Is Substance Use the Treatment or the Disease?

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Editor’s Note: Most of us seem to believe that alcoholism is a kind of treatment: an attempt to resolve an underlying trauma or a “spiritual void” and not, initially at any rate, a “disease” of the brain. Is that correct? If not, why the emphasis, for example, on dealing with “character defects”?

This is an important article for those of us interested in The Practical Book, a book that will explore and share tools we find helpful in recovery.

We are now posting articles on Tuesdays and Thursdays, but not on Christmas or New Years eves. We will be back to posting potential chapters / articles for our new book project in the new year. Please consider writing for this very special new book! Information is available here: The Practical Book.


Is addiction a primary brain disease or a maladaptive response to something else? Is there always an “underlying issue” in addiction — an injury to be soothed or an emptiness to be filled? If maladaptive substance use is a response to other, more primary issues, does it tend to result from specific events, as in trauma, or is “the void” something more pervasive, like Freud’s “neurotic misery” or the “dizziness of freedom” of existentialism? A clinician’s view of these questions is central to his or her approach to treatment. Do we “attack the root” because a presumed underlying cause of addictive behavior must be understood before true recovery can occur? Or is the “underlying issue” construct really a red herring that engages therapists but is not in their clients’ best interests? Dr. Mark Schenker, a psychologist who has grappled with these questions for more than three decades, shares his thoughts below. What do you think? Please leave a comment after the article… Dr. Richard Juman


By Mark Schenker PhD
Originally posted on The Fix on December 17, 2015

In Psychoanalysis: The Impossible Profession, journalist Janet Malcolm presented a brief vignette which illustrated some basic differences between two different schools of therapy. What do you say when a patient comes in for a session and tells you that his father died? If you offer condolences, you may be robbing the patient of the opportunity to voice contrary feelings. (I remember once offering sympathy to a friend in that situation, who responded, “I’m not sorry. I hated the son-of-a bitch.”) However, if you take a dispassionate, analytic stance of saying nothing, or asking a neutral “How do you feel about it?” you risk being perceived as callous and unsympathetic. At the crux of this dilemma are two very different views of what is important in therapy: Is the healing of therapy based on a process of self-discovery and self-expression, or is it based on a “corrective emotional experience”? The answer to this question yields two radically different approaches to the therapeutic process.

I was reminded of this dilemma recently in a session with a young woman in early recovery from alcohol addiction. About a year ago, “Lois” spent 90 days in rehab, escaping a legal penalty, but she had continued to drink erratically and at times excessively after being discharged. After a serious blackout relapse, she returned to rehab and has now been sober a few months. She has been attending AA regularly, and will even report getting something out of the meetings. She describes a stronger motivation for sobriety and is taking Campral, which seems to be somewhat reducing the degree of her cravings. Lois has established a relationship with a young man who is himself newly in recovery, and while I don’t believe that early recovery is the ideal time to embark on a new romance, her relationship seems light-years better than those with the “drinking buddies” she had previously hooked up with.

The other night Lois spoke convincingly of her desire for sobriety and her diminished craving for alcohol. “But,” she added, ”even with my life going better, it still feels like something is missing.” To me, this comment, which I have heard many times before (albeit in different ways) opens up a view to one of the critical issues in addiction: what is the nature of this void? How do we interpret Bill Wilson’s description of his first drink: “That strange barrier that had existed between me and all men and women seemed to instantly go down.”?

To many in our field, this comment signifies a deep psychological or spiritual longing, a void which the use of alcohol or drugs seems to fill. As Richard Thompson sings in his brilliant (but morbid) “God Loves A Drunk”: “A drunk’s only trying to get free of his body/ and soar like an eagle way up there in heaven,”; This parallels Bill’s description of intoxication: “I belonged to the universe.” Different schools of therapy, as you might expect, construe the void differently. Early analytic thinkers described unresolved oral fixation, more recently others see unresolved trauma. Some view the pernicious influence of family dynamics, especially in those who grew up in alcoholic homes, leaving an empty heart. Others see a spiritual void, a lack of fellowship or “social interest,” which remains unfulfilled. I even remember reading a theory of alcoholism as a response to the unfulfillable expectations raised by a capitalist consumer culture.

It seems that an aspect of the belief systems among most addiction professionals, even if unarticulated, is the understanding that substance use and misuse is a response to another, more primary problem. There is a desire to probe the “underlying problem” which generated the addiction in the first place. Without healing the source wound, it is thought, the addiction is never resolved, and remains lurking around the edges of the addict’s life. From this perspective, once the addiction is resolved, the true underlying psychic dynamic emerges and must be wrestled with. Let’s call this the “underlying problem” approach.

For others, Lois’s comment signifies the void created by the loss of the alcohol or drug itself. It is familiar to hear from those in early recovery that they miss the comfort of their “best friend.” For these clients, the relationship with the substance has replaced healthy human relationships. A client once articulated to me that losing opiates was “like being permanently kicked out of the Garden of Eden.” As much as I could try to persuade her that her life was improving in numerous ways, for her, there was a core truth in the reality of this loss, a loss which needed to be honored and validated. In this scenario, then, the void is seen as a consequence of the addiction, not as an underlying cause. Could Bill’s experience describe the unique neurochemical effect that alcohol brought him? This can be labeled the “primary disorder” approach.

In this approach, much of the therapeutic effort is spent on addressing the client’s barriers to accepting and dealing with the addiction itself. Rather than searching for a presumed underlying cause of the addiction, clinical attention is paid to the defenses presented by the patient, the misunderstanding of the disorder, the displacement of responsibility for recovery and the subsequent development of sobriety and lifestyle skills. Harry Tiebout described the ego factors that make it difficult for individuals to accept their disorder as “defiance and grandiosity.” Is it necessary to explore the origins of these stances, or is it more important to come to an existential recognition of their role in blocking the path to recovery? Stephanie Brown’s empirical study of the process of recovery itself,Treating the Alcoholic, describes the recognition and acknowledgement of the loss of control inherent in addiction as the pivotal point of treatment and recovery, and an ongoing reassessment of one’s identity.

A Clinician's Guide

I believe that there are several reasons for the popularity of the “underlying problem” theory. One of these is historical: Functional psychological theory (e.g., “What function does this behavior serve?”) has dominated our thinking on all things psychological since the days of William James. The profound influence of psychoanalytic thinking on our culture is still felt, despite the decline of analytic practice. There is an appealing logic in the assumption that attacking the root will be more effective than the superficial manifestation. Perhaps the more powerful appeal of this approach, at least for the clinician, lies in its clinical excitement—it’s juicier, sexier, to be addressing an emotional childhood struggle than dealing with resistance (pardon my use of the word) to recovery. And, if we also incorporate 12-step approaches in our treatment, our role becomes a bit more peripheral to the healing process, again diminishing the clinician’s perception of his value.

I recognize that those we see in our clinical practices may not represent the full range of addictive disorders, almost by definition—if someone is able to “mature out” of their addiction, there is little reason to see a professional, and many if not most people who struggle with addiction eventually arrive at a safe relationship with their demons or become abstinent. I have come to view most addicted individuals who present to treatment as suffering from a primary disorder, based on physiological (so often genetic) risk factors. I may be in the minority of psychologists who view the search for underlying psychological phenomena as a distraction from the primary task of recognizing one’s disorder, achieving sobriety, maintaining sobriety and learning (or re-learning) to live a healthy, balanced life.

I also feel that this presumption of underlying disorder may needlessly pathologize our clientele, and is, in essence, a contradiction to the view that addiction is a primary disorder or disease. This perpetuates the feelings of shame and isolation which are ubiquitous in these individuals, and which keep them out of treatment. I have seen as many psychologically well-adjusted individuals who have lost control of their substance use as those who present horrific backstories, and these folks tend to stabilize with sobriety (granted, there’s a lot of reparative work that usually needs to happen, and some truly do have a secondary psychological problem).

It seems helpful to recall the concept of “functional autonomy,” the idea that a behavioral phenomenon may develop a life of its own independent of its origins. A saying heard in AA is that “when you have diarrhea, figuring out the cause will not stop the problem.” Another possibility, perhaps a more radical one, is that addiction may truly exist as a primary disorder of loss of control and physical dependence, independent of any other psychological factors. Although the proponents of “addiction is brain disease” philosophy may at times overstate their case, it may be that the oft-cited (and little-understood) “Disease Concept” of addiction may have literal truth. If so, it shifts the focus of our practice away from the search for root causes and unresolved emotional conflict, toward a here-and-now existential exploration of the barriers to engaging in a process of recovery, however the client may define that journey.


Mark Schenker, Ph.D. is a clinical psychologist with over 30 years experience, primarily in the field of addictive disorders. He is the author of A Clinician’s Guide To Twelve-Step Recovery (Norton, 2009) and the chapter “Addiction Treatment Settings” in the forthcoming APA Handbook of Clinical Psychology. He has presented nationally on substance use disorders and related topics. He is currently a member of the Board of the Society of Addiction Psychologists, a division of the APA. He has a private practice in Philadelphia, PA., with a focus on addiction, individual therapy and couples/family therapy. His website is here: Dr. Mark Schenker.


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Is Substance Use the Treatment or the Disease? — 16 Comments

  1. Certainly an article worth digesting by anyone hoping to better understand and help the suffering or even potential addict/alcoholic. After years of recovery as well as practice as a mental health and addictions specialist, I have no question about the variety of reasons, predispositions and processes at work in addictions and dependence. My mentor and adviser years ago in attempting to open our minds to emerging understandings and treatment options, said, “Addiction is a multivariate problem, and therefore needs a multivariate solution.” In my experience, no two persons have the exact same issues of physical or underlying emotional issues, but without first addressing and mastering the physical dependence, it is impossible to work on “underlying issues.” For many, replacing carbohydrate intake with sweets serves as a helpful step away from the primary “fix” that alcohol provides, thus enabling the individual to begin the other work. With mindful progress then on physical, mental and emotional issues, we develop increasing personal power, freedom and contentment with life. At least, that has been my observation and experience!

    • This is all well and good but the doctor’s terminology is troubling to me. He says that after going out and coming back to treatment the “craving” seemed to not be as strong. AA’s position is that we suffer from an “allergy of the body” coupled with a mental obsession. The “craving” is a direct result of touching alcohol to our lips and does NOT occur in the mind. The whole program is designed to relieve us of the mental obsession. Recovery is simply, identifying old thinking, breaking the cycle, and replacing it with new thinking.

  2. I do not buy into the disease concept – perhaps dis-ease. I much more believe alcoholism is a self imposed compulsion – that sorta looks like a disease. Don’t expect one can catch it by having a drunk cough on ya LOL – for me the disease concept excuses what one did to themself – I undid it 24 yrs ago.

  3. Being a recovering alcoholic myself, the meetings of A.A. and the disease model work for me…

    I have been abstinent for 11 years when nothing else would work. A lot of people I’ve met have suffered from trauma at times when they were vulnerable and perhaps lacking the emotional resources to deal with the trauma. A combination of the ‘talking cure’ and 12 step programmes seem to work the best, and should be made available to more people. Destigmatization is most important. Society would benefit in so many ways if resources were made available in these areas.

  4. It’s good that Mark Shenker, a clinical psychologist expresses reservations about the prevailing “psychogenic” model of alcoholism – the idea that alcoholism is merely a symptom of underlying psychological problems. But he then counterposes this to a “brain disease” model. Why just the brain? Alcoholism affects every organ and every cell in the body, including the pancreas, liver, stomach, etc.

    Alcoholism is a physical addiction to the drug, ethyl alcohol. It results from the continued intake of alcohol in a susceptible body, with the susceptibility being largely inherited. Alcoholism cannot be cured, but it can be arrested: through total, lifelong abstinence. A day at a time we stay away from the First Drink.

    Shenker might have mentioned James R. Milam, the foremost proponent of the “biogenic approach” (alcoholism is a physical addiction, which can be arrested by abstinence). I reviewed his two books in AA Beyond Belief: Under the Influence and Ending the Drug Addiction Pandemic by Dr. James Milam.

    Other authors advocating the biogenic model include Martin Nicolaus, Empowering Your Sober Self). and Irving Maltzman (articles on-line).

    Recovering alcoholics may be helped by psychotherapy – or harmed by psychotherapy. What they do need is to get their health back, which means good nutrition, exercise, and no cigarettes. They need the moral support and guidance of other people, which for most of us means AA.

    • John, the biogenic model which Martin Niklaus talks about was basically developed by Dr Sinclair, and his associates. And while I agree that lifelong abstinence is desirable, please read about the Sinclair method/naltrexone (aabeyondbelief a few weeks ago). The problem with craving is it is so damn persistent, and if it can be taken away with pharmaceutical extinction, let’s consider promoting that. Same if we can ease early withdrawal symptoms.
      “Science may one day accomplish this, but it hasn’t done so yet” (1939)

      • I agree, any non addictive method of eliminating alcoholic craving would be a good thing. Hopefully, we can learn from scientific answers as time goes by!

      • Let us stop touting the “Sinclair Method”, which is a direct attack on the true AA, the AA that works: the AA of total abstinence under the 24 Hour Plan together with the Fellowship. Abstinence is not merely “desirable” — it means the difference between life and death for true alcoholics. Through many decades of experience we know that alcoholics who have crossed the “invisible line” can never again drink safely: “You can’t turn a pickle back into a cucumber.”

        It was not Sinclair, but James R. Milam, who developed and analyzed the two competing models: the prevailing “psychogenic” model (alcoholism is just a symptom of psychological problems) and his own “biogenic” model (alcoholism is a physical addiction).

        The great danger of the “Sinclair Method” is that it will delude alcoholics into experimenting with “moderate drinking” — an experiment which will end in death for many or most of them. Let there be no doubt what Sinclair is advocating; he himself states: “The Sinclair Method is simply taking an opioid antagonist before drinking.”

        Let’s not be fooled by Big Pharma’s propaganda. Naltrexone, a drug with its own toxicities, will not allow alcoholics to drink safely. We don’t need this pill. It is not necessary to drink. Millions of recovering alcoholics, through abstinence, are leading good lives in the Fellowship of AA.

        If a craving for alcohol persists, long after the last drink, this is the “protracted withdrawal syndrome”, which discussed by James R. Milan in his book, Under the Influence. Treatment consists mainly of diet. No sugar.

        Life-j, not only did I read your article in AA Beyond Belief, I commented on it.

    • Having a body that reacts very differently to different forms of alcohol, it was pretty clear to me that there is some pure physiology, including genetics, involved. Yet trying to harness ‘why’ I was still taking the 50/50 risk of use (euphoria/disaster) of an allergen is certainly a mental health issue. Why would I do that to myself?

      What is the reward worth that risk? Until I crash, I get a happy high and it’s sublime and delightful. Talking to private pilots, extreme skiers and climbers, I hear the same thing. Their doctors and families twist in the wind too.

      Maybe my brain just gets a lot higher with my preferred drink, thus I got a greater reward, “worth” the greater risks? I could certainly take or leave hard drinks. (Who knows? Nobody answers questions at a meeting – they just get their own stuff off their chests and ignore it.) I know for a fact that my nose is much different than most peoples’. When I go to a public rose garden, I can spot the other “noses” visiting. I’m not looking forward to old age when that diminishes markedly. I’ve already had to give up the exquisite pleasures of high heels, dammit. And now the happy bubbles too.

      So how to fill that hole left behind by champagne, that “plugging in to the universality”? I have to retrain the circuits in my brain with other behaviors, pleasures and best of all: GOALS. This is a physiological process undertaken for a psychological reason: I want to be happy!

      For me, it’s a hybrid. I know I have a weird chemical problem with alcohol. I am getting medical treatment that happens to be psychological, not pills. There isn’t contradiction in that. We are whole beings. The mind defines us as a species.

  5. I have been working on this for the past three years. I have a book coming out from Palgrave Macmillan in March (can be pre-ordered on Amazon.com now), called Addiction: A Philosophical Perspective, which addresses this issue at length. It was important to me to write it, because everyone in my birth family died of addiction. My son, on the other hand, got past his bad years and is now living sober and free. We need to understand the complexities of the issue.

  6. This is really a good article, and deserves to be spread around. what I would add to it is that we need to get away from binary thinking. Most complicated things in life are not either / or. I would lean toward that there are two, three, four… causes of alcoholism, and depending on invividual circumstances one or more of these play a role. Without a doubt Dr Sinclair’s finding that alcohol consumption releases endorphines which attach to opioid receptors and create a pleasure that overrides all else, and that only pharmacological extinction whereby those opioid receptors are blocked, say, by something like naltrexone – in other words that alcoholism is something akin to a pavlovian learned response which needs to be unlearned – is a primary factor in alcoholism. Whatever goes on in the brain that makes alcohol *work* is primary.

    And I can imagine that one can be addicted in this manner without much other cause, but I would think it unlikely in most cases. There are the entirely well adjusted folks for whom drinking simply is an unimportant part of their lifestyle for whom it somehow takes over, and I have met some of those in AA, but I do think that in most cases there is an underlying problem. Maybe I’m just thinking this because in my own case there is. We all want to be part of “most cases” in order to be less alone. But I was a mess before I started drinking, and alcohol was the solution.

    So I see at least two causes.

    I think the reason we can’t get anywhere with it is that we in AA have focused on abstinence as the only solution. And it works for those of us who either are strong-willed – or the opposite, as Bill Wilson would have it – have a pipeline of grace from god. But abstinence may be as much of a problem as a solution, it takes a long time for it to take effect. It worked well for me with both alcohol and tobacco, but now, sober many years I’m struggling with sweets. I’m relatively sane, clearminded, and healthy, and so able to observe this in a much more close way than I could in my early sober days. I have not had any cookies, or practically any other carbohydrates for a month now. I can tell I feel so much better, my gut, my joints, my mood, all better, there is no reason on earth why I should not continue with this, and yet, there are days when I’m jonesing so bad for a cookie – I’m even staying away from the primary AA meeting in our town, because it is a sweets orgy.

    I’m believing more and more that unless we address both the biochemical issues of craving, and the underlying emotional causes we won’t have much success. At the present time with regards to the sweets problem, I am not jonesing because of my bad childhood, I am a fairly well adjusted person by now, but I also have to recognize that I have been working on those childhood issues for 25 years both inside AA and out. But I think in my drinking days and early recovery they played a big part. I was an existential mess. I think of it mostly as emotional, but maybe there is a ‘spiritual’ component too? I would tend to downplay that one though. I think it is mostly a result of Bill Wilson’s evangelism that we put so much emphasis on that one, and for most of us it is not major. I could see situations where an alcoholic has done a lot of bad things in their life, killed people, stuff like that that the psychological “debts” are so great that it makes sense to think of it as a qualitative change over into being a spriritual problem, but for most ordinary assholes like myself I don’t see it as a big issue.

    But what is rarely addressed within AA, because it was a program made for type A personalities, is the abuse that so many of us went through as children, emotional, sexual, religious, the pain of all that, how beaten down we got to be as a result, the way alcohol took it away, and let us participate in life as real human beings, at least for 20 minutes, can not be dealt with simply by abstaining from alcohol, nor with pharmacological extinction from craving with naltrexone, we need to recognize that a multifaceted approach is necessary in all but a few cases.

    • I can sympathise with the sweets problem. Sugar is a very addictive substance. In my case I’ve known for 47 years that I have hypoglycemia and must avoid sweets entirely and most carbohydrates as much as possible. When I do, I’m healthier and happier. However, I occasionally get a craving for a hot fudge sunday, and about every five years will yield to that craving.

      With alcohol it’s different. As a low-bottom drunk, I know for a certainty that picking up the First Drink would be signing my death warrant.

      I hope that you are not contemplating or experimenting with “moderate drinking”. For a true alcoholic, “moderate drinking” is not a viable option. There will never be a cure, pharmaceutical or otherwise, for alcoholism. We can lead good lives by arresting our addiction — through total and life-long abstinence.

      AA — like LifeRing and S.O.S. — is based on abstinence. This is essential, not optional (like the Steps). How could an AA meeting give out chips to “moderate drinkers”?

      • John, no I’m not contemplating experimenting with moderate drinking, nor am I advocating it as an alternative to abstinent sobriety. But I am advocating it as an alternative to continued out of control drinking.

        If the Sinclair method can get 40% to stop drinking altogether, that is a better outcome than we can present in AA. Does not mean that I’m not still advocating AA, but it appears that with the Sinclair method we can a) help a person stop drinking without the DTs and other acute withdrawal symptoms which are otherwise often enough to keep a person drinking, and b) apparently extinguish the craving pharmacologically which otherwise is likely to rage on for years for some. Then once that is accomplished and a person is stably sober (and preferably even concurrently) I would recommend AA and any other work on the underlying problem. This then constitutes the 40% we can help actually get sober, and do it better than with AA alone. As for the other 40% that we, with the sinclair method, can only help cut back on their drinking, well, we’d all like them to quit, but I see no greater harm in their merely cutting back than in their not doing anything at all. I know this goes against the protestant philosophy of AA of complete defeat. I like many other aspects of AA, but that is one I’m not buying. We don’t need to drive those people to complete defeat by taking the option of cutting back away from them, if we can, by avoiding TSM. Our (at least my) purpose in life is not to promote and build AA into a grand(iose) movement, our purpose is to save fellow alcoholics from a miserable life and/or an awful death by any means possible. And while I would certainly focus on the 40% that really want sobriety, I would still think of the other 40 as a bonus, it almost feels like you think of them as collateral damage to AA.

  7. Fascinating article — thanks Roger.

    It reminds me of a YouTube presentation I saw yesterday by Martin Nicolaus, the founder of LifeRing: LifeRing’s Martin Nicolaus on the Medical Model of Addiction. ().

    In his fascinating talk to mental health professionals in Vancouver, BC, he posits that addiction, to include alcoholism, is truly a disease, but that it needs to be radically updated from the concepts and descriptions that most mental health providers of treatment today still follow, which are the original concepts of alcoholism being a “disease,” as they were formulated and articulated in the Big Book of Alcoholics Anonymous, which was written between 1937 and 1939.

    We have a lot more information about the disorder of addiction, to include alcoholism, then was known in the first four decades of the last century. Medicine and society need, he suggests, to update their database about the Disease Concept of addiction, so that it is not a binary of either/or but incorporates elements of both/and…