Don’t Medicalize My Eschaton (or, What If Addiction Isn’t a Thing?)

Don’t Medicalize My Eschaton (or, What If Addiction Isn’t a Thing?) June 14, 2016

Three blind men are feeling around with their hands, trying to determine what’s in front of them.

“I feel something long and ropy, with a bristly end,” one says.

“I feel something thick and wrinkly, muscular and prehensile,” one says.

“I feel something curved and hard and smooth, like a shofar,” one says.

I’ve got it!” the first one exclaims. “It’s an elephant!”

And they spend the next five days trying to feed hay to a table with a rope, a shedding python, and a shofar on it. After days of increasing anger they give up, saying, “This is a lousy elephant. It doesn’t even want to eat.”

So we spend a ton of time trying to figure out what a thing called “addiction” is. Is it a disease? Is it a sin? Is it a floor wax, or a dessert topping? Here is my personal theory, which is worth about what you paid for it: Addiction is a symptom. Like a fever or a cough, it can be the sign of a vast array of different underlying conditions, requiring vastly different treatments.

Trying to treat ropes like elephants, and pythons like elephants, and shofars like elephants, doesn’t just lead to frustrated elephant-keepers. In the realm of addiction the one-size-fits-all model kills.

Maia Szalavitz argues, mostly correctly, that the criminalization and spirituality which surround American addiction treatment undermine any notion that addiction is a “disease” or a “health issue.” She writes,

While 12-step programs claim to be “spiritual, not religious,” they aren’t like any other mainstream medical or psychological treatment. Do oncologists ask cancer patients to find a Higher Power? Do psychiatrists suggest that people with depression must to take “a searching and fearless moral inventory”? Do any other patients routinely get told by the medical professionals that their problem involves “defects of character”?

While this language—taken directly from 12-step programs—remains a fundamental part of treatment, why would anyone believe it is a medical issue, rather than a problem only bad people have?

Indeed, if you sought any other type of medical care and were informed that the best treatment is meeting others with your condition, praying, confession and restitution, you’d likely rapidly conclude that you were seeing a quack—or at the very least, had wandered outside of mainstream medicine.

But what if you worked this comparison the other way around? If most people who got cancer recovered completely without any treatment–and when you asked them how, they said things like, “Oh, you know, cancer was starting to really mess up my life, so I knew I had to get past it,” or, “I met my wife, and she really pushed me to grow fewer tumors,” or, “I kind of just grew out of it, I guess”–I would think very differently about cancer.

If I could find like five people on any rush-hour 70 bus who recovered from cancer by prayer and restitution, I would think differently about cancer.

Addiction is a modern cultural construct, covering a broad range of behaviors with an even broader range of origins. If addiction is a symptom, we can start asking what it’s a symptom of, and start trying to treat the wide range of underlying causes–and we’ll expect both treatment and causes to vary from person to person. Trauma is a really common underlying cause, for example, but it isn’t universal.

And one symptom can be the result of multiple underlying conditions, or the result of the interaction of multiple conditions. Something can be both grieving and selfish, and recognizing both those aspects may be part of learning to grieve without harming oneself and others.

12-step rhetoric tends to conflate moral and spiritual conditions. It might be more helpful to separate them: Selfishness and idolatry are moral categories, in which the given order–the proper hierarchy of our loves–is disrupted. That’s different from addiction as a misdirected expression of a spiritual longing, an attempt to feed a spiritual hunger. A lot of the people who relate strongly to sublime addiction narratives have experienced that gripping, insatiable spiritual need, which alcohol etc fills briefly and then intensifies. Other people recognize a moral element in our addiction–the ways in which it did make us self-absorbed, narcissistic, idolatrous–and turn to God for rescue, for healing and forgiveness, for a life of love and relationship rather than constantly-violated moral strictures.

But for other people these moral and spiritual narratives don’t actually play much of a role in their addictions. I don’t totally understand that whole worldview, so I’m not a good advocate for it, but I do actually believe that lots of people don’t need God or repentance in order to get well. (They do need God and repentance, but only for the same reasons everybody does.) If we accept that addiction is a symptom, we can start looking at all the underlying conditions that strengthen it and, more importantly, all the widely-varied ways people get better.

I suspect most people who seek any kind of treatment at all will end up needing more than one form of help: medication-assisted treatment and spiritual solace (the theological virtue of hope, which is often the one that gets most damaged by the misery of addiction), for example; support groups and antidepressants; cognitive behavioral therapy and prayer and embedding oneself in a home community. Some of these will be more widely-useful than others–MAT seems to be super-useful, whereas even I think of 12-stepping as kind of a niche thing, so it’s sort of terrifying that the ratio of MAT to 12-step stuff in the USA is basically the reverse of what it probably should be–and which things are useful probably varies by culture and subculture as well as by individual. And maybe also by drug of choice, although that’s super speculative on my part.

(Small Catholic side note: I got some of the idea for this post while praying the fourth Glorious Mystery of the rosary, the Assumption of Our Lady. This mystery, to me, expresses the weirdness of what it means to be embodied. We will be raised in our bodies; we aren’t people inhabiting a body, we are embodied beings. We should not be surprised when we can’t always tell whether something’s a physical or a spiritual sickness. We should not feel entitled to a clear division between body and soul.)

So yeah, I’m arguing that I personally wasn’t sick, I was awful. Don’t take my right to make immoral choices away from me! Don’t deny me the voice of my conscience, man, I need that thing.

But at least as intently I’m arguing that knowing that some other person exhibits the symptom of addiction tells you nothing about their moral character, spiritual needs, or best path to recovery.

We are all gonna have to accept that sometimes you have to forgive people who really do choose to do the wrong things; and we are also gonna have to accept that knowing someone is hurting themselves and others tells you basically nothing about why they do it, whether they are culpable, or how they can stop.

The two things you can know about the people with active addiction in your life are: they are suffering, and they are stigmatized. To know more than that, you have to ask them; and be willing to be surprised by what they say.

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