I think the disease model is in many ways flawed. It posits one notion of normal and then divides everything into "normal therefore fine" or "different, therefore broken".
Some good, HN-relevant examples are ADD and autism-spectrum "disorders". One of the hallmarks of ADD is hyperfocus, so ADD is a misnomer; it could easily be called, "doesn't pay attention when the teacher wants syndrome," or "is not interested in your boring trivia syndrome". There are a ton of people previously diagnosed with Asperger's who lead happy, productive lives. Both of these characteristics can be positive in the world of tech entrepreneurship, and could well have been positive in previous environments. [1]
That said, I think this guy making his central message, "Addiction is not a disease," is dangerous to the point of idiocy. In our current society, we really only have one mechanism for aiding those who will need a lot of help, and that's saying that they're sick. If he would like to make a full-scale assault on the disease model, godspeed. But a lot of people already want to believe that addicts could quit any time if they just applied a little willpower. Reinforcing that means that people who could be saved will die unnecessarily.
15+ years sober here, mostly through some recovery programs and a lot of AA.
Neither the "disease" model (which has connotations of communicability) nor the AA "allergy" model (there's something wrong with my body) make total sense. Rather than try to fit other terms into a procrustean bed, I just call it addiction. Everyone is different, but there are a lot of commonalities.
Given the amount of denial that is present in most cases of addiction, trying to fit it into other categories can make more room for rationalization and avoidance. "I clearly don't have a disease, I never caught it from anyone," someone might say, or "It's not an allergy, I don't break out in hives." And delay treatment that much longer.
I'm a firm believer in getting whatever help works for you. If that's Rational Recovery, great. If that means an AA meeting every day, great. Just get help. Get it earlier than you think you need it. Tell your boss (s/he probably knows something is up anyway, just not what). Drop in on a meeting [yeah, AA, I know]. Tell a friend. Tell your doctor. Make a call and get into treatment. Do something, because until you do that, nothing is going to change.
16 years ago I was without a job and essentially unemployable, on the verge of being homeless, drinking 750ml+ of hard liquor a day, and this close to offing myself to end the misery. Today I'm married, doing really, really well financially, am bringing up a kid, and have a 6100+ karma score on my non-throwaway HN account. Life is good :-)
Congrats on the sobriety. 11 years myself here on my non-throwaway account (don't hire me, then, we'll both be better off).
As for the disease model, and as a partial response to the comment sibling, it is my understanding that the disease model was cooked up specifically to address the "weak willed" label slapped on those that drink too much. If that's true, and I don't have a reliable source to back that up, it would fit well with AA's overall program. IOW, like other diseases, you don't have control over it (if you did, you'd quit), and it is not reflective of a base character flaw, etc.
I dunno, I don't get too hung up on it myself. As you said, get whatever help that fits your model of the world, but get help. I don't even buy into a lot of what AA touts, but simply sitting in a room with a bunch of other folks with similar struggles was a lot of what I needed. (Granted, for a lot of AA meetings "similar struggles" means "the court says I need this piece of paper signed".)
Good for you, random internet person, good for you.
Do you think the disease model implies more some kind of genetic/environmental slant, as opposed to a 'weak character'. I think what the disease model is putting forward is that something outside of your control led to your addiction rather than something you're supposedly meant to have control over, that is to say your decisions and will.
Thanks for posting this.
edit: And I just remembered, the clinical/medical label used is actually "illness", not disease...
Illness, they say, refers to the patient's experience of the disease. A person with a disease might not feel ill, and a person who experiences illness might not have a disease.
>it could easily be called, "doesn't pay attention when the teacher wants syndrome,"
This is a common misunderstanding. My experience with ADD is that it's not just "doesn't pay attention to what someone else wants"; it's "I can't pay attention to what I want to pay attention to".
And yeah, I do think that ADD has some beneficial effects as well. Syphilis can sometimes attack the nervous system in ways that create permanent elevated mood. I don't think that makes syphilis "not a disease".
It's both. Certainly there are those who legitimately suffer from the condition, as you put it, but there a greater amount of young boys who are misdiagnosed by teachers with no legitimate experience over the ability to diagnose besides: "he's a distraction to my classroom".
This characterizes Zimbardos more recent work on "The Demise of Guys" where you can learn an overview about it here[0]
The great issue is the vast amount of boys being misattribute with the condition, from predominately female teachers.
I was one of those boys, but I was one of the few lucky ones who's father is a doctor and never had me prescribed medicine I didn't need. I ended up excelling in upper school.
Hi! As someone also diagnosed with ADD I know what you mean. But that's still a control relationship, whether it's the teacher controlling me or me controlling myself to do something dull.
I don't know about you, but I've never had any problem focusing on anything I found interesting; even in high school 12-hour coding marathons were easy for me. In one of Hallowell and Ratey's books they talk about how a better name for it would be "Attention Inconstancy Syndrome". But we have the name because in our industrial model of education teachers expect controllable students, and so see our difference as a deficit.
All humans have limited attention spans, and different people have different limits. The problem for me wasn't my difference per se, but the expectation that I conform to patterns of behaviors that work for others. Now that I'm an adult and can define my own life, I'm no longer a "problem", just different.
> My experience with ADD is that it's not just "doesn't pay attention to what someone else wants"; it's "I can't pay attention to what I want to pay attention to".
So kids with ADD can't concentrate for hours on, say video games or other interests?
A kid might focus for hours on video games, while telling himself he really needs to write that paper for class tomorrow. Maybe you could say his id is in control of focus, not his ego.
If you're curious, I found the books by Hallowell and Ratey helpful. One of them contained a self-assessment quiz. It's meant to be descriptive, not diagnostic, but it was very useful to me in seeing the pattern. Here's a web version:
Most people, if they could actually choose what they're able to sustain focus on, would not choose video games or other forms of idle entertainment. Wouldn't you rather do something that brings some lasting value to your life?
Since video games are designed to capture attention at the expense of all other qualities, they're like a last refuge for people who want to have the experience of really getting into something, but don't have the focus control for something more substantial.
It also applies to films and to a lesser extent, novels. Of course, some truly great games provide more than just temporary entertainment, and the same applies to TV shows.
As an ex-heroin addict, I agree. I also agree with the author/scientist who was interviewed in the article; my personal addiction was far more behaviour based than it was a disease. Becoming an addict takes practice and choices, and it was taking responsibility for that, along with a great support system from my family and governmental medical help that helped me break the 6 year cycle. As of today, I've been clean for three years. That said, N=1, and from others I used to associate with (many who are no longer with us), the disease model makes more sense.
Basically, I think addiction is complex, and any one way of thinking about it will likely miss a lot.
Oh, definitely. Many things have complicated relationships to behavior like that. When I talk to friends with chronic diseases like Celiac's or diabetes, they spend a lot of time thinking about behavior, choices, and responsibility in ways similar to my recovering addict friends.
Congrats on being clean 3 years, by the way. That's an enormous accomplishment, especially with something so socially stigmatized as heroin.
I'd never heard of the hunter vs farmer hypothesis. But, it's very interesting. A disproportionate number of my friends and I, although intelligent, had lifelong difficulties with ADHD, bipolar disorder, and substance abuse (as did many of our parents). We always used to ponder and hypothesize, as kids (in the 80s / 90s), that we just weren't built for modern life and that our recent ancestors were probably nomadic hunter gatherers. We felt like our bodies and minds truly were trying to push us to escape, to run wild in the forest.
Regarding bipolar disorder, you might enjoy reading Jameson's "Touched With Fire". She looks at the family trees of Romantic poets and how so many of the creative ones struggled, and how they had relatives that were thoroughly troubled in a way that made them unproductive. It's a great look at creativity as a double-edged sword.
> it could easily be called, "doesn't pay attention when the teacher wants syndrome," or "is not interested in your boring trivia syndrome".
"Doesn't fit into modern modes of domination and unquestionable authority" syndrome.
How many diseases are "isn't productive under capitalism and is therefore less useful to society" syndrome?
There is a presumption that we treat people the way we should treat people (we being society in the abstract, of course). Well yeah, if you take that as a premise then the only conclusion you can make is that people who cannot participate in society effectively for their own benefit and the benefit of others are sick!
How many diseases are culturally specific, both geographically and historically? Depression is on the rise in many countries. Are people getting sicker, or is society becoming more inhospitable?
If drug addiction is perceived as a symptom of a sick society, suddenly the logic of treating it is completely different.
The definition of all mental disease is completely based on social norms, a mental disease is just something which prevents you from behaving in a way certain people deem 'normal'. People like Szasz have posited it as a method for social control, where psychiatrists are proxies for authoritarian state power. I think if you asked Nietzsche he would say it's a natural response to the death of god; people look for something else to worship, and it's capitalism/obedience, and people who don't believe in it need help much in the way heretics of old were deserving of our help and pity to find God. Now instead of priests we look to psychologists, the priests of our new religion.
If you need evidence simply look at homosexuality; this was a mental disease while society didn't accept gay people (being gay made it impossible to live a "normal" life in society). Now that we think being gay is just fine it's no longer a disease. Nothing medical changed, ergo the definition was not in essence a medical one.
"If drug addiction is perceived as a symptom of a sick society, suddenly the logic of treating it is completely different."
Couldn't agree more (see my post elsewhere in this thread). I think the campaign against addicts (drug war) was indeed started from the 'isn't useful to capitalist society' angle, but now addicts, at least in the US but I'm sure pretty much everywhere else, are actually what bring massive profits to capitalist society through our government's prosecution and persecution of them. While it probably was not the intended result for most prohibitioners when they started the drug war, the war itself has created a whole new multi-billion dollar industry and front for many capitalists, especially the manufacturers of weapons, law enforcement, etc.
Society, at least in the US, refuses to look at itself as the source of the problem because it enjoys the problem. Much of society has benefitted from persecuting and prosecuting drug addicts and the inevitable supply lines that are caused by the existence of a black market. Police, military, politicians, and other beneficiaries of all these billions (trillions over time) refuse to ever acknowledge there is a problem because that would mean the end of their nice perks, the end of the pina colada machines in the police station, the end of the fun SWAT raids, the end of selling so many assault rifles, tanks, and other death equipment that doesn't belong in civilian police hands.
Damn straight addiction would be treated differently if it was seen as what it really is: a symptom of an incredibly sick society that no longer cares about its members and values profits above all else, including all human life, even that of its own citizens.
Every institution of power has its own designator of "bad" that justifies dehumanization. Police: Crime. Medicine: Disease. Military: Terrorism (nowadays). Religion: Heresy. etc. We should not be surprised when they overlap.
Your point about the disease hypothesis is flawed because one of the main questions asked during diagnosis is "does this affect your day to day living? How much?"
I think that changes treatment choices, but I don't think it changes diagnosis. Plenty of people with cancer aren't affected by it (yet), but that doesn't mean they wouldn't be diagnosed with the disease.
DanBC is talking about the diagnosis of addiction (or indeed most mental illnesses), not diagnosing any disease.
For example, a patient would likely not be diagnosed with an anxiety disorder if symptoms did not have a marked effect on their day to day living.
This means that the disease model can not be said to be a tool used to enforce normative cognition or behavior, but a model to help decrease suffering.
And there are scads of articles critical of the way ADD is treated in the US, and specifically critical of how the diagnosis and medication are used to create classroom compliance. A teacher friend once substituted in a classroom where every single child was on medication. Given that the disease prominence is circa 10% and not all kids are on medication, either she should have bought a lottery ticket or there was some other factor than strict medical necessity going on there.
That's the problem with attempting to use Wikipedia as an authoritative expert source: it's not, and it's not what it attempts to be.
The part about marked effect on the life of a would-be patient would not be explicitly stated amongst DSM diagnostic criteria, as it is not a symptom of the illness in question, but rather something most mental illnesses have in common (i.e. a large part of the reason for viewing mental disorders as illnesses).
However, the second sentence in the Wikipedia page on GAD (to which you linked) starts "This excessive worry often interferes with daily functioning".
Seeing "excessive" used in the context of the listed symptoms (DSM-5, your link), I'm hard pressed to view this as any sort of attempt to cull diversity.
As it is rather late in my timezone, I'm not going to go trawling for definitions, but if you're interested in reading more I can recommend NAMI, NIMH, the Mayo Clinic, etc. as good starting points.
As this isn't my area of expertise, I'm in no position to argue the specifics of ODD, but it has always been somewhat controversial [1], and particularly around the release of DSM-5, IIRC. But even if the whole world were to agree that ODD was poorly defined, or pehaps even concede that it was "designed to enforce normal behavior", it would not really say anything at all about neither the disease model, nor the field in its entirety.
Regarding ADD, the major controversy seems to be about possible overdiagnosis, and to some extent about relying too much on medications as opposed to therapy, AFAIK. I think there are several legitimate issues here, some of which are likely specific to culture, some to specific socio-economic contexts, others perhaps to the handling of ADD at large.
I'm not saying it's an attempt to cull diversity. I'm saying that when the disease model is all you have, it's easy to say, "there is a difference we don't like, therefore it must be a disease".
> E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
I get what you're saying. We used to lock people up for many years just because they had an abortion at 17 and liked wearing yellow tights. But "Does this interfere with your day to day life? What do you want to change?" is an important part of diagnosis.
I think the problem I have with what you're saying is that I see, very often, people (mis)using psychiatric language to describe behaviour they don't like in other people.
Asshole boss? Sociopath.
Asshole employee? Asperger's.
Asshole with a gun? Psychopath. (Or, worse, psychotic.)
> A teacher friend once substituted in a classroom where every single child was on medication. Given that the disease prominence is circa 10% and not all kids are on medication, either she should have bought a lottery ticket or there was some other factor than strict medical necessity going on there.
Over-diagnosis is probably a problem, especially in the US. I don't know how diagnosis works over there. Over here it's probably too hard to get a diagnosis. But I'd be interested to know what a statistician would say about a class of pupils who were all on medication. We'd expect some clumpiness. And unless you know that 10% is evenly distributed (is there any reason to believe it is) you'd expect even more clumpiness.
What I'm pointing at is that the GAD criteria, as with the criteria for many diseases, is not, "Hey patient, is this a problem for you?" It's a judgment by the clinician over whether the impairment is significant. That's generally fine with wise clinical judgment and clear signals of illness. (E.g., there's little dispute over whether a broken leg is a problem.) But I think there are issues when things are only a problem for other people, or only a problem because other people are different. There I think applying the disease model can be mixed, both helpful (when it allows addicts to get the support they need) and harmful (when different people are treated as broken).
This is especially problematic in the US because medicalization is not just socially convenient, but frequently profitable.
I also agree that people casually using diagnostic language is a problem. Indeed, I think it's closely related to the problem that concerns me, where people take traits that are helpful in some contexts and harmful in others and declare them to be diseases.
Regarding addiction, it would seem to me pretty obvious that it can be diagnosed even when the person doesn't admit that it affects their day to day living. I've met homeless drunks who swear to me that they don't have a problem with alcohol, and denial is a large part of addiction. And then there's the category of high-functioning alcoholics [1], where even outside observers can say it doesn't affect their day to day living.
Sure, which is my point. DanBC is claiming that the person with the nominal disease is the source of deciding whether it affects day-to-day life. I'm saying that's not the case. Other people get to decide whether it's a disease based on what's normal to them.
An example others brought up was that homosexuality was defined as a mental illness for many years. That's the same dynamic I'm pointing at.
Clients are typically asked to assess to what extent the perceived symptoms affects their day-to-day life, any changes, etc., in addition to conferring with friends/family for their point of view on this. These are considered in addition to an absolute deviance from the "average spectrum" and diagnostic criteria.
I don't really think the pathologization of homosexuality is comparable to modern issues, as the reasons for this were very much informed by its historical context (its history as an immoral concept in christian/western culture, the state of psychology and psychiatry as fields at the time vs. now, etc.) in a way modern diagnoses aren't.
Also, according to Wikipedia [0], APA members were critical to homosexuality as a disorder at least from its inclusion in the first DSM.
What's your source for your claims? In the US, a lot of mental illnesses are medicated by general practitioners, and mental health insurance coverage is notoriously poor. That sounds like a great way to work, but it's not how I see the system actually working.
That you don't think pathologization of homosexuality is comparable is, I suppose, fine for you. I obviously do or I wouldn't have made the comparison. It's not like we don't have a historical context now as well; it's just a different context. In particular, the US has some very deeply culturally embedded notions about work ethic and willpower that are relevant to ADD and addiction treatment. That we corrected one mistake does not mean we corrected the general pattern of mistake.
Regarding the last bit, glad to know Wikipedia is now a reliable source when you're citing it in your favor.
There are sources abound [0-3]. The four Ds of abnormality [0] might be of particular interest.
The point may be better explained (as I'll get back to) by textbooks and lecture notes, also available via Google.
That's the case in much of the world, which is indeed considered a problem, and may explain why medication may be overutilized.
But the fact that the system's current practice is unfavorable, does not really say anything about the models used to understand mental illness.
ADD comes with certain dysfunction [0] (and perhaps distress) that homosexuality just doesn't, which is one of the reasons for my objection.
While the field of psychopathology is certainly influenced by culture (as is readily acknowledged) I have yet to see any reasonable argument that addiction and ADD are pathologized on the sole basis of falling outside of "normal" experience.
Additionally, the notions of work ethic and willpower that you mention might just as well be used to explain stigma towards the mentally ill – that they should just apply discipline and willpower.
Apropos of sources, I should very much like to see some that claim that ADD as diagnosis is inherently problematic, as opposed to it being abused as a consequence of certain cultures.
My gripe with your previous use of Wikipedia was not about Wikipedia itself, but the way it was used.
By this I mean that while Wikipedia articles might contain misinformation, it is known to be surprisingly good, for the most part (though certainly no credible academic source).
The problem, though, is that it will in quite a few cases not provide readers with minute details, standard practice or underlying assumptions – Wikipedia is an encyclopedia, not a practitioner's handbook.
You seem to be arguing from the theory of mental health; I am talking about what people do in practice, and the cultural norms and views that shape the application of theory.
As to, "I have yet to see any reasonable argument" bit, I can certainly believe it. But I think that's mainly because you haven't looked. Plenty of people have talked about rampant overdiagnosis of ADHD in the US because putting everybody on stimulants makes classrooms easier to control. Overdiagnosis here means taking healthy but inconvenient behavior and pathologizing it. If people only have "dysfunction" in particular classroom environments with particular teachers, I think it's reasonable to suggest that what's dysfunctional is the environment and the expectation of universal conformity, not the people who are different.
It seems like we are mainly talking in circles here, and given that this is a topic on which I have paid attention to for a couple of decades and also have direct experience, your arguments from Wikipedia theory links aren't going to do much for me. Maybe we should stop now?
The problem is that you talk about what you perceive as flaws in the disease model (theory) in your original post, and unsubstantiatedly claim that 'It posits one notion of normal and then divides everything into "normal therefore fine" or "different, therefore broken".', which is incorrect (as pointed out by DanBC).
If someone applies the model incorrectly, that doesn't undermine the model.
I have looked, and I have heard the arguments you are talking about, some of which I agree with (as you can see from earlier posts), but a common sentiment amongst some of these seem to be the almost conspiratorial belief that it is all based upon suppressing anything other than normal behavior.
I think it is more reasonable to suggest that the bar might be set too low when it comes to this diagnosis in the U.S., than it is to discredit the illness entirely because of what amounts to misdiagnosis. The subject is fraught with nuance.
As for the use of sources, there is clearly a discrepancy between our posts, though mine are admittedly often from Wikipedia.
If a lot of people use a model incorrectly, I think it's worth asking whether it's a bad model. E.g., "Good vs evil" is a popular model, but it leads to enough stupidity I don't think it unreasonable to say that is often applied without nuance.
If you would like a better source, take a look at Hallowell's work. His basic take is that ADHD is not a disease, but a trait:
Of course, he's only a psychiatrist who specializes in ADHD and has written a half-dozen books on the topic, so I'm sure he's just lacking your subtle understanding of the perfection of the disease model. And probably a conspiracy theorist too; there are so many of those on the Harvard Medical School faculty.
And if you'd like more on how the disease model is misused, start with the literature on the medicalization of deviance:
What you're talking about in this thread doesn't translate to applying the model "without nuance", but to wrongly apply the model or to not apply the model at all (since the model is not followed).
That's why I think your first post is wrong; the disease model does not claim that deviancy == illness.
Rather, it claims that the identified problematic behavior is a result of a chemical/biological issue, and doesn't deal with definition of problems at all.
Also worth noting is that the purely biologic view isn't really en vogue any more. AFAIK, the biopsychosocial model is more popular.
In practice, it is valuable to view mental disorders as (i.e. not claim that they are) illnesses, one of the reasons for which you touch upon in your original post.
I have of course heard arguments like Hallowell's before, and I don't think that they're entirely unreasonable, although the gist of them can be applied to psychiatric diagnoses in general, seeing that all symptoms and traits can be said to exist on a scale/spectrum/continuum. Most literature I've seen readily acknowledges this (and notes pitfalls of other kinds, like being somewhat based on social norms). This is the one of the nuances I've previously alluded to.
As I think is quite clear from our exchange, positions like these are not the ones i disagree with, nor the ones I refer to as conspiratorial – that would be those that actually posit conspiratorial "theories", e.g. willful persecution of those outside the "normal" by practitioners, the powers that be, etc.
I'll refrain from commenting on your rude sarcasm and unreasonable assumptions, but know that cherry picking a source and appealing to its authority doesn't make for a convincing (nor logical) argument.
I'm also familiar with medicalization of deviance, though I don't see how this pertains to the disease model, as this kind of social control is possible (and has been performed) via a plethora of means.
P.S. Just came across an editorial [0] that deals with some of this that might be of interest.
I've certainly not intended to come across as rude, only as challenging your assertions. But I guess you'll read into it as you may.
And I certainly don't go attacking straw men before you've even had a chance to answer accusations (as in the rude sarcasm part).
I also note that you have yet to back up your original assertion that the disease model "posits one notion of normal and then divides everything into "normal therefore fine" or "different, therefore broken"', which is hardly surprising, as it doesn't deal with this definition at all.
I'm obviously not saying that, but it gets said a lot. Anything defined as a disease is seen as a problem, even when the person with it just sees it as a difference. An example people gave elsewhere in the thread was homosexuality, which was defined as a disease for years and years.
A better understanding of addiction is the key to effective treatment – and treatment really isn't very effective right now – so the question is whether the harm from any increased stigma is offset by the benefit of better treatments.
It's always possible to willfully misinterpret Marc Lewis' message as saying that addicts just need to grow a spine, and it's definitely possible that a certain group of people will try to appropriate him to that end, but the interview itself is very nuanced.
Having been diagnosed with it in college, and knowing many similar people, I agree that it isn't all puppies and flowers. However, if that's how all humans were, it wouldn't be defined as a disease, it would just be human nature.
It's also about human performance in very specific environments, that being certain industrial and early-post-industrial environments. And I'll add that most humans have inadequate attentional mechanisms for those environments, which is why 80% of adult Americans consume attention-enhancing stimulants every day, and why it is extremely rare to find an office environment without ready caffeine.
One caveat: there are a variety of things that get lumped under the term ADD, like organophosphate pesticide poisoning [1]. There are people with severe attentional issues who do indeed suffer, and would even in historical human environments. Here I'm speaking only of the 5-10% of the population with the standard sort of ADD that appears to be genetic, and wouldn't have been recognized as a disease until recently.
Some good, HN-relevant examples are ADD and autism-spectrum "disorders". One of the hallmarks of ADD is hyperfocus, so ADD is a misnomer; it could easily be called, "doesn't pay attention when the teacher wants syndrome," or "is not interested in your boring trivia syndrome". There are a ton of people previously diagnosed with Asperger's who lead happy, productive lives. Both of these characteristics can be positive in the world of tech entrepreneurship, and could well have been positive in previous environments. [1]
That said, I think this guy making his central message, "Addiction is not a disease," is dangerous to the point of idiocy. In our current society, we really only have one mechanism for aiding those who will need a lot of help, and that's saying that they're sick. If he would like to make a full-scale assault on the disease model, godspeed. But a lot of people already want to believe that addicts could quit any time if they just applied a little willpower. Reinforcing that means that people who could be saved will die unnecessarily.
[1] See, e.g., the hunter vs farmer hypothesis for ADD: https://en.wikipedia.org/wiki/Hunter_vs._farmer_hypothesis