, I worry we do people a disservice. If someone claims AA isn’t for them, is that like anyone else claiming that taking responsibility for their desires and choices isn’t for them?
Just like any other area of life for anyone else, this person is free to disregard an intentional focus on their own character, inner life, and choices. Having an addiction might make that oversight more acute, and pre-existing problems more obvious, but the person is still free. Free enough anyway.
Learning Addiction
Marc Lewis acknowledges the limitations of the brain disease model of addiction but tries to scrub away allusions to morality in a description of an alternative path:
“So, what exactly is addiction? It’s a habit that grows and self-perpetuates relatively quickly, when we repeatedly pursue the same highly attractive goal. Or, in a phrase, motivated repetition that gives rise to deep learning. Addictive patterns grow more quickly and become more deeply entrenched than other, less compelling habits, because of the intensity of the attraction that motivates us to repeat them, especially when they leave us gasping for more. Often, emotional turmoil during childhood or adolescence initiates patterns of personality development that anchor the search for addictive rewards, serving as sources of relief and comfort. But there are other points of entry too, based on various intersections of dispositional and environmental factors. However it is entered, and however it is eventually left, addiction is a condition of recurrent desire for a single goal, but also an aspect or phase of personality development that leaves enduring footprints in neural tissue.”
Lewis argues that “the appropriate response to addiction is neither shame and isolation nor submission to a therapeutic regime. Rather, it is further growth. … growth beyond addiction exemplifies developmental progress, powered by one’s own efforts.”
I appreciate Lewis’s nuanced position because it highlights the power of habit and learning in everyone’s life - whether you’re burdened by an addiction or not. It sets the frame to consider tools that empower people toward positive change.
However, in an attempt to carve a middle way between the brain disease and moral models of addiction, Lewis stumbles into something moral anyway, now with the companion of modern psychological insight. Whenever we think of “growth,” the next reasonable question to ask is, “Growth toward what?” Cancer grows, but we agree that is not good growth. Whenever we think of “learning” or “development,” we should ask, “Learning and development for what, toward what?” Learning and development are necessarily teleological. These things have aims, purposes, ends. Maybe we shouldn’t “shame and isolate” the one who is learning bad habits, but that doesn’t mean there’s nothing moral about their education.
The language of hijacked brain circuitry is disempowering and erases large swaths of a person’s story. I appreciate this learning and development model because it opens up more questions about what might be going on, like, “What is the cocaine good for?” It helps us appreciate this person’s story and the role an addiction plays in it. Satel and Lilienfeld want us to see that the stories of people with addiction as making tragic sense:
“These stories highlight one of the shortcomings of the neurogenic view of addiction. This perspective ignores the fact that many people are drawn to drugs because the substances temporarily quell their pain: persistent self-loathing, anxiety, alienation, deep-seated intolerance of stress or boredom, and pervasive loneliness. The brain-disease model is of little use here because it does not accommodate the emotional logic that triggers and sustains addiction.”
Because addiction afflicts persons, not brain circuits (even if there are problems with the brain circuits), we can’t overlook that person’s story. With someone’s story in view, the language of learning gives an entry point into a broader understanding of how addiction carries with it a moral valence. We can ask, “What are those characteristics someone needs to grow, learn, and develop well?” and “What are those characteristics that should be discouraged?” I’m not saying the clinic or hospital should be the primary site for such exploration, but it could be one such site.
Shannon Vallor, drawing on ancient philosophical traditions, describes how such moral formation could happen in a world laden with technology. That might make us think about the addicting potential of social media and smart phones, but cocaine and slot machines are technologies too. Technologies shape us as much as we use them. Sometimes we unleash their power but can’t constrain their ongoing use.
Vallor describes seven facets of a framework for moral formation that are mutually reinforcing:
Moral habituation
Relational understanding
Reflective self-examination
Intentional self-direction of moral development
Perceptual attention to moral salience
Prudential judgment
Appropriate extension of moral concern
In the brain disease model of addiction, we can describe circuits of reward, attention, rumination, and so on, but that can’t help us grapple with our most earnest questions about ourselves. I don’t make a decision I regret and then ponder how to fine-tune my neurotransmitters to make a different choice next time.
Lewis’s argument that addiction is a kind of learning helps me discover questions relevant to all these areas. Those questions could further empower someone with an addiction, just like they would empower any learner: what habits am I cultivating in my life? Are they helping me live a good life? How do I relate with others? Who am I? What am I doing this for? How can I best use my time?
Some of these question might lead to blame. Maybe they need to. If you killed someone else because of your drunk driving, should you be blamed for that? In a biologically over-determined way, we could say no: your past traumatic experiences and your current addiction shackled your will to the drink. You couldn’t help yourself. But such reasoning removes you from the community of moral agents. By claiming you cannot be blamed for this, we break a powerful means of your development as a person. We destroy a means of redemption.
Communal evaluations of blame, guilt, and shame that don’t rise to the level of a legal infraction but rather enforce social mores help people see things about themselves they might otherwise miss. Sometimes shame is the appropriate thing to feel, if you’ve done something shameful. It is indeed challenging to settle on what is shameful when we live in a pluralistic society, but maybe we can avoid throwing the baby out with the bathwater. There are numerous stories of how shame was metastasized in ways far beyond healthy. But it can also flag a truly big problem within our character: this person often tells lies and he’s a liar - that’s shameful. If we zoom back to consider the bigger picture in which we see how he came to be the kind of person to tell lies, that might garner sympathy toward his plight and mitigate some of the blame, but it would do him no favors to say we can then discount the responsibility he has toward himself and his community.
A Good Life is a High Life?
Alduous Huxley, in Brave New World, showed us a city full of people at ease. Comfort, leisure, and pleasure were available everywhere. Everything had its place. Everyone had a role. There was no fear. There was no scarcity. But Huxley pulled back the curtain on how empty this life is, and how empty it leaves those who live it. The irony of Huxley’s world is that its citizens attempt to seek freedom in that which enslaves them. So, too, can biological reductionism tighten its cords around us if we depend too much on its explanations. We embrace the brain disease model of addiction hoping that in its explanations of brain activity, we might find not just freedom for the one with addiction, but freedom for ourselves. Maybe, somewhere in there, we’ll have the control and virtue we struggle to gain through more rudimentary means.
What about people who aren’t ashamed of the things they do while intoxicated or seeking drugs? What if D’Agata’s father never felt shame? Should he have felt ashamed of himself? What if we could overcome the shame of using a substance but not quit - is that something medicine should seek to do, pharmacologically or psychotherapeutically? Is a life spent pursuing cocaine a good life?
I don’t think the brain disease model of addiction can ferry us to safety away from deeply existential and moral questions. I’m not saying we abandon medication. But can addiction help us better see the limits and potential of our own humanity?
I considered how best to use terms here: substance use disorder, substance abuse, addiction, service user, etc. I settled on the language I did because I find it the most accessible, particularly when discussing behaviors that don’t involve substances (e.g., gambling).
That does not mean animals, very young children, and trees share moral equality or warrant the same degree or kind of moral regard.
A truly timely and urgently needed piece. Think there’s a lot of potential overlap here with how the discourse surrounding “trauma” has turned overtly mechanical-biological as well. There may be a place for its insights insofar as they’re true and helpful, but as the *dominant* view of trauma and psychology, it overlooks the fact that all of the things about the person/people who have hurt you could very well be true, *and* you may be making things worse for yourself by how you’re responding to it.
But buprenorphine won’t make someone apologize. “Methadone won’t fix a marriage. Naltrexone won’t resurrect the person killed by a drunk driver. These medications are helpful tools, but they’re not cures, nor can they absolve wrong-doing. The gap is dark and deep that the disease model can’t bridge.”
Gotta get to self examination and accountability. Drugs won’t do that.
Good piece!