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A Critique of the Disease Model of Addiction

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A Critique of the Disease Model of Addiction University of Tennessee, Knoxville TRACE: Tennessee Research and Creative Exchange Doctoral Dissertations Graduate School 12-2003 A critique of the disease model of addiction Annette Mary Mendola Follow this and additional works at: https://trace.tennessee.edu/utk_graddiss Recommended Citation Mendola, Annette Mary, "A critique of the disease model of addiction. " PhD diss., University of Tennessee, 2003. https://trace.tennessee.edu/utk_graddiss/5156 This Dissertation is brought to you for free and open access by the Graduate School at TRACE: Tennessee Research and Creative Exchange. It has been accepted for inclusion in Doctoral Dissertations by an authorized administrator of TRACE: Tennessee Research and Creative Exchange. For more information, please contact [email protected]. To the Graduate Council: I am submitting herewith a dissertation written by Annette Mary Mendola entitled "A critique of the disease model of addiction." I have examined the final electronic copy of this dissertation for form and content and recommend that it be accepted in partial fulfillment of the equirr ements for the degree of Doctor of Philosophy, with a major in Philosophy. John Hardwig, Major Professor We have read this dissertation and recommend its acceptance: Accepted for the Council: Carolyn R. Hodges Vice Provost and Dean of the Graduate School (Original signatures are on file with official studentecor r ds.) A CRITIQUE OF THE DISEASE MODEL OF ADDICTION A Dissertation Presented for the Doctor of Philosophy Degree The University of Tennessee, Knoxville Annette M. Mendola December, 2003 Copyright © Annette M. Mendola, 2003 All rights reserved 11 Dedication This dissertation is dedicated to all who struggle with addiction, in solidarity and hope. lll Acknowledgements It has taken me a long time to complete this dissertation. Through it all, I had a fantastic committee: John Hardwig, Jim Bennett, Glenn Graber, and Bob Kronick. Their patience, enthusiasm, and expertise were vital to my finishingthis project. Special thanks to John forskillfully facilitating my authentic choices, and to Jim for his dedication from the verystart (and for giving me the space I needed to work). Other members of the Philosophy Department - past and present -- have energized me with their interest in this project over the years. I would especially like to thank Kathy Bohstedt, Phil Hamlin, Mike Lavin, Jim Nelson, Hilde Nelson, Frank Marsh, and Carolyn McCleod. Thanks goes to Ann Beardsley, Rebecca Loy, and Marie Horton for cheering me on and answering all my stupid computer questions. Additionally, Ron Hopson (formerly of the Department of Psychology) and Beth Haiken (formerly of the Department of History) were very helpful in the formative stages of my thinking about addiction. I would also like to thank Jaak Panksepp of the Department of Psychology at the University of Bowling Green, for his generous critique of my third chapter. Deep gratitude and affection goes to my friends and colleagues at Oswego Hospital Mental Health Division and Emergency Department, where I had my initial experiences with addiction. The same appreciation goes to the clients there, and to those who shared their experience, strength and hope at all the Twelve-Step meetings I've attended. Similarly, I am grateful to my mentors at V the Department of Philosophy at SUNY-College at Oswego, who encouraged me to pursue my interest in bioethics. Graduate school would not have been halfas much fun without my friends. I won't name names-you know who you are. However, I would like to express my gratitude especially to Karl Kreis, for all his support and encouragement. Finally, I offer my appreciation to my families. Much love and gratitude goes to the family that created me: my parents, Michael Mendola, Jr. and Kathy Bardo; my brother, Michael III, and my sister, Laura Mendola Lusk; my grandparents, aunts, uncles, and cousins. They have blessed me with the foundation for living authentically. Likewise, much love and gratitude goes to the familyI am creating: my husband, John Nolt, my daughter, Evora Mendola Kreis, and my stepchildren, Jenna and Ben Nolt. They give me the motivation to try to live authentically each day. VI Abstract While there is widespread disagreement as to just what addiction is, the two most popular models are the moral model (i.e., addiction is a moral failing) and the disease model (i.e., addiction is a kind of disease). Both of these models have serious problems, for theory and for practice. Furthermore, since competing models for addiction have differentimplications for treatment, law, social norms, and so on, it is important to find a single model for addiction that works in every arena. We need an account of addiction that avoids the problems of the disease models and the moral models. That is, it must be able to accurately describe the lived human experience of addiction, account for allthe major features of addiction, and accord them appropriate weight. Furthermore, it should point us toward treatment options that will work, social policies that make sense, and laws that are fair. Finally, the new model should reflect the complex nature of responsibility, and should avoid overly simplistic attributions of blame. This dissertation presents an alternative definition of addiction, one that is fundamentally different from both disease models and moral models of addiction. Rather than describing addiction as a moral, psychological, or physiological defect of the addict, this proposed model, herein called the existential model, describes addiction as a compulsive, inauthentic habit: a compulsive habit that the individual does not endorse. Compulsion and habit are frequently included in descriptions of addiction, but authenticity and addiction is relatively new. The existentialmodel rests on the idea that vii addiction is an inauthentic response to the experience of angst, or existential anxiety. These inauthentic responses to angst may begin as compulsions and become entrenched as habits, or begin as habits and become compulsive. In either case, these are addictions. There are implications of this model for theory and practice, as well as indications for further research. Perhaps the most interesting implication of this model concerns the importance of strengthening individuals' authenticity, both to protect against addiction and to recover from addiction. Vlll Table of Contents Chapter One: Philosophy andAddiction ................................................ 1 Chapter Two: TwoAnti-Disease Model Theorists: Fingaretteand Peele. 53 Chapter Three: The New Disease Model and Beyond........................... 107 Chapter Four: The Existential Model of Addiction............................... 149 Chapter Five: Implications of the Existential Model of Addiction......... 195 Bibliography....................................................................................... 215 Vita .................................................................................................... 223 lX Chapter One: Philosophy and Addiction Toward dipsomania there are many attitudes. To the theologian it is a sin; to the moralist a vice; to the lawyer a frequent cause of major crime; but to the student of medical science it is a disease. 1 When all you have is a hammer, everything looks like a nail.2 Like many topics in applied ethics, addiction is on our minds and in the news. Everyone has opinions about it, and nearly everyone knows someone who has struggled with it. The fact that some people regularly engage in drinking, gambling, or some other activity to the point that they endanger other, ostensibly more important desiderata like health, relationships and work arouses our scholarly interest, our desire to help, and our morbid fascination. Addicts can be infuriating to work with professionally and heartbreaking to know personally. Addiction can present difficult legal problems (should addicts be sentenced differently than non-addicts when an offense involves their addiction?) treatment issues (can we help addicts who don't want to be helped?} and public policydilemmas (how should doctors manage severe chronic pain when there is a risk that patients will sell their prescription narcotics to - or have them stolen by -- neighborhood addicts?) Because of the nature and significance of the debate, addiction has inspired a literature that is mind­ bogglingly large, diverse, and unwieldy. Clearly, this is a topic worthy of serious critical attention. 1 Yandell Henderson, Liquor: A Plea/or Dilution. (New York: Doubleday, Doran and Company, Inc. 1935) p. 124. Dipsomania is a Victorian term for alcoholism. 2 Anonymous The Oxford English Dictionary indicates that the term "addiction" first appears as a term used in Roman law: ad means to or toward and dicere means to say. To be addicted to something or someone was to be attached to it by decree. While initially this was a legal term, e.g. a tenant was "addicted" or bound to a piece of property by a lease, later it came to mean that one was bound to a practice, habit, or vice. Around this time, the word acquired the familiar negative connotation. Today, addiction is used colloquially to describe anything fromjust really liking something to the excessive, compulsive consumption of something harmful. More precise usage is harder to pin _down: competing models of addiction spar with one another and vie for universal acceptance. The most popular conception of addiction in the United States today is that it is a disease, but that description is by no means
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