Charlie Sheen and America’s Addiction to Disease Theory

Last night’s prime-time interview with the disgraced Hollywood actor Charlie Sheen (who really needs no appositives by now) provides an excellent window into the manner in which the public health problem of substance abuse is handled in the United States. Sheen’s interrogator, a prim-and-proper Jeff Rossen of NBC, served as Sheen’s foil, masterfully feeding Sheen softball-style questions firmly grounded in the puritanical morality of America’s middle class: “Gee there Charlie, you live with two girls half your age; and wow, you’ve been known to stay up all night partying, in places like New York City for heaven’s sake, and you smoke cigarettes as well as God knows what else; and you really think you’re worth all this money, what, two million for only half an hour’s worth of work?”

Egged on by Rossen, Sheen obliged his audience with delusional, repetitive, practically autistic gibberish about “tiger blood” and “rocketships to the moon and beyond.” More to the point of this article, however, is what someone reading between the lines could discern from Rossen’s conspicuously conventional wisdom about how those battling “the disease” of addiction to alcohol or other psychoactive drugs “need AA” in order to “stop using and get sober.”

Current medical opinion in the United States runs something like this—those who are addicted to drugs have a disease requiring medical treatment, like cancer or pneumonia. Left untreated, the disease may result in death. Treatment for addiction, after the initial detoxification stage, is two pronged: first, doctors look at the underlying causes of drug-seeking behavior, such as depression (also characterized as a disease); then, due to the patient’s history of drug use and concomitant emotional problems, doctors recommend therapy, which typically takes the form of either a 12-step program like AA, or, for those who can afford it, psychotherapy faithful to 12-step principles.

The American medical establishment basically accepts these premises without a whole lot of critical evaluation. The result is that addiction treatment, fueled by insurance premiums, has become a multi-billion dollar business, a truly vested interest, right down to claims of infallibility, demonization of critics, and other forms of intellectual defensiveness. Yet even with divine intervention, the success rate of “rehab” programs is uncommendable. In light of the intellectual incoherence of the disease theory of addiction, perhaps that should not surprise anyone.

The American philosophy of addiction treatment (which I call “disease theory”) is an admixture of evangelical Protestantism and Freudian psychoanalysis, which generally reflects the northern European roots of American thought. Heavy on determinism,  disease theory is attractive because it absolves the patient of all moral culpability while holding out the promise of immediate redemption. If one is born predisposed to be an addict (or depressed, or a murderer), it is hardly his fault when he turns out that way. Such people are not to be judged, but to be treated with compassion. After all, God loves a sinner who has seen the light.

So far so good—but if addiction is really a disease, then what is the cure? As it turns out, the answer is largely that the addict needs to stop getting high. At this crucial point in an addict’s recovery, disease theory collapses under its own deterministic weight. Indeed, as is the case with all modern psychology, disease theory is structurally unsound, in that it posits a fundamentally deterministic theory of causation, while placing all hope for future success on the patient’s dogged application of free will. Now, it may be objected that 12-step programs solve this problem by substituting God for the free will of the patient, but that is not an argument that a twenty-first-century Western physician is going to make in public. And yet our doctors have no choice—pushed into the deterministic corner by economic and cultural forces, they have to make a stand. Should the medical establishment flirt with the forbidden fruit of free will, disease theory comes undone at once, and with it, the ability to place addiction within the purview of the health-care industry.

Enlightened physicians today, both here and in Europe, will tell you that people have been self-medicating the human condition since God kicked Adam and Eve out of the Garden. What in other times went by the more poetical names “ennui” or “melancholy” today have rational, scientific labels like “unipolar depression” or “attention deficit disorder.” The point is that certain people, for whatever reason, are more easily seduced by a chemically altered state of mind. Thus the greatest advances that have been made in modern times toward battling addiction (and its cousin, depression) have come from pharmaceuticals themselves.

It is unclear what position 12-step programs take on the use of a mind-altering substance such as Zoloft. However, anti-depressant drugs, while potentially dangerous and certainly capable of creating physical dependence, are finely tuned tools befitting the twenty-first century, which, with near-surgical precision, do a far better job than such blunt instruments of the past as alcohol, cocaine, or opium.

Charlie Sheen’s outrageous remarks will not shift the debate on disease theory in a positive direction. If anything, he only bolsters the deterministic refrain of every backwoods preacher, namely, that one either admits he is doomed or is in denial. Thoughtful doctors who are familiar with the canon of psychiatric literature but still care about helping patients must recognize in their heart of hearts that disease theory is on its last legs, as the power of prayer simply cannot form the basis for an effective medical treatment plan in this day and age.

Rather like the southern officer at Gettysburg, who, faced with Colonel Chamberlain’s bayonet charge, shot at the Yankees with his right hand and offered his sword in surrender with the left, today’s doctor battles addiction with an untenable mix of newfangled pharmaceuticals and old-time religion. Times are clearly changing. When it comes to mental illness in general, and substance abuse treatment in particular, the ultimate question is this: Will history judge today’s practices as harshly as we now judge those of our ancestors? I suspect it might.

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