Subjectivity and Addiction: Moving Beyond Just the Disease Model
Posted by dlende on January 17, 2009
By Daniel Lende
This week when students in my Alcohol and Drugs class spoke of their obessions, of MySpace and gambling and television and text messaging, they easily acknowledged their own subjectivity. Winning big, losing big; getting away from reality; having fun; becoming wrapped up in whatever particular compulsion is their own – they spoke of what it meant to them, why they did it, what sorts of feelings and experiences characterized that activity.
On Thursday I started class by asking them to write down their own definition of addiction. Unlike the descriptions of their own activities, there was a marked move towards a more causal and biological framework: “dependence” was the first word that came out of one small group discussion. Uncontrollable, using to fulfill a need, both physical and psychological, a disease – these were all other ways to characterize addiction.
Obsession did appear as well, the only clear link to a subsequent discussion on the popular sense of addiction, of what people mean whey they say they are addicted to Facebook, to a favorite food, to a friend or lover. “Need” came up too, but more as an afterthought, a recognition that sometimes their popular obsessions get too strong a hold on their everyday lives.
After discussing these two senses of addiction, as a problem and a type of involvement, we turned to looking at how the Diagnostic and Statistical Manual IV (DSM-IV) defines substance abuse and substance dependence. These are the guidelines that health professionals use to diagnose mental health problems.
For abuse, oddly defined as being the lesser problem, some of the main criteria include: “Recurrent substance use resulting in a failure to fulfill major role obligations,” “Recurrent substance-related legal problems,” and “Continued substance use despite having persistent or recurrent social or interpersonal problems.”
For dependence, the worse diagnosis, the criteria start out much as my students did – tolerance and withdrawal – but then turn to things like “taken in larger amounts or over a longer period than intended” and “a persistent desire or unsuccessful efforts to cut down or control substance use.” One of the last criteria is, “The substance use is continued despite knowledge of having a persistent physical or psychological problem.”
The DSM-IV was marked by its effort to focus on diagnosis, not on assumptions of causality. It’s to help a doctor in an emergency room to determine whether someone suffers from alcohol dependence or for a psychiatrist to guide treatment options and insurance reimbursement with a new patient.
To sum up, addiction in the DSM-IV actively incorporates social and subjective aspects of substance use as part of its diagnostic approach. And that’s entirely right. With substance abuse, there is an emphasis on social criteria – major role failure, legal problems, interpersonal problems. With dependence, we find more personal domains – intention, desire, effort, knowledge.
At that point I returned to the class portrayal of our two senses of addiction and drew ↔, an interactive arrow between the two domains. The popular sense of their obsessions, what they recognize so readily, does not disappear when someone starts to abuse and then becomes dependent on alcohol or drugs. The subjectivity stays, and remains constitutive of the problem.
Caroline Knapp, the journalist and memoir writer, conveys this aspect of alcoholism well in her book, Drinking: A Love Story. As she writes in the opening chapter:
“Yes: this is a love story. It’s about passion, sensual pleasure, deep pulls, lust, fears, yearning hungers. It’s about needs so strong they’re crippling. It’s about saying good-bye to something you can’t fathom living without. I loved the way drink made me feel, and I loved its special power of deflection, its ability to shift my focus away from my own awareness of self and onto something else, something less painful than my own feelings (5).”
In the second chapter, she writes, “Mostly I got loaded quietly, politely. It was something that took place in my own head (18).” Why? “I was drinking every night, drinking to get drunk, to obliterate (14).” Knapp never loses sight of her own subjectivity, both personal and social, in writing about her involvement with and recovery from alcohol.
But we can also find aspects of the physical side, the reductive causal side, in her words. Addiction involves the intensification of use, and here she writes, “Conveniently enough, my twenties coincided with the 1980s, the decade of excess: if the line on my drinking graph began to creep upward, intake and frequency rising, it did so culturally, as well: I had plenty of company (18).” Intake and frequency arose, echoing the DSM-IV’s tolerance and dependence, but these activities happened in company.
“I was clicking away at my computer with a pounding hangover, or sitting there at the end of the day, my body screaming for a drink (14),” Knapp tells us. Here we find that other criterion, of craving and relapse leading to a sense of lost control. But even here Knapp brings us back to the context of her life, of those major roles she has.
I’d created two versions of myself: the working version, who sat at the desk and pounded away at the keyboard, and the restaurant version, who sat at a table and pounded away at white wine. In between, for five or ten minutes at a stretch, the real version would emerge: the fearful version, tense and dishonest and uncertain. I rarely allowed her to emerge for long. Work – all that productive, effective, focused work – kept her distracted and submerged during the day. And drink – anesthetizing and constant – kept her too numb to feel at night (17).
To me, all three of those versions are equally real – all three involved sociality and experience and doing. In Knapp’s case, her eventual recovery depending on negotiating all three versions of herself, along with the simple fact of no longer drinking. The subjectivity and the drinking or not drinking went together.
I used to think that the dichotomous views the students presented, a reductive, causal view of addiction as a problem and a more personal and social view of their own pet obsessions, could be explained in reference only to how humans think causally. As George Lakoff outlines in Women, Fire and Dangerous Things: What Categories Reveal about the Mind, people in the West generally think in two ways about cause – we do something to somebody, or some thing does something to some other thing.
We use intentional causes and billiard-ball causes, categorizing our understanding of the world into one or the other. The students embrace their own experiences in talking about their own compulsions. They speak of disease and dependence and physical and psychological issues when it’s about addiction as a problem. Intentions becomes one pool ball hitting another.
The vast majority of research on addiction falls into the billiard-ball category. Most of that work is done within a biomedical and psychiatric framework, where physical and psychological causes are the assumed white ball, bouncing the poor people into an addicted or not-addicted pocket of the pool table. But the social science research also uses the billiard-ball approach. Here it’s inequality and culture and social context that push people into the different pockets of the table.
In class on Thursday, I realized that the embodied view of causality, of how our minds work, is not enough to explain the bifurcation in beliefs about the two senses of addiction. In the United States we have historically used two cultural models to understand substance use and abuse. We have an older moral model and a more recent disease model. The recent HBO documentary. “Addiction: Why Can’t They Just Stop?” neatly summarizes the first moral view in its title, before going on to present the disease model through a parade of experts in the film itself.
Even as the disease model has gained prominence, the moral model remains a powerful framing of the problem in the United States and elsewhere. The students referenced that by initially describing addiction as “uncontrollable.” That characterization is both a diagnostic criterion and a moral judgment. “Why can’t you stop? I can with my own normal obsessions” is the implied contrast. Our way of explaining that contrast has become the disease model.
To sum up, the dichotomy between the moral model and the disease model sits on top of our intentional and billiard ball thinking. The disease model cannot incorporate intentions except as outcomes of physical and psychological causes. Thus, our cultural way of thinking and our embodied way of thinking combine to produce a tunnel vision approach to understanding addiction.
Yet the students recognize how much subjectivity plays into their obsessions. Caroline Knapp shows us how much subjectivity carries over into alcoholism itself. The subjectivity doesn’t go away, whatever our explanatory models say. Knapp acknowledges that when she writes about alcoholism as “a slow, gradual, insidious, elusive becoming (8).”
So our billiard ball model is the one that is mistaken. Addiction has its fair share of billiard ball causes, to be sure. But subjectivity and intention are constitutive of the problem as well. It is the combination of both types of causality that makes addiction such a hard problem to understand. It’s morality and disease, intention and cause all at once.
We won’t understand addiction until we see what I drew on the board, that it is a two-way street between our subjective sense of our own involvements and our characterization of the problem of addiction. Addiction involves human subjectivity, the way we experience and act and feel and understand our lives and the world. And that subjectivity matters.
As a young girl told me some years ago, she used marijuana so much for two reasons – the sensations that came so present to her mind when she smoked, and how that put her in a video that took her away from her troubled home life. The sensations came from the drug. The meaning of it came from her.
Thanks to my students for being so open with sharing their own experiences and ideas. To read more about addiction, a good place to start on-site is with Studying Sin, as well as Wanting to Craving. For subjectivity, try The Everyday Brain and Our Everyday Life.