xxAACP Newsletter, Volume 13, Number 3, Summer 1999
EDITOR'S COLUMN
The Dangers of Reductionism:
Illness and Volition
The stigma associated with mental illness and substance use disorders has a long history and has been largely responsible for the inadequate, discriminatory, and in many cases, dehumanizing treatment that persons suffering from these disorders have received by our society. In recent years, persons suffering from mental illness and their families have achieved some relief from this "mistreatment" with the discovery and dissemination of information regarding the biological underpinnings of these disorders by the medical community. The validity and importance of these discoveries have rarely been disputed within the medical community. On the contrary, in many cases psychiatrists have adopted a biologic perspective to the extent that they devalue the contributions of other factors in the psycho-social realm and the treatments associated with them. This "reductionism" point of view, while limited in its capacity to address the complex needs of clients who present with mental illness, has contributed to a gradual decrease in the shame associated with mental illness and an increase in the resources devoted to its treatment.
Unfortunately, similar progress has not been made on behalf of persons who suffer from addictive disorders. Substance dependence remains highly stigmatized and its status as an illness remains controversial even within our own profession. Even as the biologic foundations of addiction have been elucidated, rather than uniformly embracing these findings, many continue to refute their importance and portray persons with addictions as perpetrators rather than victims. This has been most evident in recent commentaries by Sally L. Satel, M.D. in Psychiatric Times and Psychiatric Services. In these publications Dr. Satel rightly attacks would be proponents of a biological reductionist model of addiction but erroneously proposes a "volitional" reductionist model in its place. Although this volitional model reluctantly acknowledges biologic factors contributing to addiction, it would deny it the status of other chronic relapsing illnesses, ignoring overwhelming evidence to the contrary. As with many other chronic diseases, addictions have clearly established genetic components, involve dysfunction of an organ system (alterations of neuronal function in the limbic system), have secondary effects on physiologic and/or emotional function (e.g., tolerance and withdrawal, substance induced mood disorders) and a fluctuating course marked by periods of quiescence and exacerbation. The volitional model would redefine these similarities as differences compatible with the accusatory posture that unavoidably follows from its premises. (It would have us believe that recovery is a matter of "will" and that the disability associated with it is not as "real" as that limiting the lives of persons with mental illness or respiratory disease). Periods of quiescence and exacerbation are presented as evidence of control when considering addictive disorders, but as lack of control when considering other illnesses such as epilepsy, diabetes or cancer.
These attempts to devalue the biologic underpinnings of addiction are emotionally stirring but logically flawed and would appear to be motivated by something other than science. Many of the concepts espoused by Dr. Satel and other proponents of a volitional model correctly point out the role of responsibility, context and motivation to recovery from addiction. They fail to see the applicability of these concepts to other chronic relapsing illnesses, however. Choice and behavior clearly influence the development, and course of addictive disorders just as they do with cardiovascular disease, diabetes, emphysema, cancer, and mental illness. Fear and hope unquestionably influence a substance using person’s capacity to engage in recovery oriented behaviors, but this too applies equally to persons who suffer from other chronic illnesses. Culture, exposure and stress contingencies play a significant role in determining behavior associated with drug use, but once again, they are frequently important variables in other illnesses. Proponents of this model correctly observe that persons with addictions cannot be passive patients in the recovery process, but any thinking contrary to this would be anachronistic in any field of medicine.
For practitioners who have engaged persons with addictive disorders the tragic nature of this illness is poignantly evident. As this disease progresses its victims gradually lose their sense of self; their concept of who they are. They lose their hopes, their dreams, their values, their relationships and eventually everything that they used to define themselves as a person. All that they have left is their enslavement to a drug. To suggest that anyone would choose such a fate is absurd, just as it is absurd to suggest that they can simply choose to end their suffering. The understanding that advanced substance dependence is, in fact, a chronic illness with significant biologic underpinnings in no way implies that medication should provide a complete cure, anymore than it does in illnesses like schizophrenia or arthritis. We know that recovery is a complex process and that many different interventions may be required before it is accomplished. Whatever illness we choose, this requires hard work, tenacity and some capacity to endure suffering.
The most disturbing aspect of these volitional views are not their inaccuracies, but the pejorative undertone that frequently accompanies them. Labeling persons with substance use disorders as instigators, as persons undeserving of our assistance, as suffering from an entity that is most responsive to criminal justice behavioral control measures indicates a fundamental misunderstanding of addiction. The classic confusion of bad behavior with a bad character has clearly been a counter-therapeutic social and professional response to this problem, and is often the result of unexamined counter transference. The fact that respected members of our profession continue to proselytize for this view of a person with a substance dependence should remind us how poorly we have educated ourselves about this illness, and how far we have to go before we have a consensus to support a more compassionate understanding of addiction. Until this occurs, substance use will continue to be a nagging and destructive force in our communities.
Wesley Sowers, MD
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