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A History of “Addiction as a Disease”

Traditional Conceptions of Addiction

Traditionally, addiction was seen as a social issue, which could be solved by moderation since addiction itself was characterized as excessive desire and a matter of choice. Prior to the 19th century, alcohol was treated as food and social lubricant if consumed in moderate amount. In ancient Greece, for example, wealthier households in Athens would have drinking parties (symposia) where men would drink bowls of wine and engage in lively debate. The drinking party ends when “the love of drink overpower[ed] love of truth”.

Religious figures prior to the 19th century also preached moderation. Churches traditionally believed that there was nothing inherently evil in the individual or the substance (which would have made moderation unsuccessful).

In the 18th century, philosopher Jonathan Edwards (1703-1758) countered Enlightenment philosopher John Locke’s (1632-1704) distinction between “desire” and “will.” For Edwards, desire and will are identical: “A man never, in any instance, wills any thing contrary to his desires, or desires any thing contrary to his will”.

The traditional view also equated desire with choice. For example, Edwards argued that there was always a choice: “…If he wills to drink, then drinking is the proper object of his Will … If he chooses to refrain, then refraining is the immediate object of his Will and is most pleasing to him”. Consistent with Edwards, the church also considered drunkenness a choice.

The Origins of the Disease Concept

19th Century Developments

The religious community established the Temperance Movement largely in response to increased alcohol consumption. Inspired by Benjamin Rush, the Temperance Movement gradually changed their policy from moderation to abstinence between 1800 and 1825, then from voluntary pledges of abstinence to legal prohibition of alcohol between 1825 and 1850. Over the course of 50 years, the Temperance Movement influenced the prevailing view of habitual drunkenness that transitioned from an indulgence to something evil.

20th Century Developments

The 20th century was a time of further entrenchment of the “addiction as a disease” concept. This is evident in the growth of Alcoholics Anonymous (AA) and the criminalization of addiction. AA was established in 1935 as a self-help group for alcoholics and has since been adapted to become the dominant treatment model for addiction. AA equates alcoholism with a failure of willpower, resulting in an individual who is “powerless over alcohol” (Step One in AA).

The influence of psychology in the development of AA is a curious one with both William James and Carl Jung cited as validating AA’s spiritual approach: James explored the potential role of religious conversion as a cure for alcoholism, while Jung suggested that the only hope for an alcoholic is a “spiritual awakening” or religious experience.

The criminalization of addiction (also referred to as the “war on drugs“) began with the call for prohibition by the Temperance Movement and continued into the 20th century with Prohibition taking place from 1920 – 1933. The Movement’s promotion of addiction as a vice helped law enforcement agencies conduct their controversial and largely ineffective criminalization of cocaine and heroin.

The Current Status of the Disease Concept of Addiction

The preferred definition of addiction as a disease continues today. For example, on the American Psychiatric Association website, addiction is defined as “a complex condition, a chronic brain disease that causes compulsive substance use despite harmful consequences”.

According to psychologist Bruce Alexander, however, the deeply-rooted traditional definition of addiction has never been displaced. One only needs to pay attention to daily conversation or the media to notice that addiction is now being used in reference to e-mail, work, chocolate, cell phones, and a myriad of other substances, objects, and activities. Arguing on behalf of disease model advocates, the neurobiologist Carlton Erickson laments the loose application of the word “addiction”, warning that, “it detracts from the seriousness of problems with heroin, cocaine, alcohol, and nicotine”.

Returning to Moderation

While I concede that the disease concept of addiction is still predominant, I would argue that society is returning to the traditional view of addiction (e.g. moderation). And returning to a traditional understanding of addiction would address two important flaws in the development of “addiction as a disease” resulting from substances.

First, it would facilitate the concurrent treatment of process addictions such as sex and gambling, not just drug and alcohol addiction. Second, it would allow treatment approaches that permit individuals to practice moderation as many refuse to abstain completely from drinking, resulting in stigmatization when they return to it.

Additionally, a return to the traditional conception of addiction would encourage the development of non-medical addiction-specific approaches such as Alan Marlatt’s cognitive-behavioral-based Relapse Prevention Therapy.

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