Addiction as a Progressive Disease
From the first day that I sought help for my problematic relationship with substances, I was told that I had a progressive disease and that I needed to find a progressive recovery. Many people believe that the disease of addiction is progressive, a progression that occurs even without using substances, and only a forever strengthening defense will provide hope for a meaningful life.
Progress in All that We Do
I have found the need for progress to be true in my career, even more than my addiction recovery, as someone who works in the field of addiction treatment. What is imperative?
- Academic knowledge
- Scientific research
- Critical thinking
- A sociological view
…each of these are imperative unless I want to fall victim to my own laurels and become obsolete. Ironically, the more I progress in my thoughts about addiction, the further it takes me from those core values that once laid at the foundation of what I thought it means to “be an addict.”
In this article, I will outline the progression of my thoughts on addiction; using my own experiences to show the evolution of my understanding. It must be understood that I do not claim to be an expert on addiction; only someone who has spent almost every waking moment of the last 10 years thinking, learning, and observing what it means to be addicted. If nothing else, this article is a personal exploration, an intellectual exercise, of my thoughts and experience so I myself can better grasp my understanding of drugs, addiction, and society.
My Introduction to Addiction Recovery: 12 Steps or Nothing
I walked into my first attempt at solving my relationship with substances when I was 24 years old in 2007. It was a residential treatment center in Northern California that my family paid over $10,000 to send me. The program was 12 Step based and followed strict adherence to the disease model of addiction.
Upon arrival, I was told that I had a progressive disease that could only be arrested by abstinence from all mind altering substances, excluding caffeine and nicotine (of course). Further, abstinence could only be obtained through working the twelve-steps of recovery and going to meetings for the rest of my life. To make matters even direr, I was told, after spending $10,000 that I had about a 2% chance of success
I left that program in 30 days equipped with the book Alcoholics Anonymous and a 12 Step meeting guide. At that point, I’m not sure if I believed that I had a disease or not; but after relapsing shortly after, I quickly came to embrace that I had a fatal illness that must be addressed.
I started attending a twelve-step fellowship, got a sponsor, and worked the twelve steps. I bought into the disease concept of addiction and jumped into recovery with both feet. The belief that the twelve step approach was the only way to avoid a horrible drunken death, nestled down into the core of my being, and became the central part of my life.
My Academic Journey: Differing Definitions of “Disease”
The second best decision I ever made, the first being stopping using drugs, was going to college. I was less than one year in recovery when I joined a friend who wanted to go to school for addiction counseling. The only reason I went to school for counseling was because my friend was going and I had nothing better to do. So I went and began a journey in education that after nine years is still ongoing.
When I started school I was a 12-step fundamentalist; believing that the book Alcoholics Anonymous was divinely inspired and adherence to the 12-steps was the only way to find true recovery. What I started to learn in school was different than my core beliefs about recovery and left me on somewhat shaky ground. Apparently, belief in a higher power was not a central point in addiction counseling. Also the academic definition of disease was different than the 12-step understanding. These discrepancies left me confused and frustrated at times; but also intrigued.
How the 12 Step Program Oversimplifies Addiction
In the twelve-step fellowship, addiction was oversimplified: you were either an addict or you weren’t. Addiction, from the twelve step disease perspective, takes on an anthropomorphic persona within the addicted person. It is common to hear someone say “that’s your addict talking,” or something similar. In academic models, the disease of addiction develops from the neurochemical changes caused by using drugs themselves. These are two completely different concepts, yet often used interchangeably in addiction treatment.
The most dangerous part of academia? It made me critically look at my own drug use and recovery; which made me question whether or not I was a real addict. Luckily, my friend informed me that that was my disease trying to get me to use, which reinforced my recovery and, of course, its dogma.
In fact, the disease concept is great because it takes the guess work out of diagnosing a complex disorder. However, if addiction is on a spectrum, with different degrees of severity, which is caused by use over an extended period of time, then I would have to admit that – at 24 – I most likely did not progress as far as I thought, therefore not a chronic addict. This type of reasoning could be equally as liberating as it is dangerous.
Are the 12 Steps Halting Progress in our Classrooms?
Although there were new recovery concepts in the academic setting, enough of the students – and a few of the teachers – were in recovery to perpetuate the ideology of the 12-steps in the classroom. The fact that many people in the addiction treatment field are in recovery themselves, has kept the field as a whole from moving towards more progressive thoughts about treatment.
Those of us who are in recovery will rarely find ourselves outside the company of recovering people. They are our classmates, colleagues, teachers, supervisors, and most importantly, clients. Even when a scientific ideas run contrary to our dogmatic understanding of addiction, the collective conscience out numbers the voice of reason and writes it off as an opinion of those who don’t really understand addiction.
Being an Addiction Counselor: We Need to Examine our Assumptions!
Although there are ideas in academia that challenged my views of addiction, those challenges were only theory and had little application in the working world. This was because in the working world, most counselors were in recovery and therefore bought into the 12-step fundamentals of addiction as a disease. The academic ideas were fun to flirt with in the classroom but at work we had little time for nonsense and these dangerous ideas.
Q: What is an important idea can we consider?
A: Levels of addiction differ by individual and require different interventions.
1. I’ve come to believe that counselors are in as much denial about the disease of addiction as our clients are. First, we need to look at addiction along the spectrum of progression. Each client is not equally addicted!
2. I’ve come to see that substance use occurs on a spectrum of severity; one that is constantly changing for each individual. No doubt, there are people on the far end, the most severe, who are in the grips of a chronic condition and can likely never use a particular substance safely. How many people are at this far end of the spectrum is unknown because all people who seek treatment are assumed to be in the progressive chronic diseased category. To treat all clients as having the same level of addiction is misleading, harmful, and dishonest.
3. I came to realize this in my work in a residential detox facility that also had over twenty beds for long-term sober living apartment tenants. When being hired I believed that all addicts were the same and required the same treatment––residential treatment and then continued twelve-step attendance. In the detox we saw about 60 people a month be admitted for short stays up to two weeks. In the six years I worked there I saw about two thousand new clients (not including countless repeats) be admitted to the detox.
That is a lot of people and a lot of experience working with people who are acute in use and withdrawal.
What I saw was often contrary to my beliefs. Often, the experiences of the detox clients went against everything that my colleagues and I knew about recovery. For one I have seen countless people detox and remain “clean and sober” without any type of treatment or recovery program. It appeared that they simply choose not to use anymore. Choosing not to use drugs, after they had clearly met the criteria for severe substance use disorder, went against everything that the disease model stands for.
Some would say that those people who chose not to use anymore were just not “real” addicts. This kind of defense leads to even more questions and concerns about the disease of addiction. By accusing substance users of not being authentic addicts runs in direct opposition to telling all substance using clients that they have the same disease.
Another disturbing trend that I have seen in my time at detox are people who have detoxed from a substance, having met the DSM criteria for severe disorder, and continue to use another substance while appearing to be able to function and manage their lives. This is particularly true of marijuana and I’ve seen this more so in my twelve-step fellowship.
Everything I knew about addiction told me that addiction is addiction and a drug is a drug; that an addict cannot use any drug in any form without disaster. My observational experience tells me that this is simply not true. If a hopeless alcoholic is able to abstain from alcohol but smokes some pot, who am I to say that he is not in recovery or not sober?
Social Worker and Harm Reductionist
Currently, I am two quarters away from finishing my Master’s in Social Work. In my first year of my MSW program I had the privilege to intern at a supportive housing building in San Francisco. Supportive Housing operates on a housing first paradigm, where basically people are housed as the first stage of their treatment. Once housed, social services attempt to use interventions on other aspects of life such as substance use.
Again, in this setting I saw people who used substances and did not fit the disease model of addiction, but met the criteria for a substance use disorder. The biggest eye opener for me was seeing that opportunities, or lack thereof, affected a person’s drug use.
The Disease Model of Addiction Ignores Sociological Factors
The disease model leaves little room for external factors in recovery and completely ignores systems of privilege and oppression. There was one resident in particular who was able to abstain from methamphetamine when she was employed. Since she was employed seasonally her use was patterned and cyclical. For her, treatment for her addiction was employment; something that most treatment counselors would balk at. But if she worked year round her life would have remained manageable and would never have come close to receiving a diagnosis of substance use disorder.
Case Management is An Effective Tool
Because of the examples above I have come to believe that case management is an effective tool for treating substance use. Most importantly, I have changed my definition of “success” in treatment. Since people seek treatment when their lives become unmanageable, I consider any improvement in the ability to manage one’s life a success. With this definition of recovery I see harm reduction as the only effective and ethical treatment path that can be taken, especially when using motivational interviewing to guide clients towards a more manageable life.
Ironically, I entered graduate school to get out of substance use treatment. Now, I feel that my passion for the field has been rekindled with the discovery of the new ideas that I have mentioned above. No matter where I end up after graduation, I will carry the thirst to learn more about what it means to be addicted.
Substance use treatment has remained rather stagnant, at least at the ground level, and we owe it to ourselves and our clients to progress in our understanding in the same way we expect our clients to progress in their recovery.