Archive for February, 2013

Introduction:

Within this essay I am going to critically examine the evidence supporting the concept of the disease model, and I am also going to examine the research which counter acts this evidence. I am going to initially explore the development of the disease model of Addiction , then examine the process which allowed this model to dominate the area of drug use, and explore some of the arguments, social control, social construct, and the discourse that enforces these concepts which have been used to counter and discredit this model and how one of the most important factors “Spontaneous Recovery” calls the core concepts of this model into question.

Addiction: The Definition of a Disease.
For the purposes of this essay I am going to use the definition of Addiction as first muted by Benjamin Rush (1745-1813) and Thomas Trotter (1760-1832) who suggested that “alcoholism” & Substance Use could be viewed as a disease rather than as an issue which had its roots in loose moral fibre and weakness as the previous moral model of addiction had suggested.
Rush and Trotter suggested that drunkenness was a process of disease, a mental illness and as such displayed specific symptoms and was not a character flaw. Further weight was added to this concept of a disease of the will by Magnus Huss (1807-1890) in his book Alcoholismus Chronicus, or Chronic Alcohol Illness. A Contribution to the Study of Dyscrasias Based on my Personal Experience and the Experience of Others, in which the phrase alcoholism was first used, when in it he also highlighted symptoms of this new disease. According to the model “inebriety” (Courtwright 2005) has several main characteristic of this “disease of the will” and these were “loss of control”, or “craving”, and a progression of the disease, leading to an irreversibility of the problem which led to the person becoming addicted to a substance which made them an addict with a chronic condition that once treated, would always run risk of re-occurring. This model also suggested that the addict was different from the normal person, in a way that was reminiscent of the moral weakness that afflicted the drunkard of the moral model. Rush suggested abstinence was the only realistic cure to this disease, and this Disease concept, also relied on the “alcoholic” to see the need for change, and embrace the abstinence that would allow this change to happen. Rush suggested this could be achieved in “Sober Houses” or institutions where alcohol was banned.

The Development of the Disease Model
To understand the development of the disease model, we have to step backwards and briefly explore the moral model, and the influence it had on society.
This moral model perpetrated by the church suggested that alcohol was directly responsible for the ills of society, and the movement which grew out of this model, the temperance movement, advocated abstinence as the main treatment for this issue. This model also gave birth to the concept of the “Work Ethic” which was pushed by the church and the newly developing industrialists as the ideal, and that those in society should aspire to achieve this, stigmatising those who drank or used other drugs to extreme. Those who drank too much or utilised other substances, were deemed to be criminals and deviants and were treated as such. This work ethic which was the result of a redefinition of the traditional social order which had existed pre industrial revolution, where the relationship between society and substances was less prohibited acted as a social control on the use of substances, and the stigma around drunkenness, and in turn this social control also served as a social enforcement. The treatment with regards to this model was to repent the behaviour and the cause of it alcohol and embrace total temperance whilst promising not to drink again, on the pain of eternal damnation.

The Aetiology of the Disease Model

The disease model concept was developed when Physicians like Rush Trotter and Huss, began to feel that the traditional Moral Model and the concept of alcoholism being a sin perpetrated by the devil was not the answer. They also felt if alcoholism/addiction was a disease then it could be treated, and if it could be treated then and also as with other diseases it could be understood, and prevented. The new professionals utilised the process of scientific enquiry, to look at this issue, and identify what were the factors causing the disease, Huss being a good example of the use of this process, by utilising his research and observations from other physicians to coin the phrase alcoholism, and publish his work, All of this research identifying the core characteristics outlined above with all of the theorists suggesting the only treatment for the disease process of “inebriety” was abstinence, because the alcoholic would always be at the mercy of the need to drink, and the inability to control this drinking behaviour.

With the acceptance of the Disease Model the 19th and 20th centuries heralded the adoption of stricter prohibitionist legislation, which utilised this idea of an incurable illness to forward the introduction of the said legislation, and develop the concept of the drunk as being deviant and in need of treatment. This legitimised medical treatment, and also allowed the substance misuse to abdicate personal responsibility as they suffered a disease and as such any behaviour or misdemeanours were as a result of this disease process and not the person themselves. By the very nature of their social standing and the existing class system the new medical professions were inevitably supporters of the temperance message along with the temperance ideal and embraced this condition and used the spectre of addiction and “loss of control” to target other substances and ensure that their professions were the only ones qualified to treat this disease. The new medical based professions, Pharmacists and Physicians also used this new disease and the introduction of the dangerous drug acts (1920) for example which targeted the sale and prescription of opium ( Berridge 1999) to professionalise the concept of addiction, and introduce the idea that substance misuse, and the resulting bad behaviour could only be treated legally by them, in effect beginning medicalization of this issue, a concept of addiction which society still uses today. Whilst in Britain the temperance influence produced strict regulatory apparatus, in the United States the temperance movement used this model to forward the Temperance cause so successfully that in 1920 the use of alcohol was banned nationally in the US resulting in the prohibition of alcohol from 1920 To 1933.This period allowed the concept of the disease of addiction to be further ingrained into the general populations psyche, by the demonisation of addiction, alcohol in particular and its use, although the concept of addiction being a disease, and the idea of drug induced addiction was beginning to take on a more racist base, with cannabis(marihuana) and opium in the US and UK respectively, being linked with immigrants , and the spectre of drug use and addiction being used to demonize and marginalize immigrant populations. This process was also used as a vehicle to to introduce more prohibitionist legislation, the Harrison Act (1914) and the Defence of the Realm Acts (1915) (Gossop 2007) The media was also used to reinforce and further disperse the desired image of the addict as being a diseased person who can’t control their behaviour when confronted with their choice of drug by creating a moral panic utilizing the press and film industry, publishing story lines playing on the fears of the WASP majority, scape- goating the targeted populations and making films which added to the already growing myth around addiction as a disease which afflicted those who were different.
In Britain, stories were rife in the press suggesting that Chinese immigrants were responsible for the corruption of single females, and the proliferation of “opium dens”, a topic backed up by “Fu Man Chu “ stories, which were incidentally made into films in the fifties and sixties , with the undercurrent of the “yellow peril” still unaltered in the modern adaptations.

With the repeal of Prohibition in 1932, and the resumption of normal drinking patterns, but without the increase in “Alcoholics”, The temperance movement were forced to re evaluate the disease model, and EM Jellinek with funding from Marti Mann and the help of members of Alcoholics Anonymous carried out research in 1946 which resulted in his book in 1960“The Disease Concept of Alcoholism” in which he further reinforced the concept of alcoholism as a disease by his classification of the types of alcoholic identified in his 1946 study. This book also started to separate Alcohol as a substance from that of other drugs (Ref) and slowly began the process of moving the 12 step process into the realm of treatment provision, and began to perpetrate the modern concept and discourse of what addiction is, but more importantly what the concept of recovery within addiction was.

Again as with Rush and Trotters concept, within this version of the model Abstinence was the only true treatment, but this time with the use of the added support of peers, as provided by AA, the AA movement also suggested that the “alcoholic “ would always be an alcoholic, and this very statement began the discourse, and reinforced the construct of Alcoholism being a disease with its own specific mysticism, and process that only alcoholics could understand, further reinforcing the concept of the alcoholic being different from other “normal people “adding to the already common belief that the disease was an entity in its own right.
There was also a more concerted move by the authorities, towards the inclusion of other substances into the model, and the concept of drug induced addiction, or the one hit and your addicted concept began to gain more acceptances in the eyes of the general public. This move by the apparatus that originally was set up to police prohibition, mainly driven by Henry Anslinger also began to utilise the concept of ethnic minorities and the relationship of these populations with certain drugs to perpetrate the concept of race related addiction , with the stereo types already mentioned previously, and this became a form of covert social control, utilising a similar process of demonization,and the resulting moral panic to force further prohibition as the moral model had used religion and the threat damnation to advance social control centuries earlier. With the added development of the expert addict, and the discourse that this provided to the public backing up the ideas of Jellinek and the disease model as a whole was beginning to resemble what today we see as the condition of Addiction.

As outlined in the brief history above, the concept of addiction as a disease arose at the beginning of the 19th century, and can trace it’s routes through to E M Jellinek in the 1940’s as well as the research into discovering a genetic cause for addiction, which could be said to be the modern arm of the existing disease model.
These differing versions of the model, all have one major factor in common, and that is the main core concepts of the model, which subscribe the process of addiction being caused from within the addicted person. They also all suggest that addiction is a discrete commodity, as previously touched on and I would suggest that the modern day compulsion to explore the human G-Nome for genetic markers for all sorts of diseases, inclusive of the search for a definitive causal gene for addiction is a direct extension of this centuries old concept of an addiction disease process. This eugenic approach, is very similar to the older concept of inebriety in such that, it aspires to remove the locus of control from the addiction sufferer, and put it squarely in the realms of medicalised treatment, in effect removing all emphasis from the actions of the substance user, and laying the blame for their subsequent actions and behaviours onto a disease process, which they are susceptible to because of their genes, which has predisposed them to suffering from, or caused them to become addicted. So is it any different from the disease of inebriety, and moral weakness?

Addiction as a Disease : Proof of a Myth

There are many factors which have led to this concept being one of the most popular explanations, and we can also see that over the years, many agendas and professions have spawned from the concept of addiction being a disease. These concepts with some revision have becoming all encompassing, Initially the research from the 18th & 19th centuries, which posed the concept of inebriation, and Rush’s disease of the will, backed up by the writings of Huss and then E M Jellinek and his research in the 1940,s all produced a more scientific explanation for the disease of Addiction by utilising research practice to identify the progressive nature of the disease. This concept of an internal disease process, backed up all of the thoughts and reductionist ideals of 18th, 19th and early 20th century medicine as the scientific inquiries focused on finding a central cure for the problem of substance misuse. The expert patient, testimonies backed up by the recovering “alcoholics” and substance misusers from Alcoholics anonymous, and other peer support/12 step based groups only added weight to these scientific inquiries. This is the basic concept on which modern disease theory is based, it portrays alcoholism, as a chronic disease, ideas that are backed up by researchers such as White et al (2008), and policy documents such as the road to recovery( Scottish Government 2008) all of which in their own ways reinforce this idea within the public domain. These ideas have very close resemblance to the original ideas of the 12 step movement, and preach abstinence as the only solution, the document “Road to Recovery” actually talks about “moving towards an approach to tackling problem drug use in Scotland based firmly on recovery.” and about guiding substance users “towards a drug-free life” phrases that hint towards the ultimate goal of a drug free society, which can only be achieved through abstinence.

The concept of abstinence being the only cure for addiction, and the equally popular concept of drug induced addiction, are the disease models down fall.
The disease model relies on the core elements as highlighted at the beginning of the essay which are “loss of control”, “craving”, the progression of the disease, leading to an irreversibility of the disease, and the idea of addiction in some way being intrinsic to the sufferer. All factors whose validity has come under scrutiny from behaviourists and sociologists who suggest that the disease model is more myth than fact (Peele,1998 Szaz 1996, Alexander,2002, Schaler 1991 , MacAndrew & Edgerton 1969 & Gori 1996).They all in fact suggest that this model is no more than a social construct, or a form of Social Control.

The first of the many areas of research that have cast doubt on the model was the studies of MacAndrew and Edgerton into drunken comportment in 1961. This study was a large scale study, which looked at drinking culture across a number of societies, inclusive of primitive and industrialised ones. The study concentrated on how a society interpreted the concept of intoxication, and how they acted whilst being drunk. This study suggested that the common perception of the drunk being seen as a deviant, and alcohol being responsible for criminality within society was proven not to be as common as was indicated by the disease model. MacAndrew and Edgerton observed that the behaviour of the intoxicated person was governed by how society expected them to behave, and inevitably in society where expectations were negative, then the resulting behaviour was negative, it was also noted by the study, that in most societies the expectation of the society and the resultant acceptable behaviour when intoxicated fell within that societies idea of normal drinking behaviour. So the idea of intoxication and addiction through drug use, was deemed to be an exception rather than a norm. Stanton Peele has also suggested in many articles that addiction rather than being a disease was more to do with the persons experiences and life themes, which also included the ability to spontaneously recover from excessive substance use and maintain controlled drinking which indicates the usefulness of harm reduction within addiction, concepts which are totally at odds with the core concepts of the disease model, irreversibility and uncontrollable drinking as advocated across the previous three hundred years by addiction treatments. His work also discusses the validity of denial as part of the overall disease model, and likens it to “a web” (Peele 1996) which only acts as a reinforcement of the model, which suggests that the very discourse involved in the disease model, as touched on earlier, which is specific to twelve step models is self fulfilling in that it “brainwashes” the subject into believing that they are incapable of dealing with their addiction without the support of the other “brothers” in recovery.
Davies in his book The Myth of Addiction (2009) also discusses the use of discourse within the disease model of addiction , suggesting that the very nature of this discourse, and the way it is used between practitioners and clients, reinforces the specific roles of the of the two opposing groups. He suggested that substance users learn the specific language of the disease model, and they also learn how to manipulate this language to maintain their identity as addicts. This is supported by the practitioners who prime the substance users by asking specific questions, expecting the learned responses from the user, which then adds validity to the whole exchange. This suggests that the whole disease model of addiction is a construct between two individual groups, which legitamises the treatment and stigmatisation endured by one of the groups, and reinforces the concept of the addicted person being different from the general population, the suggested discrete entity of addiction, which is part of the core concept of the disease model.
The idea of professional constructs has also been voiced and championed by Thomas Szasz,(1920-2012) who consistently suggested that the idea of the disease of addiction as part of the trend for the medicalisation of bad habits, suggesting that the concept of a disease that is addiction is a way of utilising social control, and that the disease concept basically allows governments to enforce treatment , and this treatment paradigm allows for the creation and support of the treatment industry. He also suggests that addiction is a form of scapegoating utilised to maintain social control, a similar idea to the use of peer support to maintain the concept of recovery amongst 12 step societies. He also constantly refers to the inability of researchers to identify the cause of the uncontrollable excessive use an idea which has been explored by Gori (1996) in a paper which looked specifically at the failures of the disease model. Within this paper Gori discusses the ambiguity of the definitions as used by the world health organisation, and the moral attachment of the language in the definitions from WHO and how this allows treatment to be loosely prescribed, which in turn can be “subject to Social & moral Sanctions,” hinting at the religious overtones of treatment, and the disease model itself.

Conclusion:

Within this essay I have explored the idea of addiction as a disease, exploring the model from its beginning through to its modern incarnation. From the ideals of forward thinking professionals, to the voices of a few of the many critics of the idea of addiction as a disease. I have attempted to show how the ideas of commentators like Szasz , Peele and others have attempted to highlight inconsistencies, and dangerous assumptions within the model, and how the core concepts can be explained by other means. The one idea that has been constant through out this essay has been the idea that the disease model is a construct utilised to explain the condition of addiction. We have seen how traditionalist medical model users such as Trotter, Rush and Huss utilised it to try and explain addiction in a more understandable way than the previous moral model had. I also feel that they were trying to de stigmatise the idea of addiction and find a way to help those afflicted. We then saw how this model then developed into a tool for social control, with the use of scientific enquiry and the perpetration of the myth around the core concepts of the model and how organisations and governments manipulated the ideas of society towards addiction, and the resultant stigmatisation of those who become addicted high lighting how the disease model is in deed a modernised version of the moral model, with a new lexicon allowing a new set of professionals to take over from the original perpetrators of social control, the churches and the industrial complex.

References:

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