We often refer to addiction and alcoholism as a disease, but what do we mean by that? We certainly aren’t talking about some airborne, Outbreak-style virus. Some non-addicts despise the disease model, as they believe it to be a mere excuse for destructive behavior. Others have mocked the disease model due to a perceived comparison between addiction and other, more tangible diseases. Comedian Mitch Hedberg, who died tragically of a multiple drug overdose in 2005, once referred to alcoholism in his stand-up routine as “the only disease that you can get yelled at for having.”
The disease model of addiction may be misunderstood by many, but this is a downright shame. Those who enter our programs stand little chance of recovery if they do not understand the element against which they are struggling. In order to cast a little more light on the disease model and what it truly means, we’d like to examine the issue through three separate lenses: that of medical science, that of 12-step programs such as AA or NA, and that of our personal experiences. First, however, we feel we should talk a bit about how the disease model came to be.
Origins of the Disease Model
Our most recent article focused on the work of E.M. “Bunky” Jellinek, the biostatistician whose research resulted in a chart portraying the general timeline of alcoholism. This chart, known as the Jellinek Curve, is generally seen as one of Bunky’s greatest contributions (even if he had nothing to do with its actual formulation). But as a science-minded researcher of alcoholism and addiction, dear Bunky had much time to formulate theories on chronic substance abuse and how it works. And as it turns out, he played a major role in the acceptance of alcoholism as a disease.
That is not to say that Jellinek developed the idea all by himself. Science is essentially a marathon of evolving ideas, and Bunky was passed the baton by Swedish physician Magnus Huss. It was Huss who, in his 1849 essay Alcoholismus chronicus, coined the word “alcoholism” to describe what he perceived to be a chronic disease causing systematic physical damage with occasional periods of relapse. And while comedians like Hedberg may laugh at the perceived comparison between alcoholism and conditions such as lupus, you’ll notice that the description of alcoholism as a disease as determined by Huss shares many similarities with fatal conditions such as cancer.
While Bunky may not have coined the notion of alcoholism as a disease, he certainly assisted in rounding out the theory. In 1960, over a century after Huss had devised the basic disease notion, Jellinek published a book entitled The Disease Concept of Alcoholism. In this book, Bunky provided us with five basic stages of alcoholism. The stages found in this book are not the same as the phases found in the Jellinek Curve, but are rather different forms of alcoholism that alcoholics are more likely to experience at different points throughout their period of active use.
The first of these stages is alpha alcoholism, the stage in which psychological dependence begins to develop. Jellinek did not consider this to be a disease, but rather a symptom of the mere problem drinker. The second stage is beta alcoholism, in which a heavy drinker begins to suffer cirrhosis of the liver. Again, these drinkers were not considered by Jellinek to be diseased, as they had no physical addiction nor suffered withdrawal symptoms during the detoxification process.
The last three stages were considered by Jellinek to constitute a disease. Gamma alcoholism involves increased tolerance and symptoms of dependency, accompanied by a loss of control over one’s drinking. Delta alcoholism is similar, although at this point abstinence becomes much more difficult. The final stage is epsilon alcoholism, the most advanced form of the disease in which the drinker experiences dipsomania, a medical condition associated in the nineteenth century with chronic drunkenness but commonly related to binge drinking as well. Today, it is frequently used to describe any intense physical craving for fluids such as alcohol.
As might be predicted, Jellinek’s work was highly influential in developing a scientific viewpoint of the disease model of addiction, which will be explored in further detail below.
The Medical/Scientific Lens
The above discussion of Bunky’s five stages of the disease concept may make it sound as if medical science has a rather solidified view of alcoholism as a chronic illness, but this is not entirely the case. Jellinek’s work was primarily used to differentiate those who were afflicted by an actual disease from those who simply had a few too many every once in a while. The medical science community as a whole, however, has viewed alcoholism and addiction through a much broader lens in order to determine where it comes from and how it affects the body and mind.
One of the biggest theories regarding the spread of this disease is genetic predisposition. According to the National Council on Alcoholism and Drug Dependence, our genetic family history is about 50% responsible for our risk of becoming addicted to drugs or alcohol. Our family history in general can be largely responsible when genetic and environmental variables mix in such a way as to create an inclination toward addictive tendencies.
Heritability (the likelihood that we will receive these addictive traits) is often dependent on the substance in question. Two of the most heritable drug disorders are those related to cocaine and opiates. Alcohol is of a more average heritability (as are smoking, sedatives, and even gambling), and three of the least heritable addiction disorders are those involving cannabis, hallucinogens and stimulants. It should also be noted that heritability is more likely to be influenced by social and environmental factors in adolescence. In middle adulthood, genetic influence will reach its peak. If we are not addicted by the time we reach our golden years, the chances of becoming so will greatly decrease.
Another approach that some science-minded individuals take to understanding the disease model is the naturalistic approach. Many naturalists can’t stand the disease model because they feel that it does not fully account for the element of choice. While physical cravings and mental obsessions can be overwhelming, the addict does essentially choose to use their substance of choice. This is why relapse prevention revolves so heavily around ensuring that our circumstances aid us in being prepared to make the right choices. But naturalism actually does fit in with the disease model when we consider the role of dopamine.
Dopamine’s role in addiction is more complicated than some might think. Many are familiar with its role in activating the reward centers of the brain via the mesolimbic pathway, but it actually serves many functions. The D2 family of dopamine receptors can cause pleasure when various activities cause activity between the nucleus accumbens and the frontal lobes, but they can also cause psychosis. These regions of the brain are activated during unpleasant experiences just as often as pleasant ones, which makes a lot of sense when you stop to consider that many addicts and alcoholics are far from the happy-go-lucky hedonists we see on Cheers.
The brain’s D2 receptors can be caused by a broad array of stimuli ranging from drugs and alcohol to text messages and social media, but substance abuse causes some of the most troublesome spikes. These dopamine spikes can damage the associated receptors, which is one of the reasons that the Jellinek Curve discussed in an earlier article notes a decrease in substance tolerance after prolonged periods of heavy use. This is when our cravings become particularly aggressive, and we find ourselves stuck in a vicious negative feedback loop. If you’re wondering how this fits in with the disease model of addiction, South Park actually explains it best. In a semi-recent episode, Satan of all people explains to one of the children (while dropping a heavy dose of NSFW language) that addiction is not unlike type 2 diabetes. In a similar fashion to that in which unhealthy dietary choices can disrupt our ability to properly manage insulin, frequent damage to our dopamine receptors can result in addiction.
The major problem with the pop cultural reference cited above is that the creators of that show have previously exhibited a certain distaste for the spiritual approach to addiction recovery, as evidenced by some of the characters’ comments on naturalism. But while addiction is a disease that can be caused by environment, genetics, or simply enough bad choices to damage our D2 receptors, there is most certainly a spiritual element that cannot be fully explained by approaching the matter through a purely scientific lens.
The Spiritual (AA/NA) Lens
One of the reasons that many members of 12-step groups such as AA and NA will likely find the above South Park clip unsettling or even offensive is that it uses the scientific elements of genetic predisposition and dopamine receptor damage to argue that there is no spiritual component to the disease model. It also outright mocks the notion that addicts and alcoholics must fill their spiritual void in order to stay sober. While everyone is entitled to their opinion, it isn’t too hard to see how this might be a dangerous thing to tell someone in early recovery who may be looking for excuses to put less effort into working their recovery program.
The same show has mocked the spiritual aspect of the disease model before in more direct fashion, with one character denying the disease model and calling AA a cult while another takes issue with the use of the word “God” in the Twelve Steps. But these arguments against the spiritual side of the disease model are based on some common misconceptions that often come into play whenever the “G” word is used. In most AA literature, this word is eschewed in favor of the term “Higher Power,” which is a bit more open to interpretation. If we may, we’d like to other another pop cultural example in the form of a snippet of dialogue from Season 6 of the television series Dexter:
Brother Sam: It’s about surrender to something greater than yourself.
Dexter: I don’t get it.
Brother Sam: Man, just look around. You think you can make the sun come up in the morning? You think you can make the tide come in?
Dexter: No, but that’s the Earth rotating on its axis, the pull of the moon.
Brother Sam: So you do believe in something greater than yourself.
Dexter and his friend Brother Sam are not discussing addiction in this scene (although the topic actually arises surprisingly often on the show), but they are touching upon the manner in which many have chosen to interpret the words “Higher Power.” Not everyone prays to a deity, and that’s their choice. Those who have religion do not have to stretch too far in order to get in touch with the spiritual side of recovery, but others must learn what spirituality means when religion is taken out of it. For many, the answer is simply humility. They come to realize the futility of trying to control their addiction alone. They realize that they do not have as much control over life as they once thought, that there are greater forces at work.
When people talk about the need to fill a void inside of themselves in order to recover, they are talking about the very same void they were trying to fill with drugs and alcohol. A Huffington Post article on the spiritual side of the disease model quotes M. Scott Peck, author of The Road Less Traveled: “We sense that something is missing but don’t know what it is. We long for relief from the aching void inside…but we’re confused about what will ease our existential disease.”
Humility allows the addict to fill this void through spirituality, which many have found in those around them. Recovering addicts and alcoholics who have spent time building a strong and sober support network often find themselves reaching a level of spiritual fulfillment like never before. Their religious views are irrelevant; religious fulfillment necessitates spirituality, not the other way around. Examples of Higher Powers outside of God may include family, friends, AA, NA, or the various nature-based elements and phenomena that keep us all breathing so that we may be connected within a single universe. When we accept that we are not more powerful than forces such as these, we are able to find relief from the void of isolation that once consumed us. If, however, we remain in isolation, then our disease will likely metastasize and our condition will only worsen.
But surrounding ourselves with loving people is not enough. While the spiritual component of the disease model stems largely from our isolation and lack of contentment, many of us also suffer from a sense of restlessness and irritability that interferes with our ability to empathize. We cannot merely partake in the love of others without giving anything back. Brother Sam, the Dexter character quoted above, tells the eponymous anti-hero in one episode that his love for his son will help him overcome the darkness inside of him. More specifically, he tells him that this love fills him with light, and that he must simply learn how to let it out.
In many ways, this relates to the AA/NA notion of service work. We all have people we love, and we are all capable of feeling compassion for our fellow man. But when we keep this light bottled up inside of us, it does nothing to help us heal. Doing good deeds for others helps us to sleep more soundly at night. It gives us a task to cure our restlessness, a soothing sense of well-being to calm our irritability, and a stronger feeling of purpose to ease our discontent. Even the simplest of acts such as sharing our stories with other addicts or making coffee before a meeting can go a long way. Because when we do these things, we become a part of something greater. We are no longer locked away in isolation, as we have revealed ourselves to the world. It’s a darn good feeling.
If one cannot believe in a spiritual component to the disease model without hearing from a scientific authority, look no further than Swiss psychiatrist Carl Jung. As the founder of analytical psychology, Jung was a man who understood the human condition. And as the man who introduced the notion of synchronicity to quantum mechanics, he was certainly a man of science. But he was also a very spiritual man, and he recognized the need to fill our spiritual void when he wrote in a letter to AA founder Bill Wilson that addiction was symptomatic of “the spiritual thirst of our being for wholeness.” Having treated many alcoholic patients, he was thoroughly convinced that to attempt recovery without spirituality was a fool’s errand.
In short, addiction is a disease of isolation for which only a spiritual remedy may be sought. But no matter what we say about the spiritual malady afflicted upon the addict, there will doubtlessly still be those who find fault with the spiritual viewpoint of the disease model. This is why we would like to finish with a brief word based upon our personal experiences.
The Personal/Anecdotal Lens
Both the scientific and spiritual takes on the disease model are rather effective in explaining the causes and symptoms of addiction. Yet many still fault the disease model due to their perception that it does not hold addicts accountable for their actions. Of course, this is not entirely true. If our actions were not considered to be an element, then the spiritual remedy discussed above would not place so much focus on learning positive behaviors.
The disease model is best understood by those who have lived it. Those who have entered recovery can often recall many times during which we tried and failed to control our substance abuse. And while it may have ultimately been our choice to use again, this choice was not easily made.
If a non-addict truly wants to understand the cravings and obsession which arise from the physical dependency of alcoholism and addiction, they should try a week-long dietary fast. It will not be more than a day or two before their body begins to crave sustenance. Shortly after these cravings begin, mental obsession will follow. It will be difficult to focus on even the most menial of tasks because the thought of eating and putting an end to the hunger will consume their minds almost entirely. And in an era in which fast food can almost always be found right around the corner, it will be all too tempting to go out and put an end to the craving.
Of course, maybe the non-addict in this scenario thinks they could be successful if they were to simply empty out the refrigerator and cabinets. Perhaps they must merely board up their doors and windows in order to fight off temptation. But even if they take such measures, they will likely find themselves scavenging every corner of the house in the hopes that food has been stashed away and forgotten somewhere. If they are desperate enough, they may even try eating a non-food item such as toothpaste, much the same way that many recovering addicts have relapsed on things such as mouthwash and rubbing alcohol.
We are not saying that no one can make it through a week-long fast. Many can, just as many addicts struggling to control their disease have been able to go a week or even longer without using. But what happens at the end of that week? Think of how intensely a person would enjoy the first meal they were to consume after their seven days of flavorless misery. They may even take their first meal quite ravenously—no time for table manners when you’ve been starving yourself. This is the same intensity with which an addict takes the first drink after a period of abstinence, especially when they have not taken enough time for the symptoms of physical dependency to wear off.
The disease model is largely based on these physical cravings, and the loss of control which results when mental obsession is thrown into the mix. When Bunky Jellinek devised his five forms of alcoholism, he eliminated the first two from the disease model strictly because they did not emphasize this loss of control. For those of us who have experienced this loss firsthand, it can be a devastating experience. We often feel like failures when the urgency of the cravings becomes too much to bear, and this feeling is amplified ten times over if we eventually give in.
Our point is that, while there are certainly some addicts and alcoholics who use the disease model as an excuse for making selfish decisions, there are also many who feel the weight of those decisions but cannot control the intense hunger that is inside of them. The fasting metaphor is not perfect, as drugs and alcohol are not essential to survival. But when we are living with this disease, our body does not know the difference. To the afflicted individual, drugs and alcohol are sustenance. We may know that our substance abuse is killing us, but withdrawal sets in when we try to abstain and the symptoms cause us to feel as if we are going to die. We are trapped, feeling that our existence is bleak no matter what choice we make. This is why we must make both a medical and spiritual recovery if we are to combat this disease.
Addiction is a matter of life and death. Our hope is that, armed with a more thorough understanding of the disease model, more people may choose to live.