We’re Thinking About Addiction Entirely Wrong

Your question assumes that the brain disease model has taken us away from the moral model. In one sense, of course, it has. The moral model treats drug use as morally wrong and judges people, including people with addiction, for using drugs. The brain disease model claims that people with addiction cannot help using drugs because they have a brain disease that compels them to use. To this extent, they shouldn’t be judged, because they have an excuse. But notice the moralism implicit in this line of thought. We only need an excuse when we do something morally wrong. Like the moral model, the brain disease model invites — even if it does not explicitly state — the idea that drug use is morally wrong.

Before we talk about a “psychology first” orientation and what it can offer us, I want to say directly and plainly that I think we must recognize and reject the tendency in all of us to moralize drug use.

There is nothing intrinsically morally wrong with using drugs. Yes, of course there are particular contexts in which it is morally wrong to use drugs. For example, it is wrong to drink and drive. It is wrong to use drugs in ways and at times that compromises your ability to look after your children, whether you are addicted to drugs or not. But there are many, many cases of drug use, both in addiction and apart from it, where absolutely nothing is done that is morally wrong. Remember, caffeine and nicotine are drugs. Alcohol is a drug. Many of the drugs we find on the streets are pharmacologically identical to the drugs used in hospitals and for medical purposes. It is simply a mistake to think that drug use is intrinsically morally wrong, however deep in our history the mistake goes.

I make this point repeatedly in the book. I believe it is imperative to keep it clearly in mind if we are to be in any position to understand what addiction is and how best to address it and treat those people who struggle with it.

With that said, let’s talk about “psychology first.” Psychology is our most basic, powerful tool for understanding ourselves and each other. Humans are self-conscious and self-reflective beings. We understand ourselves to act for reasons, both good and bad. We take our actions to be explained by our thoughts and feelings, beliefs and desires, pleasures and pains, hopes and fears, plans and intentions. In other words, we take our actions to be explained by our psychological states. What I mean by a “psychology first” approach to addiction is that we start by seeing if we can understand why someone might be using drugs in ways that are profoundly counter to their own good by appealing to their psychological states. In other words, we use the psychological tools that are at our disposal, simply in virtue of being human. We imagine what it would be like to be in their shoes, what their inner life might be like. And to do so, we contextualize their inner life in relation to their life circumstances. Psychology and life circumstances are always enmeshed — this is one of the core lessons from the history of rat experiments.

When we take this approach, a very important feature of addiction is revealed: that addiction is heterogeneous. We are used to the idea that behaviors that look similar on the surface have different psychological explanations when we dig deep. This is because people are different. Similarly, what explains addiction is different for different people.

In the book, I document the heterogeneity of addiction that comes into view through a “psychology first” approach. Some people use drugs to get relief from misery and suffering (as if they were alone in a cage with nothing but cocaine), but some people use drugs for the opposite reason, as a form of deliberate self-harm or even to die. Some people’s identity is bound up with their addiction — they don’t know who they would be or how they would live if they quit. But, by contrast, some people are in denial. Some people experience cravings that are hard to resist but also expressive of the emotional depth of their relationship with drugs, while other people with addiction may struggle with self-control, as do we all. But all that said, I by no means rule out that some cases of addiction might be explained by brain disease. Why not, if addiction is heterogenous?

The important point is to stop thinking that addiction is only and always about the brain or the same for everyone. A “psychology first” approach reveals the heterogeneity of addiction and fights moralism by insisting on our shared humanity with people with addiction. This may not guarantee empathy, but it cannot but encourage it.