The Fix a ‘poison pen letter’ to AA? My response to the eccentric Tanya Gold

The eccentric Guardian journalist Tanya Gold had this to say about The Fix in the Guardian’s Comment is Free section yesterday:

And so to the book – The Fix, by Damian Thompson of the Telegraph. It is a strange creature, in part a poison pen letter to AA from a former member. It attacks the disease model of addiction, which has been the accepted dogma for more than 50 years, endorsed by almost every medical authority in America, where most of the research is done – the American Hospital Association, the American Public Health Association, the National Association of Social Workers, the American College of Physicians, the National Institute on Alcohol Abuse and Alcoholism.

For the vast majority of scientists, as Thompson acknowledges, you are no more responsible for being an addict than you are for having leprous limbs, even if this consensus has little impact on social policy where addicts are still treated with contempt. Even so, to dispute it is a popular game among libertarians. Last year the blogger Brendan O’Neill wrote a piece congratulating Amy Winehouse for not being suckered by the therapy industry, even as her ashes were interred in the mud. Thompson’s status as an ex-AA member renders The Fix a dangerous polemic that exposes addicts to social censure – a daft fate for sufferers of an illness so intrinsically dependent on self-hatred – and financial and occupational insecurity: it is almost impossible for addicts to be insured, even in 2012.

Thompson’s opening passage on alcoholism is anecdotal, brutal, subjective. He describes an AA member – in unflattering terms – who will likely recognise herself. He says the group “seemed almost proud they had this ‘disease’” – were they, or weren’t they? He insists the members “describe disasters that befall those who stray from the true path [with relish]“. Does he relate their testimony from memory, or did he take notes?

Thompson bases his complaint on the stories of two of his friends. Both abused alcohol and drugs: one lived, one threw himself off a building. His conclusion is that, since some addicts recover it cannot be a disease. So what is it? “The behaviour of addicts,” he concludes, “looks voluntary because it is … there will always be people who … change their mind and pull themselves out.”

What of the science? The most comprehensive study (by George Vaillant at Harvard) suggests that almost no one who drinks alcoholically ever drinks normally again; twin studies suggest addiction is hereditary; A Thomas McLellan’s enormous round-up of the data noted “higher rates of dependence among twins than among non-twin siblings and higher rates among monozygotic than dizygotic twins. Evidence,” he says, “suggests significant genetic contribution to the risk of addiction comparable to that seen in other chronic illnesses … the choice to try a drug may be voluntary, [but] the effects of the drug can be influenced profoundly by genetic factors.”

McLellan admits: “It is not yet possible to explain the physiologic and psychological processes that transform controlled, voluntary use of alcohol and other drugs into uncontrolled, involuntary dependence”, and this is the hole that Thompson crawls through. The Fix reads only like bitterness, an unconscious elegy to shame; add Iain Duncan Smith’s coerced AA meetings, and fair treatment for addicts feels, as ever, far away.

And here’s my response in today’s CiF. There is so much more one could say about colourful Tanya… and, who knows, perhaps I will before long.

Tanya Gold has accused me of writing “a poison pen letter” to Alcoholics Anonymous in my new book about addiction, The Fix. Since AA saved my life, that seems a very ungrateful thing for me to do. And, indeed, I’ve done nothing of the sort. What I have said is that I don’t buy the dogma that addiction is a disease. In that respect, I’m a 12-step heretic. The book has only been out for four days and already I can feel the flames licking around my feet.

It’s perfectly true, as Gold says, that most medical addiction specialists endorse the notion of addiction as an irreversible brain disorder. But, as I explain in The Fix, these specialists have borrowed this model from the 80-year-old doctrine of the steps, which are heavily influenced by the evangelical Christianity of “moral rearmament”.

Gold says I dismiss the disease model on the grounds that some people cure themselves of alcoholism. That’s true, up to a point: I’ve known apparently helplessly addicted drunks return to normal drinking. When this happens, AA purists retreat into circular logic. If these ex-drunks can enjoy the odd glass of wine now, then they can never have been alcoholics … because alcoholism is an irreversible disease.

There are plenty of reasons for rejecting the disease model. Perhaps the most compelling is that there is no test for addiction of the sort that exists for cancer or diabetes. There’s not even a posthumous test, as there is in the case of a notoriously difficult-to-diagnose illness, Alzheimer’s, unquestionably a disease. Two people can die of cirrhosis of the liver, one from drinking alcoholically and the other from carelessly heavy but controllable heavy drinking. If you cut their bodies open on the slab, will you be able to identify which had the “disease”? The answer is no.

My message is that addiction is behaviour – and it’s no less deadly for that. The conditions of the global free market are producing substances and experiences that target ever more effectively the pleasure centres in our brains. Perhaps the most important chemical involved is the neurotransmitter dopamine, which not only produces an agreeable buzz but also stokes up our desire. Self-described shopping addicts can experience the same hit from hearing the whirr of the debit card machine as a drunk does from the pop of a cork, or a cokehead from the chopping of a line. Anticipation is a powerful intoxicant.

I’m not denying that these people are addicts, if we adopt the sensible definition of addiction as excessive consumption that causes harm. But this consumption is behaviour that can be modified. For example, there is news this week of a pill that treats compulsive buying habits by suppressing impulsive urges. I bet it works – and not just on “shopaholics”. Shopping addicts may find it difficult or even impossible to control their purchases. That said, the architecture of their brains is not fundamentally different from that of non-addicts.

To put it simply, addictive urges are rooted in the human condition and can be placed on a spectrum from the “I really shouldn’t” reaction to another helping of pudding to the desperate plunge of a needle in an urban alleyway. Gold argues that the hereditary component to addiction supports the disease model. But there’s a genetic component to most behaviour, so one would expect addiction to run in families. There is, however, no single gene for addiction (nor the remotest prospect of one being discovered). A far better predictor of addictive behaviour than heredity is environment, and the conclusion of my book is that contemporary capitalism is ruthlessly targeting our mental reward circuits. The technology that tests computer games, fast food and painkillers is simply doing its job too well, making us like addictive things too much.

Back to Alcoholics Anonymous. If its disease model is wrong, why does it work so well? There’s no mystery. It takes drunks who want to stay sober and surrounds them with like-minded souls. The “programme” doesn’t manage disease: it creates an environment in which the temptation to drink ebbs away. Eighteen years, Tanya – that’s how long I’ve stayed away from alcohol. For which, as I make clear in the book, I’m truly grateful to AA.