which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.
I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.
But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.
Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.
Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?
At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.
There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.
Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4
According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction Medicine was created – and is dominated – by true-believer 12-step types’.5 Peele argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction. Also, 12-step advocates have proved to be expert lobbyists, persuading health institutes that theirs is the only recovery programme that works, and influencing judges and magistrates to send criminals on compulsory 12-step courses. Most substance abuse treatment in the US is based on 12-step models.6
Unfortunately, the media rarely bother to question the assumptions and allegiances that lie behind the pronouncements of addiction specialists. ‘Addiction is a brain disease, experts declare,’ said the LA Times when ASAM published its definition. ‘Addiction a brain disorder, not just bad behaviour,’ said USA Today.
But the most enthusiastic coverage came from The Fix (no relation to this book), an upmarket website aimed at recovering addicts with disposable incomes. It declared: ‘If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behaviour, get over it.’ ASAM had blown the whistle on these notions, said The Fix, by revealing addiction to be a fundamental impairment in the experience of pleasure that ‘literally compels’ the addict to chase the chemical highs produced by drugs, sex, food and gambling.7
Note the finger-wagging tone of the article. If you think choice is involved in addictive behaviour, ‘get over it’. I can imagine Pippa nodding her head vigorously at that. When I showed the article to Robin, the former alcohol and heroin addict, he smiled and said: ‘That’s exactly the sort of take-it-or-leave-it message I heard every day when I was in treatment.’
Robin was in a rehab unit run by the Priory, a fashionable and expensive healthcare provider which specialises in alcohol and drug treatment and is best known for its celebrity alumni, who include Kate Moss, Robbie Williams, Courtney Love, Pete Doherty and the late Amy Winehouse. (As that list suggests, its track record is patchy at best.) Robin told me about his experience of the treatment there.
When I was in the Priory, all the doctors and counsellors emphasised the disease concept. We had lectures in the afternoons. One was from the medical director, a psychiatrist, on the disease concept. You have a disease, the disease of addiction, ‘dis-ease’, etc. When I asked him for the evidence, he said things like ‘we can see that the metabolic pathways are different in alcoholics’. Well of course they are, because the booze, not the ‘disease’, has changed them. I didn’t think he was being very intellectually honest, but he was the expert and if we had different ideas that was just evidence of the alcoholic’s arrogance.
As for the counsellors, they kept talking about ‘the illness’. Your illness, my illness. ‘My illness tells me I’m a bad person.’ The reason for this emphasis was that ‘it’s a shame-based illness’, and the whole point is to get away from the idea that you’ve been a wicked person and you should be ashamed – such ‘stinking thinking’ might cause you to fall into a ‘shame spiral’, and shame leads you to ‘pick up’ the next drink or drug.
You’d absorb the illness chat pretty quickly, but I could never bring myself to talk in terms of ‘my illness’ – it just seemed too pat and convenient to take away responsibility and turn your addiction into something outside yourself.
Addiction specialists would reply that of course they’re not saying the disease is ‘outside’ people. But the way they talk about addicts sometimes implies that sufferers are under the control of a malign puppetmaster.
There are recognised brain diseases which, like addiction, manifest themselves as behaviour – the jerking limbs of Huntingdon’s, for example. But it’s a funny sort of primary, chronic, brain disorder that makes you drive yourself to the pub, sink seven pints of beer with whisky chasers, and then drive yourself back, turning your car into a weapon of mass destruction.
In fact, there’s a world of difference between involuntary, chaotic spasms and long sequences of actions that look perfectly voluntary, if misguided, to anyone observing them. Professor John Booth Davies, director of the Centre for Applied Social Psychology at the University of Strathclyde – and one of Britain’s most prominent opponents of the disease model – makes the
