Is Substance Use the Treatment or the Disease?

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”?

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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.

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, primarily in the field of addictive disorders. He is the author of A Clinician’s Guide To Twelve-Step Recovery.

His website is here: Dr. Mark Schenker.