Is Addiction Really a Disease? A Challenge to Twelve-Step Programs
Addiction is everywhere, it seems, as is the devastation wrought by this disease. But does it even make sense to call it that? Modern medicine thinks it does. What used to be considered a moral deficiency is now called a biological condition, and every twelve-step program from Alcoholics Anonymous to Overeaters Anonymous is predicated on this principle. But in different cultures diseases look different and, more importantly, mean different things. I believe that in digging into the metaphoric landscape of addiction and disease in the American soil we can get at the grit of where we are in our public perception and how we got here. What follows is both an intellectual and personal unpacking of the following question: what does it mean to be an addict in America?
Let me preface this by saying that I write as someone who has struggled with these issues both as an academic and as someone who has lived in the prison of chemical dependency. I have experienced the despair of finding out I had an “incurable disease,” as well as the despair of being told it could only be arrested by a Protestant-by-proxy twelve-step program. I know as well the process through which disease-identity is cultivated within the walls of Narcotics Anonymous. I experienced firsthand how the disease of addiction is a cipher for all sorts of projections and even, to a certain extent, a symbolic transformation of the Devil himself into the language of medical discourse, echoing the ancient struggle of God, or a “Higher Power” with the Devil, or “the disease of addiction.” This crypto-Christian theology is still very much alive in the treatment of addiction. And for the still-struggling addict who doesn’t subscribe to or is alienated from the Judeo-Christian tradition, this can prove to be very problematic. And although these programs encourage each wayward addict to define his or her “Higher Power” as he or she understands Him (it can be a doorknob, a doll, or the twelve-step program itself), all of the literature and even the verbiage used within the “rooms” themselves point to a Judeo-Christian concept that turns the addict into a spiritually devastated individual who can only be saved by developing a more intimate relationship with a “Higher Power.”
The Harmful Power of Misplaced Medical Diagnoses
Like dictionaries, which jettison words every year, medicine disposes of diagnoses that are no longer tenable. Such was the case with both hysteria and homosexuality in the early and mid-twentieth century. These diseases then become historical curiosities like so many of the comically absurd laws of the nineteenth century. Obviously, homosexuality is not a disease, and it never was, regardless of what medicine thought; the experience of being gay, however, for many people was one of living in illness. For some gay people, this damaging self-conception prevented actualization of a healthy sexuality and nurturing of an authentic self. In other words, this misdiagnosis was damning. Fortunately, this particular vestige of Levitican law has been abandoned by the medical community.
The metaphor of addiction as a disease is equally damning. And yet, with some procrustean acrobatics, medicine has been able to fit chemical dependency under this rubric. After all, the life of the addict is often characterized by “disordered or incorrectly functioning systems of the body,” which are the hallmark of any disease. But again, the ways we think about disease today are neither similar to how they were a thousand years ago, nor to the way they are envisioned in holistic paradigms today. What I suggest is a radical return to the way we thought about diseases of the body and of society in antiquity: as imbalances that need to be brought into equilibrium, rather than as insidious interlopers to be destroyed. The truth is, the current medical model of addiction is fundamentally modern and just doesn’t work; what we need is a metaphoric rewrite that understands the disease of addiction not as a discrete illness circumscribed by the skin of the individually afflicted, but as a societal condition reflected in the sinews and psyches of the chemically dependent. This would require quite a transformation of the clinical dynamic, but such a transformation would open it up to a more individualized and democratic environment.
For most of America, having a disease means having a foreign body assume residence in the biological tissue, multiplying itself and attacking the surrounding healthy tissue. This idea is a direct result of the discovery of microscopy and the bacterial origin of many afflictions. The metaphor here is war, and all good doctors are on the front lines, battling leukemia, eradicating AIDS and other serious illnesses. Sometimes we cause the war ourselves and sometimes we are simply invaded. But where is the infection in addiction? To what can we actually point? Carl Jung famously diagnosed addiction in a letter to Bill Wilson as “a thirst for wholeness” and prescribed analysis, creative activity, and the formation of meaningful relationships to fill in the gaps where absence has encroached. I’m not sure about the analysis part, but as for the formation of meaningful relationships, I am 100 percent convinced.
While a minority of addicts find the idea of having an arrestable, albeit incurable, condition empowering (at least according to the twelve steps), most addicts, myself included, do not. And the monopoly of the twelve-step ideology precludes the possibility of finding out about alternative therapies such as those I will discuss. It also occludes the societal etiology and responsibility for a collective condition.
Twelve-Step Programs’ Christian Underpinnings
Alcoholics Anonymous—which was really the first organization to articulate the disease theory of addiction—has influenced many in the medical community to adopt its perspective, Christian underpinnings and all.
And it’s no secret that Bill Wilson, cofounder of AA, was a Protestant and that his organization rose from the ashes of the Oxford Group, a Christian recovery initiative, thus lending the entire project a biblical perspective replete with a Job-like narrative structure and Levitican ideas of contamination and purity. Indeed the entire culture of most twelve-step programs is one of paranoid avoidance of contaminated objects and reverence for the accoutrements of the program itself—the literature, the litany, and the group of “believers.”
Let me be clear here: the twelve-step programs have many profoundly wonderful qualities. They encourage open acknowledgement that the life of chemical dependency is an unhealthy one; they provide an environment that nurtures the relationship of sponsors and sponsorees; and they also encourage making amends. What I am attacking, instead, is the cultivation of a disease identity that I believe to be anathema to health. I am also critiquing the fact that in our society, most addicts can only find recovery groups of a Christian persuasion.
Non-Christian Rehab Alternatives
AA’s crypto-Christian theology of a spiritual condition may work for some, but a variety of alternative theologies are available to those for whom it doesn’t. In Peru, for example, entheogenic intervention is allowed, and a local rehab program funded by both the French and Peruvian governments employs a shamanic narrative. Rather than using the imagery of arresting a disease process, this treatment program uses the ritual structure of spiritual sickness, departure, an encounter with some sort of spiritual realm, return, and finally reintegration into society.
In Thailand, one of the most successful treatments, which has attracted hundreds, including many Europeans every year, takes place at the Thram Krabok monastery. The treatment’s narrative structure suggests that when we ingest poisons (i.e., drugs) we make ourselves sick, but through the process of purification we can awaken a karmic commitment to harm neither ourselves nor any other beings. Although this is also a religious model of disease, the Buddhist cosmology is very different from the Christian: there is no disease with a mind of its own, and such statements as “my disease told me to do it” are unheard of. However, statements like this are common in twelve-step meetings.
Instead, the novice monks at Thram Krabok are taught that all desire is, in the end, harmful and counterproductive to attaining enlightenment. And that is exactly what addicts become: novice monks who rise before dawn and spend the day in meditation and service. The program only asks that participants pay three dollars a day to cover food expenses; although Alcoholics Anonymous and Narcotics Anonymous memberships are free, this is incredible when compared to the prohibitively expensive treatment centers in the United States. The monks teach that we are all addicts in our way, that we all experience cravings for more of a good thing. But the way to overcome this, they say, is through a complete reorientation of values. Again, while an integral component of the twelve-step recovery process includes the making and maintenance of a moral inventory, as well as significant lifestyle changes, the color of the process itself is resoundingly Protestant.
While to a certain extent we are all addicts—afflicted with the insatiable desire for more—to the “addict,” “more” is a mantra to the exclusion of all others. Nothing exists beyond this need for more. My own experience was one of losing, in stages, everything that mattered in my life, from my relationships, to my sense of worth, to finally, my career. When I sought help I was confronted with the poverty of treatment alternatives. Thailand was too far away and the waiting list for Peru promised a delay of well over six months. I went, instead, to a Catholic treatment facility, which, in spite of being staffed with wonderful, compassionate, competent people was still, well, Catholic. And the other alternatives, none of which aligned with my own spiritual beliefs, were pretty much the same. As open as I am to every religion, I felt a little annoyed by the fact that every AA meeting ended with the Lord’s Prayer. I mean, why not an oblation every now and then or a petition to Manjusri? Granted, there are now Buddhist twelve-step programs available, but their paucity is, again, problematic.
Can Metaphors Make Us Sick?
My personal experiences of treatment and my research into the alternatives led me to question the extent to which we create our illness. What I discovered was that regardless of one’s pet theory, one incontrovertible fact remains: our consciousness impacts our bodies (just look at the placebo effect). Even more interestingly, the consciousness of others can do the same, as physician and author Larry Dossey has successfully shown. This is gooey ontology, but there is a participatory dynamic at work: one can think/will oneself and others into and out of health.
The wisdom of cognitive psychology tells us that those thoughts strengthened by repetition are the ones that shape our experience. Is it any wonder, then, that addiction has assumed some of the characteristics of a disease? It has a spontaneous remission rate that mirrors that of most other medical conditions (reportedly a staggeringly low 2 percent to 5 percent) and a “genetic” etiology. The genetic neuronarrative is the dominant myth now. But if consciousness affects biology, and even the expression of certain genes as recent research reveals, then it almost seems de facto that a cultural agreement on the disease metaphor would create a fertile environment for the expression of those implicated genes and the constellation of characteristics for which they allegedly code. Put differently, I believe it entirely possible that our collective understanding of addiction as a disease may make it act like one (and certainly makes the addictive experience feel like one of disease); it follows, then, that changing the belief that addiction is a disease will eliminate some of those experiential qualities.
One of the most illuminating texts on disease is Susan Sontag’s evocative little book Illness and Metaphor. Here she argues against what she calls the “lurid metaphors” of sickness:
Illness is NOT a metaphor, and the most truthful way of regarding illness—and the healthiest way of being ill—is one most purified and most resistant to metaphoric thinking…. Any disease that is treated as a mystery and is acutely enough feared will be felt to be morally, if not literally, contagious.
I believe we have both crossed this threshold and retreated from it. Allow me to explain:
We valorized and aestheticized the barbiturate suicides of Dorothy Dandrige and Marilyn Monroe, as if overdose were a passage to a higher artistic plane. River Phoenix, too fearful in his symmetry to be framed by life, died on the sidewalk in front of the Viper Room (vipers being living symbols of potency and death). Our poets knew this long ago, as Shakespeare wrote of he who “dies in his own too-much” and Blake listed among his “Proverbs of Hell” the idea that “the road of excess leads to the palace of wisdom.”
And we aestheticized absinthe, as well as the madness that it wrought. (Though recent scientific studies have shown just how innocuous wormwood actually is, making me suspect that the green fairy’s gift of delirium was in part conferred and constructed by the culture of Romanticism.) And now addiction has also become aestheticized. I cannot and will not speculate on the psychic etiologies of cancer and addiction (yes, some evidence exists in both cases to support this). I also disagree with Sontag that metaphors are never helpful when dealing with illness. We are meaning-making creatures after all, designed by Heaven or Hell to be unable to think outside of narrative.
Helping Others: An Alternative Treatment Strategy
So how do we rewrite the metaphor of disease? I’ll get there, but first I suggest that the unconstitutional imposition of twelve-step programs for drug and alcohol offenders be replaced with labor programs coupled with volunteering. Helping others is the surest way to shift the focus of small self. However fascist it may sound (and indeed it does, even to me) something happens when we help others. We are hardwired for altruism. It has the added benefit of being secularly ecumenical. We do not need to inculcate the “afflicted offender” with the fact that they are spiritually bankrupt and bereft of a higher power. One of the most beautiful and beguiling effects of selfless labor (even if it is imposed) is that it is spiritually corrective on its own. Labor programs in Japan have been employed for decades and have demonstrated encouraging results for this method in combating and even “curing” depression. What hubris to assume that enforcing God as a punishment will work.
For all its talk of secularity, modern medicine is deeply mystical, right down to its symbol, the rod of Asclepius. And why do insurance companies, the true guardians of modern medicine, pay for twelve-step rehabilitation facilities that are unabashedly spiritual, if they do not subscribe to the metaphor of a spiritually afflicted individual? We assume the Age of Technology ushered in the era of atheistic imperialism when in fact we have just divinized technology and the idea of progress itself: a second, and deeply ironic, Romantic renaissance. We experience this technologization, however, as profoundly alienating, again, lending force to my point that we must consciously rewrite the myths we live.
I suggest we skip the first eleven steps of Narcotics Anonymous and go straight to the twelfth (“Carry the message to the addict who still suffers”), for the “addict who still suffers” is each and every one of us. The message here—of selfless labor—is that all beings suffer and, in helping, alleviate that suffering: for however short a time, we are shaken, sometimes violently, out of what Einstein called the “optical illusion of consciousness” that we are somehow separate from each other. This approach encourages all addicts to embrace a higher, more integral, perspective—a perspective that is naturally healing to all: to the addict, to those receiving help, to the local community, to the nation, and to the world.
In spite of this need for a more integral community of addicts and those who are affected by their lifestyle, the twelve-step communities are worlds unto themselves. As social creatures, we struggle with identity formation. Teenagers choose, or circumstances choose for them, which alliances to form, which allegiances to offer. And in spite of today’s identity marketplace, we are all born into allegiances to nation and religion (or lack of religion). Those active in addiction form allegiances as well. There is a definite morphology to the distinct identities of heroin and methamphetamine addiction. The qualities of each are experientially, and perhaps ontologically, participatory. Those “in recovery” abandon individual drug identity to purchase membership in the parliament of the twelve-step theocracy. “We are those who suffer from the disease of addiction,” the literature reads in a near-religious litany.
Twelve-steppers are part of a subculture in which no one understands the uniqueness of the addiction experience except other addicts. This is balderdash. Yes, the twelve steps stress the unity of addictions, the erasure of individual differences in the process of recovery, but they also reify addiction itself. The symptoms of addiction are indeed dramatic, but they are just the most visible of a syndrome we all share, inasmuch as we are members of society. While there are many different support groups for the families of those who suffer through chemical dependency, again, they are restricted to the families and not the community at large. The key here is that we all share the etiology, and as such the responsibility to fix.
How Racism and Classism Shape Images of Addiction
Like all successful metaphors, that of addiction has two contradictory sides, and in the case of the “disease of addiction,” the metaphor is, well, loaded. One side is a tubercular aura of spiritual romanticism, a spiritual sickness excused as ethereal, the natural consequence of artistic giftedness. The other side of this dichotomy is that addiction is also seen as the province of the “pestilent ghetto,” the crack-soaked streets of Chicago’s South Side. In other words, the metaphors of addiction are different for the different classes.
Sontag writes that “twentieth-century women’s fashions (with their cult of thinness) are the last stronghold of the metaphors associated with romanticizing of TB in the late eighteenth and early nineteenth centuries.” And who can deny the connection of drugs and addiction to the world of fashion and beauty? Kate Moss’s and Naomi Campbell’s very public bouts with addiction strengthen, at least in the public perception, the connection of privilege and chemical indulgence. Modern metaphors of addiction also partake in the cult of youth. One never hears about the geriatric population’s skyrocketing rates of addiction or how they dwarf the statistics of teenagers. This is because we exalt addiction as an affliction of the privileged and youthful. The efflorescence of the Beat generation, the pavonine splendor of Rock and Roll, the narcotic mesmerism of the blues, the lines between drugs and creativity (and early death) are legendary—and lethal. More public recognition and education about the elderly’s struggle with drug dependence would loosen the grip of this particularly insidious misconception.
The other, uglier side of addiction we associate with poverty and crime and, unfortunately, with skin color. This further strengthens our racial prejudices in our county, while widening the gap between classes. People of color are routinely given harsher sentences for drug-related offenses than their white counterparts, who are routinely offered treatment as opposed to incarceration. These sickening statistics betray our country’s still very real racial divide. Our system coddles the light-skinned and excoriates the darker-skinned, strengthening the supposition that dark skin = poverty = addiction = crime = hopelessness. We need to struggle as a society with the fact of our binary biases before we can move past them. Reexamining the metaphors we deploy for addiction is one way to do this.
Sontag writes about those afflicted with tuberculosis that “sadness made one interesting. It was a mark of refinement to be sad. That is, powerless.” Tellingly, step one of Narcotics Anonymous is to admit powerlessness over addiction. Sontag goes on to say that “the myth of TB constitutes the next-to-last episode in the long career of the ancient idea of melancholy [and] provided a redemptive death for the fallen.” We could easily supplant “TB” with “addiction.” To recover from addiction becomes spiritually redemptive. Robert Downy Jr.’s triumph has not been merely over substance, but over a spiritual affliction. There is a process of spiritual purification and a glamorous aesthetic associated with recovered (white) addicts. For other races, the attitude is simply that they’re just doing what they should have been doing all along.
Again, how do we change this? All successful recovery from chemical dependency is the result of a complete reorientation of values and again, alignment. In many ways, contemporary consumer society rails against alignment. Pharmaceutical companies lull us into thinking that there is a drug for every condition. And medicine is complicit in this insidious mirage. Bringing the body back into alignment with itself and entraining the self with the circadian rhythms of the community are ways to recover and even heal the rift between the classes in our culture. Maybe the answer doesn’t lie in dispensing with the idea of illness after all, but just in the military metaphors of invasion and civil war. Instead, let’s return to the original Old French etymology of desaise from des (without) and aise (ease)—because addiction is never easy, nor is recovery from it. But the idea of bringing the body back into the ease of alignment? Now that is a metaphor we can work with.
Boeving, NIcholas Grant. 2011. Is Addiction Really a Disease? A Challenge to Twelve-Step Programs. Tikkun26(4): 22.