Substance Abuse: Moving Away from the Moral and Disease Models

May 31, 2018

In her two-part series clinical psychologist Jessica Katzman writes about a way of managing addiction that is grounded in scientific research, human rights, compassion, and common sense. Click here to read part one.


The full history of drug and alcohol use in human society obviously lies way outside the purview of this post, since we would have to track back at least 10,000 years. Additionally, these substances are always inextricably bound up in the cultural, social, economic, political, religious, agricultural, and medical developments of a people.

The United States, in particular, has always struggled with a highly conflicted set of attitudes regarding drinking. The Puritanical roots of the colonial people, and later temperance organizations, had a hand in shaping the Moral Model seen in the 19th and early 20th centuries. This model can be characterized by these beliefs:

  • Addiction stems from a weakness of character, and is the result of poor choices.
  • It is naturally associated with crime, poverty, sin, domestic violence, and laziness.
  • The appropriate response should be punishment, not sympathy. (For an example of how this principle continues to impact our political policy, look no further than the War on Drugs.)
A colorful creation of a woman wth an umbrella flying surrounded by an owl, buterfly and statue.

“Hope Floats” by Genevieve Esson

This was gradually (and perhaps only partially) replaced by the Disease Model, which has been viewed as our standard approach since the inception of Alcoholics Anonymous in 1935. The precepts of this model are:

  • Addiction stems from a biological disease, which follows an inevitable progression from use, to dependence, to extreme consequences, to death.
  • It is a black-and-white issue (either you’re an addict or you’re not) and is incurable (once an addict, always an addict). This malady is marked by loss of control and powerlessness, as well as the addict’s denial of the severity of the problem. The only way to arrest the disease process is total abstinence, ongoing participation in 12-step community, and turning one’s life over to a higher power.

In contrast, the Harm Reduction Model of substance misuse holds that:

  • There is no one single cause—it is as complex as any human behavior, and often multi-determined (vs. a biological, inherited disease).
  • It is not a black-and-white matter, but rather a continuum of use that flows from abstinence to dependence. (Additionally, people may skip around on this continuum, depending on their life context and emotional state.)

There is actually a diversity of outcomes for substance misuse (vs. the “inevitable progression”). For example, it has been shown that most people stop using drugs by age 29 (and few start after this age), a process Peele calls “maturing out”, which reflects how competing values and goals can have an affect on our choices.

The most common outcome of chemical dependency treatment is relapse and continued abstinence is the exception. Miller & Hester’s review of the literature on outcome studies regarding the efficacy of methods for treating alcoholism (from 1980 through 2002) concluded that, in the year following a treatment episode:

  • 1 in 4 remained continuously abstinent
  • 1 in 10 drank moderately and without problems
  • Mortality during this period averaged less than 2%
  • Even clients who DID drink in the year following treatment showed substantial improvement, abstaining on three out of four days, and reducing their overall alcohol consumption by 87% on average, with a 60% reduction in alcohol-related problems.

Unfortunately this typical over-focus on black-and-white treatment outcomes overlooks a substantial amount of improvement in those who do not maintain perfect abstinence. Many people are able to quit or stop using problematically without outside help (by some accounts, up to 35% recover with no help from others). We are more likely to see positive outcomes from a focus on self-efficacy and the power to set one’s own goals (vs. powerlessness and surrender).


Discussion


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