Addiction as a Marker of the problem
The title refers to a perennial disagreement among people who treat addictions of all sorts, namely whether to think of addiction (to alcohol or sex or anything else) as the problem (disease, disorder’) itself, or whether to think of addiction as one sign (and not the only one) of a problem that actually generates the addiction (as well as other signs, if one looks carefully).
First a caveat: addiction is a loose term that cannot be precisely defined. People (lay and professional) speak of addiction when an individual displays sufficiently troubling behavior concerning a substance or activity (e.g., gambling) to attract concern for his/her safety and welfare on the part of other people who know and care about the course of his/her life. Such a definition, correctly in my view, cannot be reconciled with a strictly biological view of addiction.
The immediate stimulation for me to write this piece on addiction was reading a remarkable article about obesity by Felitti et al., 2010 (Obesity: Problem, solution, or both? The Permanente Journal, 14, 24-30). The authors report on their clinical and research experience treating (morbid) obesity via absolute fasting supported by nutritional supplements and group therapy. Absolute fasting supported by nutritional supplements (they say hunger is not a problem) is quite safe and takes off a lot of weight quickly if people actually refrain from eating, but in the early years of the program they observed two complications: 1. people who refrained from eating and lost a lot of weight frequently could not tolerate the emotional consequences of (presumably necessary and highly desirable) weight loss, and 2. people who did not lose weight were obviously eating and lying about it, but they none the less wanted to stay in the program for the social and emotional support they received from the group.
The above complications inspired the clinicians to conduct a detailed exploration of the life histories is of their patients (a sample of 286 consecutive patients, to be exact). The original sample grew to 2000 over the years (these were Kaiser Permanents patients in San Diego). They were surprised to discover (I should say as physicians who thought about obesity in medical and biological terms they were surprised to discover) frequent histories of sexual abuse and other features of growing up in ‘markedly dysfunctional households’ in the lives of their patients. Their findings led them to revise their treatment plan: from thinking about supplemented fasting and education about ‘how to eat right’ as the treatment to recognizing that deeply personal revelations and efforts to face and resolve old injuries in the group setting was actually the treatment. As the authors say in their article: “we have seen that obesity is not the core problem. Obesity is the marker for the problem and sometimes is a solution. This is a profoundly important realization because none of us expects to cure a problem by treating its symptoms” (p. 26). They make the same point concerning all addictions. They have a revealing saying about a person’s insatiable desire for his/her addictive substance or activity: ‘it’s hard to get enough of something that almost works.’ (p. 28).
What is the relationship between a person’s life history and obesity? Sometimes it seems straightforward, e.g., a woman sexually abused as a child reasons that obesity is good protection from male sexual interest (the authors point out that women in their groups (I assume they are referring to women) answer the question ‘What are the advantages of being overweight?’ based on some variation of the following: it is sexually protective, it is physically protective, and/or it is socially protective in that people expect less from you). Obviously all children who experience sexual abuse or otherwise grow up in a dysfunctional household do not become morbidly obese as adults. Notice I am not suggesting that such children simply shrug off what they have experienced growing up when they get older.