The slogan at this website is “addiction is not a disease, it is a choice“, and that pisses a lot of people off. They read all sorts of things into this message that I promise I do not believe nor mean to convey. For example, they often assume that those who say addiction is a choice are saying that it takes willpower and strength to quit. I do not say or believe that – I made this point back in 2011 – and I’ve gone to great lengths to continue to explain why such concepts are so out of place in the debate about addiction. Furthermore, such a position isn’t even logically implied by the simple identification of addictive behavior as chosen behavior. It’s also common for choice model supporters to be accused of calling people “bad” or “immoral” when they express the belief that addiction is a freely chosen state rather than a disease state. It is assumed that the notion of choice automatically bestows shame upon people – when in fact the opposite is true – the disease model which makes addiction into a stable trait actually pegs people as inherently bad, and inculcates shame. Again, I don’t say that substance users are bad or immoral, nor is a judgment of badness or immorality logically necessitated when one states that “addiction” represents freely chosen thoughts and behaviors rather than symptoms of a disease.
As of late, the one thing people are adding to this message that really rubs me the wrong way is the idea that by “choice” I necessarily mean something that all people will do in an instant the moment they realize their substance use is causing trouble in their lives. I do not, by any stretch of the imagination mean to communicate this. That is some people’s idea of what it means for something to be a matter of choice – but it is not my understanding. Choices are not all simple, and I don’t know why anyone would think that they are.
I understand that choices come in all shapes and sizes, and 99% of you reading this probably understand it too. For instance – want that chicken sandwich on white or wheat? That’s a pretty simplistic and quick choice to make. What tie shall I wear today? What should I have to drink, Coke or Pepsi? These are relatively simple, one-step choices. A lifetime of developing preferences probably figures into them, but these are simple matters on which to make a call and to carry out. I choose a Pepsi – ok, unscrew the cap and pour it in a glass, then drink. We’re done. Choice made and executed. But not all choices are so simple.
However, many disease model advocates act as if all choices are that simple. They act as if those of us who say that addiction is a choice would turn to the person who has a massive substance use habit and say: “agree to quit now, and so it shall be – goodbye!” We understand that choices to make big life changes can’t be commanded by others, and that much deliberation goes into arriving at such choices, and into carrying out such choices.
Choices are often very complex processes. But again, some disease model supporters don’t seem to understand this possibility when they argue against the choice model. For example, let’s look at a few quotes from a commenter on my page about the brain disease model of addiction. This commenter was very angry with me for calling addiction a choice:
Recovery is a process….its NOT A SWITCH (CHOICE) YOU FLIP.
Right there you can see he has an extremely narrow concept of choice. He looks at making a choice like flipping a switch. It certainly can be and is like that in many cases, but not nearly all cases. Look at some other ways he expresses this:
If you are able to just all of the sudden “say no” and quit cold turkey….good for you. But it is not that easy for most. If it was simply as easy as just saying “NO”…..millions and millions and millions would be able to quit after the first trauma, hardship or downfall etc… and there would be no need for “TREATMENT CENTERS”.
He also seems to assume that choice happen automatically upon facing some negative consequences – and if they don’t do so, then this is evidence that they can’t? The assumptions here are too many to deal with. Here he goes again:
IT’S A PROCESS SLATE…..ITS A PROCESS….I REPEAT….ITS A PROCESS!!!! You can’t tell “EVERYONE” TO EMPLOY “IMMEDIATELY” WHAT TOOK YOU 5 YEARS (ALLEGEDLY) TO DISCOVER AND APPLY. That’s the whole problem with your reasoning. This is why the term “disease” is used. It’s used because a person is “AFFLICTED” and many aspects of their life have to go through a transformation. And in most cases…(dare I even say YOU) it takes TIME and treatment. You didn’t simply make the “choice” to stop and move on with your life did you?
This last one is really crazy, because he’s using the fact that it took time to change as evidence that the change wasn’t freely chosen. That’s just a non-sequitur. He’s referring to my personal history with substance use problems, and he’s partially correct – I didn’t simply make the choice to stop and move on with my life… for five years. Then I did finally make the choice, when I finally believed that I could be happier without heavy substance use. I chose to think about many things differently at that point, but it was a process getting there. I’m not sure why this would disqualify it as a choice? What about people who toy with the idea of moving to a new town, getting a new job, or ending a relationship. These are big decisions that can drag on for years as a person goes through a process of discovering that these are the choices they really want to finally make.
Would you agree that becoming a doctor is a choice? Would you also agree that it doesn’t happen overnight? You obviously don’t choose to be a doctor, snap your fingers, and wake up in the morning with a stethoscope around your neck and your own private practice at which you’ll be seeing patients. But it is a choice. You don’t just fall into it. You don’t become a doctor by accident. You have to believe that becoming a doctor would be a good fulfilling life choice for you; you have to choose to believe that you can do it; you then have to go get the proper schooling and dedicate yourself to the work; and then you have to get licensed and find employment. It doesn’t happen in an instant – it takes many deliberate acts, both mentally and physically to become a doctor. Yet still, the overall journey from non-doctor to doctor would be understood as something that someone either chooses for themselves and to follow through with or not.
Likewise, if you had become a doctor, but you were thinking of moving more into research, or maybe you wanted to do something altogether different or to retire, then these choices would be processes too. Most notably, they may take a lot of time and deliberation, and you may go through great bouts of fear while choosing to leave your current position. What will it be like? Will you fail at your new endeavor? Should you just stay where you are? These are tough issues to sort out mentally, but they’re all part of making the choice to leave that position. There is a turning point where the choice is finally crystalized and fully made – but there may have been years of thought that brought you to that final moment. It was a process, but this doesn’t change the fact that it was a choice.
What about making a change in a romantic relationship – like a breakup or divorce. You may go through years of disappointment with a partner, they don’t respect you enough, or they may cheat on you, or they just don’t have goals that work with your goals. You keep thinking about it, but you don’t pull the trigger and break it off. Or maybe you do break it off, then you find yourself lonely and afraid to move on, so you decide to rekindle the unsatisfying relationship. It’s a choice to be in the relationship, and it’s a choice to leave the relationship. Not everyone leaves at the first sign of trouble – it isn’t instantaneous – and not everyone sticks to their choice to break up – many subsequently choose to get back together. But that doesn’t change the fact that these are choices. Nor, I should add, does the fact that some people choose to stay in horrible relationships somehow prove that people can’t choose to leave relationships. Yet somehow, we think that the fact that some people choose to continue destructive patterns of substance use proves that substance use is not a choice. Think again. Choices are complex. Not all choices are equal. Not all choices are instantaneous. People can make choices that look pretty bad to an outsider, or in hindsight – but that doesn’t change their status as freely chosen thoughts and behaviors.
“Addiction is a choice”
What I mean when I say that “addiction is a choice” is that people always have the free will to use substances or not, and that they have the free will to think in ways that create a strong desire for heavy substance use, or they can choose to think in ways that do not create a strong desire for substance use.
I do not mean to send the message that I think everyone who has a problem with drug and alcohol use says things akin to “when I grow up I wanna be a junkie.” Yet, it’s apparent to me that some deluded people actually think this is what I mean when I say that addiction is a choice – like that old public service announcement:
While some people have told me they admired older drug users and wanted to be the cool tough guy drug users, and in fact did come eerily close to a childhood moment of thinking “when I grow up I wanna be a junkie”, this is still thankfully an extremely rare phenomenon as far as I know. So I think it’s possible that people choose addiction in that way, but this is not what I mean when I say addiction is a choice.
I think, like the PSA above suggested, that people get into “addiction” by accident, through a bunch of choices. They start using drugs or alcohol; they start to think it’s the only way for them to have fun, or to deal with stress, or what have you; and many other thoughts and beliefs come to bear – and then people start feeling as if they need drugs and alcohol. So it’s not deliberate “I wanna be a junkie” choosing, but then again, being a junkie or being “addicted” are the wrong ways to look at this anyway. I use the word “addiction” as a shorthand – because that’s what everyone calls substance use problems, but I don’t think anyone is addicted in the sense of losing control, nor do I think then that anyone is really an “addict” or “alcoholic” even though I use these terms at times. But people get into states where they do feel stuck using, they feel stuck wanting to use. They’ve made the choices to use, they’ve made the choice to believe that substances are the best way to serve their various needs, etc. They are in charge of all of these beliefs, and can dismiss them. They can choose to stay in this position, or they can choose to start thinking differently and get out of this position. In much the same way as someone may slowly come to feel inseparable from a romantic partner, but can bring themselves around to choosing to leave them if they suspect they’d be better off with a change.
Getting to a place where you confidently and happily choose to end a problematic substance use habit is a process. Only you can choose the thoughts that get you there. Only you can choose to let go of the thoughts that continue to fuel your desire for heavy substance use. It’s a choice. You’re in charge of the process. Please don’t distract yourself from this truth by getting caught up in the illogical notion that all choices are fully rational or are automatically made instantly – if this were the case, then they wouldn’t be choices! Choices are complex, often ugly, and often irrational. Many suboptimal choices are often made in the process of finding one’s best option in a given matter. Choices come in all shapes and sizes.
I leave you with a few of my favorite quotes to meditate on. Bastiat, the economic philosopher, and thus student of human motivation said:
No conviction makes so lasting an impression on the mind as that which it works out for itself.
And Pascal, the great french mathematician and philosopher said:
All men seek happiness. This is without exception. Whatever different means they employ, they all tend to this end. The cause of some going to war, and of others avoiding it, is the same desire in both, attended with different views. The will never takes the least step but to this object. This is the motive of every action of every man, even of those who hang themselves.
It’s not enough to simply run from the consequences of substance use. If you keep feeling the urge to do it, it’s because you believe it’s your best feasible option at having a happy existence. But if you know something is upsetting about the depth of your desire for substance use and you want to change – then you, and only you, must choose to change that desire by choosing new thoughts that lead to a new evaluation of your options.
Wtf?! There’s ALOT of people dying out there from addiction? And it doesn’t matter if it’s a choice or a disease…THESE PEOPLE ARE DYING AND IN NEED OF YOUR AND MY HELP! What does this non sense have to with anything? Maybe if people like you would spend more time trying to be kind and reaching out to help instead of wasting time posting shit like this to get attention? Maybe more people would live maybe they would change there lives and maybe less would die….ever think about that?
Did you ever think of the fact that if you understand the cause of a problem then you will better understand how to solve that problem?
By definition, everyone who comes here and comments about the disease v choice debate obviously cares about it. Otherwise, they would move along to another web page quickly and not bother to comment.
I take it you are in the field of helping people with substance use problems. Have you not noticed that when people go into rehabs they are browbeaten to death about “admitting they have a disease” called addiction? Have you not noticed that if they won’t agree to see their behavior as being caused by a disease, then they will be told that they are in denial, a symptom of the disease of addiction? Have you not noticed that this is one of the central issues people face when they go for help?
Frankly, I’m a little sick of these incredulous “who cares” comments – especially when they come from people within the recovery culture. Who cares? ASK THE PEOPLE LEADING MEETINGS AND RUNNING TREATMENT PROGRAMS.
-Steven Slate
Thanks for your site. I think you make a great point about choices and addiction. My son was in a high cost and famous rehab center and a counselor pushed my son into trying to say he was powerless. My son said he wasn’t powerless and it was a choice and got into an argument with the counselor and words were exchanged. My son was actually kicked out of the program for in effect disagreeing with the counselor, even though he wanted to continue in the program. He immediately relapsed the night he was released. It shows that these programs don’t just recommend the 12 steps. They demand them. Alternative interpretations of powerlessness are not allowed, and if you disagree you are told you are in denial. It is a shame that even the most expensive programs rely on 12 steps and 12 step evangelicals as the primary method of counseling. I have nothing against the 12 steps. In fact it saved the life of two of my cousins. For some it is the answer and more power to them. But for others like my son, the steps don’t ring true and other ways should be allowed.
I also have a question. To me there seems to be a difference between substance abuse and addiction. Addiction being the point where brain chemistry has changed to the point where stopping using leads to extreme withdrawal symptoms. At that point going cold turkey can be deadly and medical detox may be the only logical alternative. I would guess most addicts would know they have that choice, but if they don’t then they are stuck. Do you distinguish between substance abuse and addiction (meaning brain chemistry changes leading to extreme or even fatal withdrawal symptoms if you try to stop using) and how does that affect the choice vs addiction question.
Thanks again for your site.
Did you ever think of the fact that if you understand the cause of a problem then you will better understand how to solve that problem?
I second that! I cannot express the resentment I hold toward the rehab industry and AA for allowing alcoholism to be labeled a disease among other deceptions. No disrespect Jamie, but it does matter rather one believes it’s a disease or a choice. In 1980, at the age of 20, I quit drinking. I had been abusing alcohol for four years and I came to a point where I said enough is enough. I knew nothing about AA and I certainly didn’t know that alcoholism had been labeled a disease. I held myself accountable for my actions and since my life was definitely on the wrong track I made the decision to quit. I didn’t celebrate a sober date, don’t remember when it was and don’t care, it was my past. I didn’t sit in AA meetings and talk about recovery as I had recovered. For 30 years I did not drink and contrary to what AA fanatics will tell you, I did not spend 30 years as a “Dry Drunk” and guess what, I also didn’t see “Jails, Institutions, and death.” Instead I married, raised two wonderful sons, and for a very long period, enjoyed life and seldom gave alcohol a second thought. Because alcohol in my mind was a choice, I did not believe I was powerless over alcohol, I asked God for guidance, and quit with his help and my own willpower. Thirty years later I experienced a series of tragedies in my life all within a period of one year. I fell off a ladder and was badly injured and required surgeries and was in constant pain, I lost four loved ones, including my Dad, and my 29 year marriage ended in divorce. Needless to say, I went through a period of deep depression and after I stopped taking the hydrocodone for pain, which I had to take for months, I decided to drink again as a means of escape. This continued for 11 months and I managed to nearly drink myself to death during that period. I decided to get my act together and once again I quit. That’s when the nightmare began! I experienced severe withdrawals and found myself in the hospital. My doctor, counselor, and my brother, who has bought into AA, all talked me into rehab. I only agreed because I wanted to safely withdrawal and I had no idea that rehab was basically indoctrination into the world of AA. Following 5 days of detox I sat in my first meeting and one of the first things they had me do was read the 12 Steps. For the life of me I couldn’t get past Step 1. My initial reaction was, BS, I’m not powerless, this is nonsense, get me out of here! Immediately following class I spoke with my counselor and informed her this was not for me. She informed me that if I left it would be against medical advice and I would be responsible for the payment of the five days I spent in detox, which was already in the thousands. Basically I had little choice, I stayed and the brainwashing began. Not once when I was in rehab was my severe depression addressed, which is precisely why I was drinking. As Steven stated if you understand the cause of a problem you will better understand how to solve that problem. Sure would have been nice if they would have taken the time with the thousands of dollars my insurance was charged to have looked into what was causing me to drink. It wasn’t a disease, I was freakin depressed out of my mind. Twenty eight days later I left rehab, brainwashed, and just as depressed as I was the day I entered. I say brainwashed because by week four they actually had me believing this “Disease Theory,” which means I also accepted Step 1, Big Mistake! I spent the next eleven months in daily AA meetings where I was constantly reminded of alcohol, which actually made me want to drink and I did on a few occasions, ironically right after meetings. I found the meetings depressing, just what a depressed person needs. I became even more depressed when I couldn’t find work. I opened up to a few ladies in the group about my problems and received the following: “Are you reading your Big Book, working your steps, attending meetings daily, and “oh my, are you keeping secrets?” “You know you can’t receive the miracle until you work the program right!” What a support team, get this for the first time in my life during those eleven months I saw institutions, not once, not twice, but three times. The third time was a charm. I won’t go into what happened, but I will just say it was the last thing I needed. I’d had it! I got wasted and when I did I took some pills and I’m fortunate to be alive today. By this time I was beginning to question the program because I was reading the Big Book real carefully and I realized it conflicted with my Christian beliefs. After my 3rd trip to an institution I decided to take a much closer look at AA. I wanted to know more about its founders, what they believed, who they got their ideas from, and what those people believed. What I discovered horrified me! As far as I’m concerned, I had unknowingly joined a cult. I can assure you, I left. Jaimie, there is not just people dying of addiction out there. Look at the suicide rate of AA members, I was almost one of their statistics and get this, one of my fellow members was there for the same reason as me on the third go round, so at least the third time I had some company. How about those who are raped, children who are molested, and even those who are killed in the program because our courts and AA seem to think sending dangerous criminals without telling the rest of us into the rooms is acceptable. Tell me why did I have to go to a computer to find that out, why wasn’t my depression addressed in rehab, why wasn’t I told that rehab would revolve around AA, why was I brainwashed, why was I fed lies, why were the secrets of the founders kept from me, I could go on. Jamie if you are a substance abuse counselor for a 12-step program you may want to spend a little less time visiting sites that your opposed to and a little more time researching the facts. AA would have you believe you will die without them, sounds like a cult tactic to me, but the truth is I nearly died with their help. I’ve gone back to the way I did things in 1980 it seemed to work much better for me and just think if I don’t pick up for another 30 years, I’ll be 83 when do. So be it! Today I have a job I love, my depression has passed, I’m spending my free time with hobbies instead of AA meetings, and living my life again. AA makes it appear that they are the only solution, for some that may work, but for many like myself, it’s not the best solution and I personally wish the rehab industry would offer a lot more facilities that are not 12-stepped based.
I responded to another thread slightly negatively and felt compelled to read more on your website in order to facilitate my understanding of your site. I think my disagreement comes down largely to semantics which isn’t a true disagreement. I would also like to commend you for utilizing your experience to help others. Some of the most powerful “moments of clarity” and change have come from someone who had walked successfully out of the woods and then shared with me the constructive things they did to become better. Addiction is NOT a disease if you consider the textbook definition. But it sure does feel and look like one. The only thing I will add is that it is important to validate the folks taking the time to explore this topic with well written arguments. (not the ones losing their mind in a ridiculous way and insulting you, obviously) A true conversation invites and encourages understanding – not necessarily agreement. One of my favorite sayings is: “sometimes it is better to understand than to be understood”. I understand most of all that those of us who are on the other side are so very lucky.
I am in the process of ending an unhealthy relationship with alcohol that has been in place, in varying forms, for 20 years.
Basically, I was using it to escape from some of the more intense symptoms of “bipolar disorder”. That is in quotes because I have some ideas about the diagnosis and treatment of disordered moods and thought, but that is off-topic and I won’t regress further.
In any case, I was experiencing a bad bout of disordered mood, and used alcohol too close to a psychiatrist visit. I walked in drunk and begging her to fix my medications, essentially. She insisted that I volunteer for their clinic’s Intensive Outpatient Program (IOP). I made it clear that I was unwilling to follow a twelve step model (because of the “higher power” problem I would encounter being an anti-theist). She said it was not a 12 step program, and I voluntarily started.
In this IOP, the first problem I encountered was the issue of perceived powerlessness. How can someone possibly recover their lives if they don’t think they have the power to do it? They have just indoctrinated a roomful of vulnerable people into thinking they would eternally be victims! That seems very counterintuitive to me. I think that the only way to succeed at anything is believing you are powerful enough to do so. When I say power, I don’t mean some imaginary force that will magically deliver you to better places. I mean simply the power to determine your future. As you would put it, to make your own choices.
After spinning my wheels listening to people talk about avoidance techniques and stress-reduction, I felt these things mirrored what, in other situations, is the exact opposite of the most useful thing to do. They were telling us to run away from our problems. It is my experience in life, the more you run away from a problem, the more doggedly it pursues you until you face it with an actual solution.
So I hopped on the net and started looking for solutions.
I found a study that extrapolated on the original “addiction model” rat study that indicated that the rat in the box with a water bottle and a heroin-laced water bottle will exclusively return to the heroin-laced bottle until he killed himself. The second study, the one I came upon, asked what would happen to heroin rat if you took him out of the box and put him in a need-fulfilling rat park with other rats and rat-pleasing activities with the same water bottles? The rat park rats rarely returned to their heroin bottles, and never regularly. From this, I took the idea that if I we make our lives pleasing, we will not feel a need for our substances of choice.
Now I have read a lot of your site. I have to say that I have some semantic and logic-execution disagreements, but conceptually what you have to say is the most sensible and rational thing I’ve found on the Web. It is one of the integral puzzle pieces I need to form my view on substance over-use and how to step away from it.
What I understand is that an heavy substance use is a behavioral adaptation to an unfulfilling situation. People who use substances heavily are doing so to increase their net happiness. That adaptation has become maladaptive, and the person who wants to stop heavily using their substance must make choices to seek happiness through healthier means, like the rats did on an instinctual level. This makes sense.
I just spent 5 weeks on a high dose of hydrocodone, post-surgery. I went through a week of nightmarish withdrawal when I stopped taking it because the pain became manageable with Tylenol. I did not seek more, I had a half-bottle sitting next to my bed. I did not see it as an Avenue to happiness. Quite the contrary, I saw how awful it was for the pill users in my IOP, and decided it was a horrible idea to invite those kinds of problems into my life. I made a choice. Everything you do is a choice.
Now, the hard part. How do I take this approach to my therapist and group? I am not generally one to have a good grasp of a situation and keep it quiet, nor am I one to pretend I buy into something I don’t. Given the almost religious attitude of the psychological community toward the addiction model, though, I am not sure if it is in my better interest to do so. What is your assessment of this?
Also, there is an attitude amongst the psych community and the medical community at large that if you are an “addict” you must never be prescribed any of the many medically useful medications that may lend themselves to misuse, because as an addict, you will automatically fall into addiction with anything. In addition to this, Doctors cease to take any reported symptom seriously, not just those that are treated with aforementioned medications. This is part of the hazard that the stigma of the addiction model presents. How does one address the medical stigma of an addiction diagnosis?
Thank you for your well-conceived site. I look forward to your answers.
“…he’s using the fact that it took time to change as evidence that the change wasn’t freely chosen.” Steve, I believe this is one of your best articles yet! You pinpointed some common misconceptions that I have been dealing with for more than 2 decades! I had a conversation with someone the other day about the concept of food addiction. She’s considering getting bariatric surgery for weight loss and has been reading a lot about food addiction. I was struck by the fact that treatment for addiction is all based in abstinence. People who are addicted are said to be powerless and unable to moderate their behaviors with respect to their addiction. And of course their addiction is not a choice…well in the case of food, this certainly gets a little sticky (no pun intended!) Clearly no one can remain abstinent from food. They must, in fact, learn to moderate their behavior and change their relationship with food. I can’t begin to tell you the extreme danger people are in after they get a gastric bypass if they believe they are “addicted” to food and therefore are powerless over it and unable to moderate their eating habits. Choosing to make the effort to change a long held eating habit and the way you think about food is also a process — but like everything else one that is freely chosen. Whether a person gets surgery or not, they will not be successful without believing (knowing) they are able to freely choose their behavior with respect to food.
‘thinking “when I grow up I wanna be a junkie”, this is still thankfully an extremely rare phenomenon as far as I know.’
I have no data on this, but I do know that some youths romanticize suicide. Romanticizing “addiction” seems like taking not one, but several steps back from that kind of thing.
Then there’s the fact that, like a recent study has shown, two thirds of millenials (in the UK, at least) are “bored of life” ( http://metro.co.uk/2016/04/28/bleak-two-thirds-of-millennials-are-bored-of-life-5846710/ ). Not simply bored with certain aspects of it but… “bored of life”. I can see how an “addiction lifestyle” might seem appealing to many of them.