By Chris Hutchison-Jones
Is substance addiction a choice or a disease?
In the recent ruling by the Massachusetts Supreme Court in the case of the Commonwealth vs. Julie A Eldred judges had to consider this question.
But they came to the wrong conclusion.
As a social worker who works with people who struggle with addiction, I work in a field of well-meaning people, many of whom are in recovery themselves. But many in the field still balk at the idea that addiction is a disease, even when confronted with evidence-based research. Feelings trump evidence.
How then are judges supposed to navigate these issues?
One of the premises of last week’s decision affirming the right of the court to treat relapse as a violation of probation is that the threat of jail can scare people straight.
Substance addiction is not a choice. It is a cunning disease.
Where I may be able to decide not to use drugs because I understand the consequences, someone living with addiction can convince themselves that even the most significant consequences (such as death) will not affect them.
Working in a residential addiction treatment program, I am confronted by different variations of this “choice or disease?” question countless times a day. The most obvious example is a client in treatment who has relapsed. Most people with an understanding of addiction know that when someone is actively using, the notion of “choice” becomes complicated.
There are real physical consequences to stopping use of certain substances. This is why, contrary to popular opinion, beds at detoxes are reserved almost exclusively for those who need a medical detox from alcohol, benzodiazepines, and opiates. The physical dependency is at best uncomfortable, and at worst life-threatening. There are also behavioral patterns that reemerge. People living with the disease readily do things that they would never do if they were not actively using.
We understand this part.
But what about when someone is no longer physically dependent?
Is it a choice then, when someone has had a period of abstinence? And if so, how long is enough? 28 days? Six months? A year? A decade?
This is a topic I frequently discuss when facilitating groups with my clients. Choice is the crux of the issue. Can people living with addiction be blamed for their addiction?
It is challenging to think of addiction as a disease. There is no blood test or full body scan. I doubt researchers will ever find an “addiction gene.” Even my clients struggle with this and are profoundly judgmental of themselves. They think they should be strong enough to “just say no.” They all know an Alcoholics Anonymous old timer who has been sober for 30 years and seemingly did it on willpower alone.
Rather than being an excuse for their actions, they see the idea of addiction as a disease as taking away their own agency. But I tell my clients that it’s in their agency specifically where we find the disease. Addiction affects their ability to make decisions.
My clients are not bad or dirty people. They want the same things many of us want. My client who uses the last of their money to buy their next fix rather than food for their kids is not a bad person. They tell me they love their kids, and I do not doubt them. They weighed the same options I would in that situation, but their scale does not function the same as mine.
I do not excuse actions, but I must consider the tools people have to make decisions. And people who struggle with the disease of addiction have different tools than I do.
In addition, years of stigma and social understanding of addiction are difficult to remove. Just like issues such as race, gender, sexual identity, and orientation, the way preexisting beliefs about addiction manifest are not always obvious.
But if we can remove the stigma and accept that people living with addiction are much more than the disease that they are living with, we can get closer to understanding the implications of addiction as a disease that affects choice.
My clients inform my knowledge of this complex issue, and one thing is very clear: the framework that places blame for making bad choices and hurting themselves and others on the clients is toxic for a country struggling with addiction, as well as the individuals living with it.
It creates a new cycle of painful and counterproductive thoughts to deal with: “If I really am a bad person, what is the point of trying again?” “Why should jail frighten me?” “Why go through the pains of withdrawal and detox or the embarrassment of asking for help and forgiveness…again?”
If addiction was a simple choice, and if everyone had access to the same mental and socio-economic resources, then a relapse might be framed as a moral failure and blame accessed accordingly. Probation stipulating abstinence from drugs would then work as a deterrent.
However, that is not the case. Resources are not equally distributed. The decision-making center of the brain is changed in people struggling with addiction. Instead of being punished, Julie Eldred, and others, should be encouraged to keep trying. She relapsed, but she remained engaged with providers, did not commit a crime other than possession, and did not spiral down to full-blown use.
Even now, the Commonwealth is seeking to do more for addiction treatment.
As someone who works with people living with addiction, the Eldred ruling is disappointing and another reminder that my work is twofold: my first obligation is to my clients, but I must also continue to advocate for better, more widespread understanding that addiction is a disease.
Chris Hutchison-Jones is a Licensed Independent Clinical Social Worker in Massachusetts. He works as the Clinical Manager of a post-detox residential treatment program in the Boston area. His primary treatment focuses are harm reduction, medication assisted treatment, and trauma-informed care.