Neuroscientist Marc Lewis has written a new book, “The Biology of Desire: Why Addiction is Not a Disease.” In it, he asserts that addiction is better explained by learning/developmental changes to the brain. This almost seemed timed to counter Nora Volkow’s renewed attempt at wonksplaining the disease theory for the layperson in the Huffington Post, in which she trots out her brain scans yet again. The disease theory has had flaws all along, and has come under fire from many well-known theorists; but the wonderful thing about Marc Lewis is that he is a neuroscientist, and understands brain scans better than most people. He is also a former addict. (Lewis does not like the term “recovery”.)
Aside from causing an entire generation of substance use professionals to adjust their paradigm, what are the implications here? The main results of the disease approach that came about in the middle of the last century were better treatment and better funding. I know there are people who will want to squash anything that threatens the disease model, since it is hard enough to get the insurance companies to pay as it is. However, how we classify addiction is not nearly as important as how we treat it. Nearly a year ago, Maia Salavitz wrote an article with similar ideas. I love the idea of addiction as a learning/developmental disorder; and isn’t this simpler than the idea of a brain disease which somehow defies medical treatment? Even though we have enjoyed the momentum created with this medical model, there was always something missing from the treatment; something that escaped us. The debate over free will is one of the oldest philosophical conversations on the planet; it has no place in clinical treatment. There is no such thing as a disease of free will; this is but so much academic fluffery designed to mask the unexplainable hole in the disease theory. We know how to treat learning and developmental problems; there is no debate about that, no stigma attached, no mystery about why people do what they do.
Anne Fletcher, Stanton Peele, and many others have emphasized the efficacy of cognitive behavioral therapy, motivational interviewing and talk therapy. They have also pointed out the inconsistency of using empowering methods alongside a dogma that devalues the self and discourages self-reliance. The disease model was ushered in by and wedded by shotgun to the 12 step ideology; as a result, the way we have historically treated this “disease” has borne little resemblance to any other clinically sound best practice in any other discipline. Regardless of what we decide to call addiction in the future, it is vital that we design treatment that is individualized, appropriate and effective. Perhaps the biggest obstacle to this is the persistent pervasiveness of 20th century ideas.
Addicts aren’t diseased, and they don’t need medical intervention in order to change their lives. What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place — while they reach toward it. -Marc Lewis