Evaluating the Brain Disease Model of Addiction

Nick Heather, Matt Field, Antony Moss, Sally Satel, Nick Heather, Matt Field, Antony C. Moss, Sally Satel

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000540062
• Edition: 1
• Topic: Psychologie
• Subtopic: Addiction en psychologie

This ground-breaking book advances the fundamental debate about the nature of addiction. As well as presenting the case for seeing addiction as a brain disease, it brings together all the most cogent and penetrating critiques of the brain disease model of addiction (BDMA) and the main grounds for being skeptical of BDMA claims.

The idea that addiction is a brain disease dominates thinking and practice worldwide. However, the editors of this book argue that our understanding of addiction is undergoing a revolutionary change, from being considered a brain disease to a disorder of voluntary behavior. The resolution of this controversy will determine the future of scientific progress in understanding addiction, together with necessary advances in treatment, prevention, and societal responses to addictive disorders. This volume brings together the various strands of the contemporary debate about whether or not addiction is best regarded as a brain disease. Contributors offer arguments for and against, and reasons for uncertainty; they also propose novel alternatives to both brain disease and moral models of addiction. In addition to reprints of classic articles from the addiction research literature, each section contains original chapters written by authorities on their chosen topic. The editors have assembled a stellar cast of chapter authors from a wide range of disciplines – neuroscience, philosophy, psychiatry, psychology, cognitive science, sociology, and law – including some of the most brilliant and influential voices in the field of addiction studies today.

The result is a landmark volume in the study of addiction which will be essential reading for advanced students and researchers in addiction as well as professionals such as medical practitioners, psychiatrists, psychologists of all varieties, and social workers.

SECTION IV ALTERNATIVES TO THE BRAIN DISEASE MODEL OF ADDICTION

31 INTRODUCTION TO SECTION IV

Antony C. Moss, Matt Field, Sally Satel, and Nick Heather

DOI: 10.4324/9781003032762-36

The preceding three sections, and 30 chapters, provide a fascinating view of the debate around the brain disease model of addiction (BDMA). Arguments have been articulately presented for and against the BDMA in Section I and Section II, and Section III contained arguments for agnosticism. Here, in the final section of the book, we present a consideration of alternative perspectives on the nature of addiction. Once more, the alternatives in question are to both the BDMA and to the so-called moral model of addiction, which holds that addictive behavior signifies a free choice just like any other and takes the addicted individual to be morally responsible for their behavior. If historically the moral model represents the thesis and the disease model (including the brain disease model) the antithesis, then we are striving here for a synthesis in the representation of addiction. However, rejection of the moral model is nearly always implicit in what follows; for practical purposes, it is alternatives to the BDMA that are considered here.

Contributors to this section took, broadly, three distinct approaches to proposing alternatives to the BDMA. First, we see arguments articulated which suggest we need fundamentally to reframe the debate; by asking ‘Is addiction a brain disease?’, we are asking the wrong sort of question. Second, other contributors make the case that part of the reason this debate exists in the first place is due to a lack of structure in how we communicate, interpret and integrate findings from diverse disciplines. Finally, we see some contributors specifying detailed alternative models for how we should understand addiction. We therefore see an interesting combination of alternatives outlined across this section, in which authors both attempt to propose a defined alternative to the BDMA and moral models, as well as offering guidance on alternative ways of approaching the study of addiction itself.

Reframing the debate

This section opens in Chapter 32 with a reprint of a recent article by Don Ross (2020). Ross is a philosopher and economist who has made significant contributions to the conceptual analysis of ‘addiction’, e.g., an influential book, with others, on gambling problems entitled Midbrain Mutiny (Ross et al., 2008) and an edited collection, again with others, consisting of answers to the question, ‘What Is Addiction?’ (Ross et al., 2010). In the more recent article reprinted here, he unpicks the conceptual confusion which has surrounded the terms ‘addiction’, ‘choice’ and ‘disease’. Ross argues that the failure to expose and engage with the pluralistic nature of relevant concepts, combined with attempts to apply very myopic definitions of these terms, hinders proper debate and development of our thinking in this field. Following a detailed analysis of these issues, Ross concludes that the way we think and talk about addiction needs to be adjusted at the macro and micro levels of analysis; he argues that at the public health and societal level, concepts of disease and disorder might have some utility, while at the individual level, it is unhelpful to apply or impose these concepts. Thus, addiction is most plausibly viewed as a disease at the scale of public health research and policy, but not – as implied by the BDMA – at the level of clinical management and intervention.

Following this, the sociologist Darin Weinberg presents, in Chapter 33, a deconstruction of both the brain disease and choice theory accounts of addiction. Weinberg is a longstanding champion of a social constructivist perspective on addiction (see, e.g., Weinberg, 2000, 2013). Here he argues that, while quite distinct theoretical positions, both the BDMA and choice theory alternatives fail to provide a compelling explanation as to why we should treat and not punish individuals with addiction. Specifically, he argues that neither approach is able to explain how the supposed loss of control experienced by people with addiction varies from any normative form of pleasure-seeking behavior. Drawing on the writings of Bourdieu (1990), and as an alternative to both the BDMA and the choice viewpoints, Weinberg then articulates the so-called ecological understanding of addiction, which attempts to present a perspective on the nature of addiction as an embodied process, influenced but not wholly determined by both neurobiological sequelae and decision-making processes.

The Australian sociologists Helen Keane, David Moore and Suzanne Fraser have made many useful contributions to the literature on addiction over the years, again from a social constructivist position (e.g., Keane, 2002; Keane et al., 2011; Fraser et al., 2014). In Chapter 35, they collaborate to present a further analysis of the way the debate around the BDMA is framed. Rather than focus on the veracity or otherwise of the BDMA, they suggest it is more important to consider the plurality of ways in which the BDMA can be framed and deployed, and the impacts (positive and negative) such framing and deployment might have for individuals. The authors present an analysis of various ways in which the BDMA is deployed, making clear that there is not in fact a singular BDMA per se, but rather it is used in different contexts to achieve different aims. Thus, as an alternative to debating the validity of the BDMA, there is a need to ask instead, ‘Which brain disease model, when, for whom and at what cost?’.

Communicating across the discipline

Another set of contributions to this section sheds a more reflective light on addiction science and considers the ways in which communication across our diverse discipline might at times be a hindrance to progress in our thinking about addiction.

For those opposed to the BDMA, or more generally to seeing addiction primarily as a medical problem, the Nordic countries have traditionally offered an encouraging example of an alternative approach – the so-called social model of addiction (Edman & Stenius, 2007). However, in Chapter 36, Jessica Storbjörk and colleagues present something of a cautionary tale of how an established socially-oriented approach to understanding and responding to addiction can be gradually eroded and changed due to changing political priorities. Exploring the shift in Nordic countries, and Sweden in particular, Storbjörk and colleagues reflect on how a non-medical understanding of addiction which emphasized the importance of social care as a policy response has been slowly shifted toward a biomedical perspective, with an emphasis on disease as the core dysfunction. The authors go on to consider how, despite this shift being in part driven by a stated aim to implement evidence-based policy, other policy initiatives such as drug decriminalization are thought of as ‘no-go zones’. This chapter, then, provides a useful insight into how biomedical science – and the BDMA specifically – may sometimes be seen as a shorthand for ‘evidence-based practice’. Due to its fundamentally myopic focus on neurobiological dysfunction as the core of addiction, policy makers pursuing and engaging with biomedical science and the BDMA may ultimately feel less concerned about those policy initiatives which might lead to an overall reduction in addiction-related harms.

In Chapter 41, Robert M. Kelly and colleagues present work toward the development and adoption of an addiction ontology (see also Hastings, 2020; West et al., 2019), as an alternative perhaps to asking whether or not addiction should best be seen as a brain disease. Their argument begins from the position that, quite aside from the debate about the BDMA, the addiction field is held back by a lack of discipline and clarity around the use of key concepts. The introduction of a formal ontology, as has been used in other scientific disciplines, would help us to define key concepts more clearly and, perhaps even more importantly, provide a clearer frame for questions such as: ‘Is addiction a brain disease?’.

Anja Koski-Jännes is a Finnish social psychologist with an established record of contributions, including international collaborations, to the addiction field over the years (e.g., Koski-Jännes, 2004; Cunningham & Koski-Jännes, 2019). In Chapter 42, she argues that understanding addiction requires more than simply acknowledging the impact of distinct biological, psychological and social factors. Rather, the importance of ‘looping effects’ between these areas is necessary to develop a full understanding of addiction. Presenting a model incorporating biological, psychological and social processes, Koski-Jännes argues that the ‘trap of addiction’ can best be understood by the looping interactions between these processes. As such, the challenge to addiction professionals is how we can best understand and communicate these interactions, rather than studying them in isolation.

If addiction is not a brain disease, then what is it?

Several other chapters propose quite specific alternative models and frameworks for the way in which addiction should best be understood. The reader may find interesting the extent to which these alternatives variously approach this debate, either by proposing an alternative intended to subsume the BDMA or by proposing an alternative in which the entire edifice of the BDMA is made redundant or irrelevant to how we think about addiction.

Chapter 34 stems from a fascinating collaboration between a neuroscientist/bioengineer specializing in cognitive neurorehabilitation (Paul F. M. J. Verschure) and Reinout W. Wiers, a leading behavioral scientist in the addiction field who has made significant contributions to cognitive models of addiction (e.g., Wiers & Stacy, 2006) and novel treatment approaches based on these models (e.g., Wiers et al., 2010, 2013). In Chapter 34, they present an approach which takes a more integrative stance – recognizing the importance of neurobiology but arguing that the BDMA itself is too narrow in focus to provide a full understanding of addiction (see too Wiers & Verschure, 2021). They propose a framework for addiction in which it is viewed as a disorder stemming from the development of biased choices. Biases in decision making are considered within what amounts to a biopsychosocial model, and so rather than rejecting any neurobiological basis for addiction, the authors instead incorporate neuro-biological evidence within a wider model.

Gabor Maté’s best-selling book In the Realm of Hungry Ghosts: Close Encounters with Addiction (Maté, 2012) has attracted a great deal of attention in the addiction field and beyond. It recounts his experiences as a physician working with the street-dwelling inhabitants of Vancouver’s Downtown Eastside, whose health and welfare have been nearly destroyed by their addiction to psychoactive drugs. Based on such experience, in Chapter 37, Maté presents an approach to understanding addiction very different from the BDMA, applying the lens of trauma and other adverse experiences which are thought to underly addictive behavior. Maté’s analysis includes a detailed assessment of evidence showing that trauma and adverse life events can, from a young age, negatively impact the developing brain, and it is this evidence which is used to demonstrate that addiction needs to be understood – and treated – as a response to such adverse experiences. The author goes on to consider the extent to which individuals with addiction may not acknowledge, or even be aware of, the role that early life events have played in their addiction. This raises an interesting point which the reader will no doubt wish to consider – whether it is helpful or accurate to always consider addiction to be the result of trauma or stress, or indeed if addictive behaviors might ever develop in the absence of significant adverse experiences.

Following this, in Chapter 38, Frank Ryan presents a therapeutically-oriented model for understanding addiction which can be considered an alternative to conventional treatment models influenced by the BDMA (see too Ryan, 2013). While Maté emphasizes the centrality of trauma and stress as antecedents of addiction, Ryan frames addiction as fundamentally a disorder of motivation. Ryan identifies a number of neural systems which are thought to underly some of the common characteristics of addiction and proposes that psychotherapeutic interventions should target these deficits. Overall, addiction is viewed as a motivational problem with a cognitive solution.

The discipline of behavioral economics has grown in importance and influence in recent decades, as has the understanding of addictive behavior that may be derived from it (see, e.g., Vuchinich & Heather, 2003; Tucker et al., 2017). Chapter 39 is written by leading exponents of the behavioral economic approach to addiction. Taking a very different perspective from the BDMA on the fundamental nature of addiction, Samuel F. Acuff and colleagues argue that a behavioral economic model is best suited to both understanding and treating addictive behaviors. More specifically, they propose the use of a molar behavioral economic framework, in which behaviors are understood and interpreted over longer periods of time. That is, rather than focusing on individual choices and behaviors, their molar behavioral economic model suggests that greater insight into the process of addiction can be...