This is well worth the read and absolutely 100% spot on!! What a treasured gift — one that I hope will be read, absorbed, and shared widely.
I had a young friend, someone I dearly loved and who I knew since she was a little girl. When in her 40s she was several years sober and doing everything "right" in her 12 Step recovery program. She worked the steps and read the Big Book, she had a sponsor and sponsored others, she was a speaker at AA conferences and an inspiration to many. And then, two years ago, she died of an overdose. I also know her history of trauma, which was never addressed in the kind of depth that she needed to heal, unburden, and transform her life. Heartbreaking. I still weep for her and her beloved family...
It has now been 41 years since I took my last drink and 39 years since I smoked my last cigarette. And today the pull of living a rich full life is stronger than any pull to ever go back. Yes, there was this part of me that was alcoholic, but this and other symptoms of trauma no longer define me. Treat the pain, the trauma underlying the addictions and they lose their power. It's that hard. And that simple. (I wrote more about what sobriety means to me today here: https://mollystrongheart.blogspot.com/2026/02/reflections-on-what-sobriety-means-to.html.)
I'm so very grateful today for the wisdom held in articles like this one and for those like Gabor Maté, Marc Lewis, Richard Schwartz, my wise therapist, and many others who have empowered me over the years to grow into the truth of who I truly and wholly am. We humans are so much greater than our addictions and the pain that drives them! May more and more of us find this freedom and peace and the resources which empower us to deeply address and increasingly free ourselves of the pain and trauma which are the roots of our addictions. May we come to deeply embody the life saving gifts of healing our hurting hearts, of supportive and loving community, of purpose and meaning, and of ever expanding compassion and love for ourselves and our sisters and brothers everywhere. May we discover and ground ourselves in the sacred journeys which empower us to remember what we have forgotten — and especially who we most deeply are.🙏💜Molly
(Highlights in this article were added by the author.)
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| Photo by Towfiqu barbhuiya on Unsplash |
Why the “brain disease” model of addiction helps some people but fails most — and what we’re missing when we medicalize human suffering
“I’m an addict. I’ll always be an addict. That’s just who I am.”
He was 34 years old, hadn’t used drugs in three years, had a stable job, healthy relationships, and a life he’d built from nothing. But he still introduced himself this way at every meeting, wore his addiction like an identity, and believed that one drink, one pill, one moment of weakness would send him spiraling back into the hell he’d escaped.
“What if you’re not an addict anymore?” I asked carefully. “What if you were someone who struggled with addiction for a period of your life, but that’s not who you are now?”
The look he gave me was somewhere between hope and horror.
“That’s not what they taught me in rehab. They said addiction is a chronic, progressive disease. That I’ll never be cured. That I have to accept I’m powerless over it for the rest of my life.”
Here’s the controversial thing I’ve come to believe after years of working with people struggling with addiction: The disease model — the idea that addiction is a chronic brain disease requiring lifelong management — helps some people. It reduces stigma. It gets people into treatment. It provides a framework that makes sense of suffering.
But it also traps people in an identity they might have outgrown. It pathologizes normal human adaptation to unbearable circumstances. And it obscures what addiction actually is: a solution that became a problem.
The Disease Model (And Why It Became Gospel)
The “addiction is a brain disease” narrative became dominant in the 1990s and 2000s, primarily through the work of the National Institute on Drug Abuse and researchers like Nora Volkow.
The model goes like this: Addiction fundamentally alters brain chemistry and structure, particularly in areas related to reward, motivation, and impulse control. These changes persist even after substance use stops, creating a chronic, relapsing condition similar to diabetes or hypertension. Therefore, addiction is a medical disease requiring medical treatment.
This model was revolutionary in some ways. It challenged the moral failing narrative — the idea that addicts are just weak-willed people making bad choices. It brought addiction into medical legitimacy, enabling insurance coverage and reducing stigma.
Research using brain imaging showed real, measurable differences in the brains of people with addiction compared to controls. Reduced dopamine receptor availability. Changes in prefrontal cortex function. Altered reward processing.
The science was real. The conclusion seemed obvious: addiction is a brain disease.
But here’s what that model misses: Those brain changes aren’t unique to addiction. They occur in response to any repeated behavior — meditation, exercise, learning a language, falling in love. The brain changes in response to experience. That’s what brains do. It’s called neuroplasticity.
The presence of brain changes doesn’t make something a disease. It makes it a learned adaptation.
What Addiction Actually Is (The Uncomfortable Truth)
After working with hundreds of people struggling with addiction — alcohol, drugs, gambling, sex, work, food — here’s what I’ve observed:
Addiction is not a disease you catch or develop randomly. It’s an adaptive response to unbearable circumstances or unbearable internal states.
Research by physician Gabor Maté and the Adverse Childhood Experiences (ACE) study shows that the strongest predictor of addiction isn’t genetics or brain chemistry — it’s childhood trauma and chronic stress.
The ACE study, which surveyed over 17,000 people, found a dose-response relationship between childhood adversity and addiction: The more adverse experiences (abuse, neglect, household dysfunction), the higher the likelihood of substance use disorders in adulthood.
People don’t become addicted because their brains are broken. They become addicted because addiction solves a problem. It numbs emotional pain. It creates predictable pleasure in an unpredictable world. It provides escape from circumstances that feel unbearable.
Neuroscientist Marc Lewis, in his book The Biology of Desire, argues that addiction is not a disease but an intense form of learning — specifically, learning to pursue a particular reward compulsively because it reliably provides relief or pleasure in a life that offers little of either.
The brain changes associated with addiction aren’t evidence of disease. There’s evidence that the brain has learned something very well: This substance/behavior makes me feel better, at least temporarily. Pursue it at all costs.
That’s not pathology. That’s the brain working exactly as designed — adapting to survive unbearable circumstances.
The Confession: What I See That Doesn’t Fit the Disease Model
Here’s what I observe in clinical practice that the disease model can’t adequately explain:
People “Recover” Without Treatment
Research shows that most people who struggle with addiction eventually stop without formal treatment. Epidemiological studies tracking substance use over time find that the majority of people with addiction histories no longer meet diagnostic criteria by middle age.
This is called “natural recovery” or “spontaneous remission,” and it happens far more often than the chronic disease model would predict.
If addiction is truly a chronic, progressive brain disease like diabetes, why do so many people simply… stop? Not through treatment, not through 12-step programs, but through life changes — getting a job they care about, forming meaningful relationships, moving to a new environment, becoming parents, finding purpose.
Diseases don’t resolve because you found meaning in life. But solutions that became problems can.
Context Matters More Than Chemistry
The famous “Rat Park” experiments by psychologist Bruce Alexander showed that rats in enriched environments with social connection and stimulation largely ignored drug-laced water, while isolated rats in barren cages compulsively used.
Human research shows similar patterns. Veterans who used heroin heavily in Vietnam largely stopped when they returned home, without treatment, without withdrawal management. The change in context eliminated the need for the solution that heroin provided.
If addiction were primarily about brain chemistry and physical dependence, context shouldn’t matter this much. But it does.
I’ve watched clients stop drinking not because they “worked their program” but because they left abusive relationships, found jobs that didn’t destroy them, or built communities that offered connection. The substance use was solving a problem. Change the problem, and the solution becomes unnecessary.
The “One Use Away from Rock Bottom” Myth
The disease model teaches that one use will inevitably lead to relapse and catastrophic consequences. “One drink is too many, a thousand is never enough.”
But research on relapse shows a more nuanced picture. Many people use once or occasionally after a period of abstinence and don’t spiral. The “inevitable” progression isn’t inevitable at all.
A study published in Psychology of Addictive Behaviors found that the majority of people who returned to use after treatment did not return to problematic levels immediately. Many moderated their use or stopped again without formal intervention.
This doesn’t mean relapse isn’t serious or that use is safe. It means the brain disease model’s prediction — that any use triggers an uncontrollable disease process — doesn’t match the actual variability in human experience.
People Who “Should” Develop Addiction Don’t
If addiction is primarily about exposure and brain chemistry, everyone exposed to addictive substances under the right conditions should develop addiction.
But they don’t. Most people who use potentially addictive substances — alcohol, prescription opioids, even cocaine or heroin — don’t become addicted.
Research suggests that only about 10–15% of people who use alcohol develop alcohol use disorder. For opioids, the rate is higher but still not universal — estimates range from 20–30% for prescription opioid users.
The disease model can’t adequately explain this variability. If it’s a brain disease triggered by substance exposure, why do most exposed people not develop it?
The answer: Because addiction isn’t primarily about the substance. It’s about what the substance does for the person in the context of their life.
What Addiction Actually Does (The Function, Not the Pathology)
In my clinical work, when I ask people what their addiction gave them before it became a problem, the answers are remarkably consistent:
“It made me feel normal for the first time.”
“It quieted the noise in my head.”
“It was the only time I felt connected to people.”
“It made the pain bearable.”
“It gave me confidence I’d never had.”
“It was the only thing I could control.”
Addiction provides relief from:
- Chronic emotional pain (trauma, grief, shame)
- Unbearable anxiety or depression
- Social isolation and disconnection
- Lack of meaning or purpose
- Chronic physical pain.
- Overwhelming responsibilities with inadequate support
- Feelings of inadequacy or worthlessness
The substance or behavior isn’t the problem. It’s the solution. The problem is that the solution eventually creates its own set of devastating consequences.
But if you only address the solution (stop using) without addressing the problem it was solving (unbearable internal or external circumstances), you haven’t actually helped the person. You’ve just removed their coping mechanism and left the unbearable circumstances intact.
This is why so many people relapse. They get sober, but nothing else changes. The pain they were medicating is still there. The isolation is still there. The trauma is still there. So, of course, they return to the thing that reliably made it bearable.
The Harm of the Disease Model (That Nobody Talks About)
The disease model isn’t just wrong — it’s actively harmful in specific ways:
It Creates Learned Helplessness
“I’m powerless over my addiction” is the first step in many recovery programs. And for some people, accepting powerlessness over the substance is liberating — it releases them from the burden of willpower and self-blame.
But it also teaches that you’re fundamentally broken, that you’ll never have agency over this part of yourself, that you’re one drink away from disaster for the rest of your life.
Research on learned helplessness by psychologist Martin Seligman shows that believing you have no control over outcomes leads to passivity, depression, and reduced motivation to change.
Some of my most successful clients are people who rejected the powerlessness narrative and instead cultivated a sense of agency: “I struggle with this, but I’m not powerless. I can learn skills, change my environment, and make different choices.”
It Makes Identity Out of Pathology
“Hi, I’m John, and I’m an alcoholic.”
This ritual, repeated in millions of AA meetings, makes addiction central to identity. You’re defined by your struggle, forever.
For some people, this identity is grounding and helpful. It provides community and shared understanding.
But for others, it becomes a prison. They can’t imagine themselves as anything other than “an addict.” Years into recovery, they still organize their entire life around not using, rather than around what they’re building toward.
I’ve had clients who’ve been sober for a decade, still attending meetings multiple times per week, still introducing themselves as addicts, still unable to separate who they are from what they struggled with.
Research on identity and behavior change shows that people are more successful at sustaining change when they develop a new identity (“I’m a person who values health and clarity”) rather than a negative identity defined by what they’re avoiding (“I’m an addict who can’t drink”).
It Pathologizes Normal Human Adaptation
Here’s what makes me most uncomfortable about the disease model: It takes people who’ve adapted to survive unbearable circumstances and tells them their adaptation is a chronic brain disease.
If you were abused as a child and alcohol is the only thing that makes you feel safe enough to sleep — that’s not a disease. That’s trauma. The drinking is a symptom, not the primary problem.
If you’re chronically isolated and lonely and gambling provides the only social connection and excitement in your life, that’s not a disease. That’s a solvable life problem. Address the isolation, and the gambling often resolves.
If you’re working three jobs to support your family and methamphetamine is the only way you can stay awake and functional — that’s not a disease. That’s structural inequality and economic injustice.
The disease model medicalizes social, economic, and psychological problems. It says the problem is in your brain, not in your circumstances. This conveniently removes pressure to address the circumstances that make addiction adaptive.
What Actually Helps (And What Doesn’t)
In working with people struggling with addiction, I’ve found that the interventions that work best are the ones that:
If someone was used to numb trauma, treating the substance use without treating the trauma is futile. Trauma-informed therapy — EMDR, somatic experiencing, internal family systems — addresses the root.
If someone was using because of chronic isolation, creating genuine community and connection is more important than any addiction treatment program.
If someone was using to escape unbearable work or family circumstances, helping them change those circumstances is the intervention.
Research by psychologist William Miller on motivational interviewing shows that addressing the life problems driving addiction is more effective than focusing solely on stopping use.
Build a Life Worth Being Sober For
This is the insight at the heart of harm reduction approaches: People don’t stay abstinent just because they “should.” They stay abstinent when they have something better.
A job they care about. Relationships that matter. Purpose and meaning. A vision for who they want to become. Activities that provide genuine pleasure and connection.
If sobriety means returning to the same miserable circumstances that drove you to use, why would you stay sober?
The most successful recovery I’ve seen involves helping people build lives where sobriety isn’t a sacrifice but an obvious choice because it enables the life they actually want to live.
Cultivate Agency, Not Powerlessness
Research on self-efficacy by psychologist Albert Bandura shows that believing you can successfully change predicts actual behavior change better than almost any other factor.
The clients who succeed are the ones who develop a sense of competence and control: “I’ve learned what triggers my use. I’ve developed coping skills. I’ve changed my environment. I have power over this.”
This doesn’t mean denying the difficulty or the biology. It means framing yourself as an active agent in your recovery, not a passive victim of a chronic disease.
Create Environments That Support Change
Context matters enormously. Research shows that changing your environment is often more effective than trying to change your willpower.
This might mean:
- Leaving relationships or communities that reinforce use
- Moving to a new location without drug connections
- Changing jobs to reduce stress or access to substances
- Building new routines that don't include use
- Creating accountability structures (not the same as powerlessness — this is choosing to involve others in supporting your goals
The disease model focuses on changing the individual. But often, changing the environment is what actually works.
The Alternative Framework (Addiction as Learning)
If addiction isn’t a disease, what is it?
Neuroscientist Marc Lewis and psychologist Gene Heyman both argue that addiction is best understood as a form of learning — specifically, deeply ingrained habits formed through repeated reinforcement in the context of solving problems or pursuing rewards.
This framework explains:
- Why context matters so much (habits are context-dependent)
- Why many people "age out" of addiction (life changes alter contexts and priorities)
- Why relapse is common but not inevitable (old learning can resurface but isn't irreversible)
- Why treatment focused solely on abstinence often fails (you haven't unlearned the pattern or addressed what reinforced it)
The learning model also offers more hope: What’s learned can be unlearned. New patterns can form. You’re not broken — you learned something very well in response to circumstances. You can learn different patterns in different circumstances.
This doesn’t minimize the difficulty. Deeply ingrained learning is hard to change. But it’s changeable in ways that chronic progressive brain diseases often aren’t.
What I Tell Clients About Their Addiction
When clients come to me identifying as addicts, believing they have a chronic brain disease they’ll battle forever, I don’t immediately challenge that framework if it’s helping them stay abstinent and build a better life.
But I do say things like:
“The disease model is one way to understand what you’re experiencing. There are others. Let’s see what framework actually helps you build the life you want.”
“What was your substance use doing for you? What problem was it solving?”
“What would need to be different in your life for you to not need that solution anymore?”
“You’ve learned powerful patterns. The brain that learned to pursue drugs so effectively can also learn to pursue health, connection, and meaning.”
“Recovery isn’t about managing a chronic disease forever. It’s about building a life where the thing you were using to cope becomes unnecessary.”
The goal isn’t to convince everyone that addiction isn’t a disease. For some people, that framework genuinely helps.
The goal is to offer hope that you’re not fundamentally broken, that change is possible, and that recovery isn’t just about abstinence — it’s about addressing what drove you to seek escape in the first place.
The Bottom Line From Someone Who Sits With Addiction Daily
After years of working with people struggling with addiction, here’s what I believe:
Addiction is what happens when people try to solve problems they don’t have better tools for. It’s an adaptation that makes perfect sense given the circumstances — until it creates worse problems than it solves.
Calling it a chronic brain disease reduces stigma and gets some people into treatment. But it also traps people in lifelong patient identities, obscures the social and psychological roots of addiction, and implies that the problem is fundamentally in your brain rather than in your life.
The truth is more complicated and more hopeful:
Your brain did change. But brains change all the time. That’s what they do. Those changes aren’t a permanent disease — they’re evidence of powerful learning that can be unlearned.
You’re not powerless. You’re someone who found a solution to unbearable problems, and that solution became its own problem. Understanding what you were solving is the first step to finding better solutions.
Recovery isn’t about managing a chronic disease forever. It’s about addressing the pain that drove you to seek escape, building a life that’s actually worth being present for, and developing the skills and support to handle life’s difficulties without needing to numb yourself.
Some people will always identify as addicts in recovery, and that’s fine. But you don’t have to. You can be someone who struggled with addiction for a period of time and then became someone else.
You’re not broken. You adapted to survive. And you can adapt again — this time toward health, connection, and a life that doesn’t require escape.
That’s not a chronic disease. That’s being human.
Please go here for the original article: https://medium.com/@constantinpatrascu/im-a-psychologist-and-addiction-is-not-a-disease-here-s-what-it-actually-is-and-why-that-7098aa588e50
Suggested reading:
The Myth of Normal: Trauma, Illness,
and Healing in a Toxic Culture
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No Bad Parts: Healing Trauma and Restoring Wholeness
With the Internal Family Systems Model
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Please also check out this related excellent video interview with Gabor Maté, Richard Schwartz, and Marc Lewis on Rethinking Addiction:
