Is Substance Abuse a Mental Illness? (Not Crazy Podcast)
Is addiction a disease? A mental illness? In today’s show, Gabe and Lisa cover every angle of this hotly-debated topic. Gabe also shares his personal experiences with addiction and how it relates to his bipolar disorder. Click on the player below to listen now!
Computer Generated Transcript for “Mental Illness- Substance Abuse” Episode
Editor’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Lisa: You’re listening to Not Crazy, a psych central podcast hosted by my ex-husband, who has bipolar disorder. Together, we created the mental health podcast for people who hate mental health podcasts.
Gabe: Hello, everyone, and welcome to this episode of Not Crazy. My name is Gabe Howard, and with me, as always, is Lisa.
Lisa: Hey, everyone. So, today’s quote is from F. Scott Fitzgerald. And he said, first you take a drink, then the drink takes a drink, then the drink takes you.
Gabe: So this should really clue everybody in that we are going to be talking about mental illness and addiction. There’s so much. Is addiction a disease? Is addiction a mental illness? And here’s where it gets, like, really crazy. All right. It’s not Not Crazy. It’s actual crazy. The co morbidity of the two is extreme. A lot of people with severe and persistent mental illness have abused drugs and alcohol. And a lot of people over on the addiction side have untreated, undiagnosed and unmanaged mental illnesses. We’re just all this like codependent little family, except we think that the other side is the problem and is worse, and we’re not really.
Lisa: It’s basically a co-morbid little family, right?
Lisa: Right. See what I did there?
Gabe: We should be friends,
Gabe: But we’re not. We’re like mortal enemies, which shows you how much stigma there is in both issues.
Lisa: Yeah, neither side is willing to take on the stigma of the other side in addition to their own. So, I was trying to look up some stats for this. How often do people with mental illness have addiction and vice versa? And it is all over the place, ranging from 9% to 90%, which means these numbers are essentially worthless. According to SAMHSA, 17% of people with a substance use disorder seeking treatment have a serious mental illness, and 27% of people with a serious mental illness have a substance use disorder.
Gabe: I think about when I was diagnosed with bipolar disorder, I then had to address the fact that I was abusing drugs and alcohol. Now, I was abusing a lot of other things. I was abusing food. I weighed five hundred and fifty pounds. I was basically, I was just abusing anything that I could to help dull the pain from the depression, from the mania, from the psychosis. And this is not an uncommon story.
Lisa: It’s very common. Yeah, we hear it all the time.
Gabe: Right, my story is very common. And I got help for it. I got therapy. I talked to a lot of people and never once did it occur to me that one was different from the other or better than the other. I really had it all framed in this is what bipolar disorder looks like.
Lisa: Really? So you personally always thought that they were all part and parcel of one another?
Gabe: I did. I subscribe to the self medicating version of addiction, which is kind of arrogant, right? I mean, it’s just. No, no, no, no, no. I wasn’t an alcoholic even though I abused alcohol. No, no, no. I wasn’t a drug addict, even though I abused drugs. No, no, no. I was self medicating. Like, doesn’t that make me sound so good? No, no, no, no, no. All the stuff that I was doing so wrong was to save myself. But that is why I did it.
Lisa: But it depends on which side you’re on, the I may be a drunk, but I’m not nuts. Versus the, oh, I have mental illness, but I’m not some junkie. It depends on which side you’re on as to whether or not that sounds arrogant.
Gabe: When I first started this journey, you know, again, all the way back in 2003 and I never considered myself an addict because once I got bipolar disorder treated, the other stuff did go away. I never had to directly challenge, fight, or get help for substance abuse disorder. As soon as the bipolar was diagnosed and treated, I did have to, like, address it. But it was always, it was always adjacent to bipolar disorder. I do wonder, and you were around, Lisa, did you consider me an alcoholic?
Lisa: I did not. Before you were diagnosed with bipolar, did you ever think to yourself, wow, I have a problem with these substances? Did you ever think, wow, I drink way too much? You know?
Gabe: Sort of, you know, a couple of times I woke up in random places just like literally straight up random places around a bunch of strangers, and I knew the night before that I had.
Lisa: Blacked out.
Gabe: Yeah. But here’s where it gets kind of sketchy in my own mind. Lisa, did I blackout because I was up for five days and my body just finally quit on me? You know, mania takes a toll. Did I blackout because I had psychosis and nobody else thought I blacked out, I just don’t remember it? Nobody was like, oh, this one was mania. This one was definitely drug use. Oh, this one was alcoholism. Oh, this over here was because he was up for four days. I don’t know.
Lisa: Ok. So what did you think at the time, though, did you think you were an addict at the time?
Gabe: I don’t know that I thought I was an addict. But at no point did I ever think that I had a mental illness. At no point did I think I was bipolar. I absolutely thought, huh, maybe I drink too much, but I’m not sure that I cared because I was just so desperate.
Lisa: Ok, so for you personally, at the time, you did not feel like you were an addict or an alcoholic, and I agree with that. Once your bipolar disorder was medicated and under control, alcohol and drugs just didn’t seem to hold any interest for you anymore. From the time you first started treatment, you pretty much never used after that.
Gabe: I genuinely believed that I was, in fact, self-medicating. I never drank or did drugs alone. I always did them in the confines of other people, signifying to me that what I was actually addicted to was having people around. And I got started with this whole drinking and drug use thing, not out of a desire to drink or to use drugs, but because people wouldn’t let me stay around if I wanted to stay sober. Nobody wants to be in a room with the sober guy. So, either get busy drinking, get busy doing drugs, or get busy leaving. And finally, the last thing that I want to say that I feel is very relevant, if you buy people drinks, if you buy people drugs, they will pretend to be your friend. And I was desperately lonely. It’s why I hired sex workers. It’s why I bought people alcohol. It’s why I spent a lot of the money I did. But to tie this back, Lisa, I’m still interested in why Gabe Howard is like, no, no, no. I didn’t have a problem with drugs and alcohol. It was just a bipolar disorder. Is it because I’ve taken an honest stock of everything that I went through and decided, OK, yes, it was a symptom of bipolar disorder? That very much could be true. Or is it because I don’t want to be like my biological father who literally died of alcoholism? Or because I don’t want to be like the town drunk? Or I don’t know? From my stay in the inpatient hospitalization, I got the bipolar disorder treated and I stopped abusing drugs and alcohol. So why when I say I have 17 years in recovery, and people say, from what? I say from bipolar disorder, I never say from bipolar disorder, alcoholism, hypersexuality, drug use. I just consider it all bipolar disorder. Is that because that is true for Gabe? Is that my own arrogance?
Lisa: Is that the social stigma of addiction?
Gabe: I don’t believe that any of these things are true. But I gotta tell you, I don’t believe that’s why I don’t say it. But why do other people not say it?
Lisa: I have just been surprised in the past. I’ve heard you tell your personal story many times. And some people really focus on the drug and alcohol thing as, frankly, a moral failing. And suddenly they lose sympathy. Right? Oh, that’s so sad. You were depressed? You wanted to die by suicide? Oh, you poor little lamb. That’s so sad. Oh. And then you shot up? I don’t know. It’s amazing how many people are judgmental of that, but not of anything else.
Gabe: It is interesting to me, and I’m using interesting in place of disturbing or incredibly sad
Gabe: That people seem to feel, I don’t know, like anger toward me for having abused drugs, like, how could you do that to your body?
Gabe: But the part where I jumped off a roof. The part where I took unnecessary risks with my life. The part where I stayed up for days at a time. They consider those almost like amusing stories.
Gabe: Yeah. They’re like, oh, that’s awesome. You did that? You must have been wild back in the day. And it’s interesting. Right. Or depressing. I don’t know.
Lisa: Well, it’s mostly depressing. But is that just a function of the circles that we run in? You’ve always stayed very much, as you should, on the mental illness side of things, because even though there’s been a lot of things, you know, the county boards in Ohio have been integrated. They’re now alcohol, drug and mental health boards. They don’t have them separated out anymore. We don’t have the Ohio Department of Mental Health and the Ohio Department of Drug and Alcohol Abuse anymore. They combined into one. Even though that’s happened, there’s still very much a divide, on all levels, between treatment providers, between people seeking treatment. There’s very much a divide. Do you think that’s partly a function of you’ve always stayed on the mental health side of the divide?
Gabe: That is the longest way of saying, Gabe, do you think you’re just talking to the wrong people? That I have ever heard. But now there’s an interesting point that needs to be discussed. Is addiction, a mental illness? And spoiler alert, just to save everybody the time, nobody can agree. Just nobody can agree.
Lisa: Yeah, it’s all over the place.
Gabe: There is just much debate. And when I say debate, I don’t mean like among mental health advocates. I don’t mean among the public. I mean, like among the people who are tasked with helping people with mental illness and addiction. Lisa, what are your thoughts like? Do you think that addiction is a mental illness?
Lisa: I do not. But I have to say, doing the research to this show, they have many more compelling arguments for the disease model of addiction than I had thought. And.
Gabe: You’re answering a different question, though. I didn’t say is addiction a disease? I said, is addiction a mental illness? So.
Lisa: Well, if it’s a disease, it has to be a mental illness.
Lisa: What else would? What? What do you think it is? Do you think it’s a rheumatology problem? I mean, what?
Gabe: No, but why is? Once again, I think this is the problem in the mental health and the mental illness field. We just have this, like, one word. No, of course, I don’t think it is cancer or a rheumatology problem or an STD or, I’m having trouble coming up with other types of things. But why is mental illness so damn broad? Mental illness. Is it.
Gabe: We need to get like definitions here. It’s bipolar disorder. It’s major depression. It’s schizophrenia, psychosis. It’s anxiety. It’s obsessive compulsive disorder. These are severe and persistent long-term mental illnesses. It just, it’s become this muck.
Lisa: So it seems like you’re saying that it’s definitely a disease, but you’re not sure whether or not it’s a mental illness? From those things you have just listed, how are they not the same? There’s no definitive test. It’s all about behavior. What makes this different?
Gabe: Obviously, this is an issue where Gabe Howard’s personal bias is going to come into play. See, I didn’t do anything to have bipolar disorder. I just have bipolar disorder. I feel that in substance abuse, you’ve got to take that first drink.
Lisa: But all sorts of social pressures determined whether or not you take the first drink.
Gabe: I get it. And it’s not your fault, and I’m certainly not trying to judge people, but I just I feel that you have more control over it and I feel like there’s less control in severe and persistent mental illness. But I also feel that it’s a quagmire of how many catch-alls can we have under mental illness? You know, right now, mental illness means, oh, I’m a little bit nervous on Mondays when I get up and I have butterflies and severe psychosis. And all of those things are tabled under mental illness. Isn’t there another category that we can put it under? I guess it is biologically brain based.
Lisa: Well, then that makes it a mental illness.
Gabe: Does it? Is mental illness the catch over all of our behaviors?
Lisa: Well, once again, mental illness is not clearly defined. So, yes, it is. Yes.
Gabe: I just.
Lisa: Yes. That is how we’re doing it. We have decided that is a mental illness. That is the system.
Gabe: Listen, here’s what I’m saying. When somebody says mental illness, I guess I don’t want them to think of a cigarette smoker. When somebody says mental illness, I don’t want them to think of somebody who drinks too much. When somebody says mental illness, I want them to think of depression, bipolar, schizophrenia. I want, and I don’t know why this is so important to me.
Lisa: Well, that’s what I’m gonna say, why is that so important to you? Is it about your own biases or your own dislike of addicts?
Gabe: Maybe. I don’t dislike addicts. I.
Lisa: Then why don’t you want them in your club?
Gabe: Because my club is so full. You know how frustrating it is? Oh, I go to a therapist. I’m just like you, Gabe. No, you’re not. You’re not just like me, OK? I’m sorry that you’re suffering from stress. And that’s like a really serious thing. But I stood outside my house walking the perimeter because demons were going to kill my wife. All right? You’re having trouble adjusting because your kids left home. It’s not the same thing, but it’s all under the mental illness umbrella. And just adding one more. When I say I have a mental illness, I want you to have some idea of what I have. Well, it’s so broad that it’s become ridiculous.
Lisa: Ok. So, it goes back to that whole we cannot have a meaningful discussion about this unless we’re all using the same terms.
Gabe: Yes, that is one of it. When somebody says mental illness and they picture in their mind a father whose child just went to college and he’s kind of feeling down. What does that do for the homeless population? What does that do for people with psychosis? What’s that do for people like me with my bipolar disorder? They’re just like, eh, he’ll get over it.
Lisa: It dilutes the seriousness.
Gabe: It dilutes it so much. I think that substance use disorder and alcoholism is extraordinarily serious. And I want people to know what that is, what that looks like and how to help. And the treatments that I, as a person living with bipolar disorder need, and the treatment that somebody with substance use disorders needs are so different that to give them the same name.
Lisa: The problem is that mental illness is entirely culturally constructed, right? The things that we determine are mental illnesses aren’t necessarily going to be in 100 years and weren’t necessarily 100 years ago. Either because of increased scientific knowledge or because social mores have changed.
Gabe: Look, all I know is that in 1950, you would have a mental illness because you’ve had sex with people who are not just your spouse, and for a woman to want to do that means that she’s batshit crazy.
Lisa: Yeah, there’s billions of examples of that. Hysteria, the mental illness of slaves who wish to escape, homosexuality was a mental illness for forever. It is socially constructed. So, when you talk about is addiction a mental illness? If we want it to be? Sure, because the whole thing’s arbitrary.
Gabe: That is like you should run for political office, because you said bunch of stuff.
Lisa: Why? It’s true.
Gabe: That like, it is true. There is nothing untrue in there. I don’t think you said anything. You basically said it could be here or it might not be. It’s all socially constructed. There’s
Gabe: Are you saying that it’s good? It’s bad? I mean, if it’s all socially constructed, then I guess nobody’s sick. We’re just making it up.
Lisa: No, that’s not what it means at all.
Gabe: But I don’t
Lisa: Be quiet for a second, and I’ll tell you.
Gabe: But I don’t know what it means.
Lisa: Well, if you’d shush, I’d tell you
Gabe: Ok. Sorry.
Lisa: I do think that the lack of definitive definitions, because we’re not even necessarily talking about the same thing. How do we know we’re even having the same conversation? If we all had a consistent way of talking about these issues, we would be able to figure out where we agree and where we don’t. And we could move forward faster.
Gabe: Our whole conversation is discussing whether or not addiction is a mental illness.
Gabe: And I do love your joke of you think it’s rheumatitis? No. I don’t even know what rheumatitis. Is rheumatitis a real thing? Did I just make that up?
Lisa: No, you just made that up.
Gabe: I just made that up. It’s not cancer.
Lisa: Well, I’m just saying, is it an endocrine disorder? If it’s not a mental illness, what is it?
Gabe: I don’t know.
Lisa: If it’s a disease, it has to be a mental illness. Because it’s one, involved with the brain and brain structures, and two, behavior. There is no other category of disease that manifests in such a way. If it is a disease, it has to be a mental disease.
Gabe: So let’s talk about that for a moment.
Lisa: I have never thought that addiction was a disease, but doing the research for this episode, I’ve learned a lot of stuff and now I’m not quite as sure as I was.
Gabe: Lisa, I understand why, as a lay person, and especially given the traumatic history that alcoholism has played in your own life, I understand why you have trouble seeing it as a disease. Because there’s sort of a moral value in a disease, right? Oh, it’s not your fault.
Gabe: But if it’s not a disease, what is it? We have personally seen in our own families alcoholism and drug abuse wreck people whom we love.
Lisa: And kill people.
Gabe: If that’s not a disease process, what is it?
Lisa: A moral failing? A poor behavior choice? I don’t know.
Gabe: And that’s, of course, something that people say about mental illness, too.
Lisa: That’s true.
Gabe: Gabe, why are you screaming at people? Why don’t you just stop? Well, it’s bipolar disorder Yeah, I don’t know.
Lisa: Why don’t you control yourself? Yeah, that’s a problem for me. That is one of the things that I’m struggling with. And I wonder if one of the reasons I’m not willing to say or accept that addiction is, in fact, a disease and a mental illness is because of my own history, how I grew up?
Gabe: You want to continue being angry at the people whom you are already angry with. You don’t want to have sympathy for them. Is holding on to your anger a form of stigma? Because you want to be mad at these people. And if you consider the part that maybe they have an illness that they can’t control, you’d kind of be a jerk for being angry at a sick person. I don’t know. You’ve never been mad at me for throwing up on you.
Lisa: Well, that’s actually an excellent example, because I am angry at you for throwing up at me, or at least annoyed. Because if you’d listened to me, it wouldn’t have happened. There was stuff you could have done that would have made you not vomit on me. And there are things that addicts can do to make their lives and the lives of the people around them not so bad.
Gabe: But isn’t that true of all illnesses, like of all diseases? I mean.
Lisa: Yeah, that’s where it breaks down. I suppose part of it is a continuing anger at addicts. And growing up, my parents did not have a high opinion of drug and alcohol users. I was heavily indoctrinated as a child, as were many people my age with Just Say No. All the anti-drug and anti-alcohol ads. If you do cocaine even one time, less than a week later, you will jump into an empty swimming pool and die.
Gabe: The propaganda was incredible.
Lisa: The propaganda was intense. It’s basically reefer madness, but for the 80s generation. And even though I now recognize that a lot of that was ridiculous, I just have never been able to get over it. I have trouble looking at an alcohol or drug user and not thinking, one, you’re an idiot, and two, people who use alcohol and drugs are bad, morally bad. Having said that, doing the research for this episode has shaken me a little bit.
Gabe: I’m glad that you’re being honest, but you’re debating whether or not addiction is a disease. I’m debating whether or not addiction is a mental illness and while we’re trying to figure out, where it falls in, how we should talk about it. What words should we use? You know, should we say alcohol abuser? Should we say addict? Should we say person who drinks too much? Like, I already know that we’re gonna get letters because we’ve defined substance use disorder in so many different ways throughout the show that I’m pretty sure we’ve now offended everybody. And it’s literally not our intention. But this is all a distraction from what’s actually important, which is how do we help people who want to get better? How do we help people who don’t realize they need to get better? How do we help?
Lisa: We’ll be right back after we hear from our sponsors.
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Gabe: Hey, Lisa, before we get back to our conversation, I wanted to ask, are you struggling with your mental health during the pandemic?
Lisa: Well of course I am. Everybody is, we’re all quarantined.
Gabe: Well, I want to tell you about a 4-week, fully remote program that I found developed by experts in digital therapeutics. It’s literally designed to help you manage excessive stress during the COVID-19 pandemic.
Lisa: Yeah, and whether that stress is about your health, the new way of life, or your financial future, this program will help you turn anxiety into a balanced emotional state, all from home.
Gabe: The program includes access to mental health resources and exercises, an app to journal your emotions, as well as weekly online 15-minute sessions with qualified coaches.
Lisa: So, we encourage all of you to check it out now at the Feel Relief website.
Gabe: Get the mental health support you deserve, all while staying safe at home. Go to the Feel Relief website for more info.
Lisa: And we’re back, trying to figure out if addiction is a disease.
Gabe: Lisa, let’s define addiction. You know, we’re halfway through the show, so now is definitely a good time to define addiction.
Lisa: Ok, going back to what we said, there are a ridiculous number of different definitions of addiction and addicts, but the ones that I found that I like were physical and mental dependence on a particular substance and inability to stop taking it without incurring adverse effects. The fact or condition of being addicted to a particular substance, thing or activity. Addiction is a complex disease of the brain and body that involves compulsive use of one or more substances despite serious health and social consequences.
Gabe: That really is sort of the definition of mental illness.
Lisa: Right. Right. It’s a problem.
Gabe: It’s a personality trait or a feeling or an emotion that lasts longer than two weeks and it interferes with the activity of daily living. It does almost mirror it exactly. And
Lisa: Well, I have a question
Lisa: When you said I’m debating whether or not addiction is a mental illness and you’re debating whether or not it’s a disease, does that mean that you do believe it’s a disease?
Gabe: I do believe that it’s a disease and I believe that it’s a disease because of all the data that’s surrounding it. And we learned a lot of stuff in doing research for this episode and we learned a lot of stuff by talking to addiction advocates, you know, substance use disorder advocates. And one of the things that they kept coming up over and over again is the mechanism of which this works. And as longtime listeners of the show and followers of Gabe know, I really like Diet Coke. I drink just a tremendous amount of Diet Coke. I get up in the morning, I drink Diet Coke. I drink Diet Coke with all my meals. I drink Diet Coke right before bed. And if I don’t get it, stuff happens.
Lisa: Yeah, you get sick. You’re definitely physically dependent on it.
Gabe: Ok, so I can’t stop. If you told me tomorrow, don’t drink it, I’d have problems. Like when I have to not drink Diet Coke for 24 hours because of a surgery, it’s real bad. I am irritable and angry. And this is soda. It’s pop. None of this has warning labels on it. None of this is street drugs. It’s not alcohol. It doesn’t get me high or drunk. I can drink Diet Coke and drive. Kids are drinking this stuff. I have managed to become addicted to something that is just part of Americana and just everywhere. We gave Diet Coke to my two-year-old granddaughter the other day and nobody thought a thing of it. So now we’ve got somebody who is drinking hard liquor or drugs and they have become addicted in the same way that I am addicted to Diet Coke. And we’re supposed to just believe what? Through power of will they can stop? I don’t even have enough willpower to stop drinking Diet Coke, but I could just wave my magic wand and say, hey, twelve liquor a day drinker. Just stop. It’s for your own good. That’s nonsense. That’s nonsense.
Lisa: But there’s a difference between physical dependence and psychological addiction. Are you really saying, do you really think that you could not go without it? Like if all the Diet Coke in the world disappeared tomorrow, would you die? I mean, what? You really don’t think so?
Gabe: I’d replace it with something else.
Lisa: Well, yeah.
Gabe: Well. OK. So
Lisa: So does that mean?
Gabe: So, if all of the hard liquor A went away tomorrow, do you really think that you’d? No, I’d replace it with hard liquor B or hard liquor C.
Lisa: Well, could you replace it with Diet Coke?
Gabe: No, because the I’m assuming that liquor is the addictive quality there. Also, these things are designed to be addictive. You know, this is where this gets tough as well. I mean, alcohol is designed to be addictive. Drugs are designed to be addicting. I mean, just.
Lisa: Yeah, there’s a profit motivation.
Gabe: I am not a doctor. That should be abundantly clear with the fact that I can’t string together a complete sentence. But I do know this. I have met numerous people, numerous people from all walks of life who were desperate for years to stop doing this, who were motivated by their children, their spouses, their friends, their families, and they could not do it without serious medical intervention. Honestly, that alone tells me that it’s more than just a bad decision that people are making. Frankly, it’s kind of offensive to say, oh, well, just stop. Like, really?
Lisa: But there are a large number of people, admittedly a much smaller number, but there are plenty of people who do, in fact, quit addictions cold turkey and stay clean. That does happen. It’s not common, but it does happen. If it were 100% disease, that would never happen. And then that starts to get into all sorts of existential questions. Does free will exist? If you are compelled to drink a substance or to behave in a certain way do you have free will? Can you choose what to do and what not to do? Are we nothing but a collection of biological impulses?
Gabe: Forty-two, Lisa. Forty-two.
Lisa: Life, the universe and everything? What’s 42?
Gabe: Forty-two is the number of people who have jumped out of a plane at over 10,000 feet whose parachutes did not open and survived. So that proves unequivocally that parachutes are unnecessary. I mean, those people use the equivalent of willpower to survive living. You said so. So, somebody was able to go cold turkey? Who the hell knows? This is, and as far as your existential crisis, and I love that I can never, ever pronounce that word, as far as that argument is concerned. I really feel like this is just such an incredible distraction, whether or not we have free will. The reality is we have free will on some things and not on others. And not everybody has the same free will. That’s the biggest myth in the world, because do you honestly believe? Like a thousand soldiers go to war and a thousand soldiers come back and let’s say a hundred of them have PTSD. So those hundred chose to have post-traumatic stress disorder? But let’s move that aside. Are you saying that the other nine hundred chose not to? Sometimes this is bad luck. You want more examples? Cigarette smokers. Well, I smoked 10 packs a day and I lived to be 109 and it didn’t cause me lung cancer. I hate it when old people say that. Cigarette smoking causes lung cancer. It’s a fact. The end. I don’t care that you’re 185-year-old grandpa survived eating a pound of bacon a day. But everybody uses these sort of folklore examples. But if you want a hard fact, science, 42 people over 10,000 feet jumped out of a plane, lived to tell about it. Therefore, according to you, parachutes are bullshit.
Lisa: That is a compelling argument, and there are plenty of people who are diagnosed with horrible, incurable cancer or diseases or whatever, and make a miraculous recovery. And yeah, choice does not determine whether or not something is a disease. One of the things that I thought was really interesting that I read about was this idea that once you start using heavily, which was a choice, it was a choice whether or not you started using the alcohol or the drugs in the first place. But once you do it, your brain is changed by addiction. And at that point, some people are saying your brain has been changed. You now lose the ability to control it. It’s no longer a choice. Well, there’s plenty of diseases that are influenced by choice. Heart disease, diabetes, cancer often involve some sort of personal choice, like your diet, your exercise, exposure to the sun. But then you get a disease as a result of those choices. Is lung cancer not a disease? Because after all, you chose to smoke cigarettes? Is that an appropriate analogy for addiction? Yeah, I chose to do the cocaine, but now I’m an addict. Yeah, I chose to smoke, but now I have lung cancer. Lung cancer is a disease. I don’t know where to go with that.
Gabe: I understand the trauma that substance use disorder causes. I look in my own family and I see the questionable decisions that some of my family members have made and the ripple impact that it’s had. I understand everything that you’re saying. But, you know, I when I was a kid, I did stupid stuff in a car and I never died. I never got in a car accident. None of those things. But we all read in the newspaper the kid who made literally a nonsense mistake.
Lisa: Or the exact same mistake you made.
Gabe: Or the exact. Yeah, and died. So, I understand how this works. I. The world is not clear and I understand the trauma that is caused by. Again, in my car accident analogy, my parents would have been devastated if I had died in a car accident. And they would have been, I don’t know, maybe more devastated? They would’ve been like, well, what was happening? Well, he turned up his music really loud and decided to drive 80 down a hill because he thought it was funny. I was fortunate and I survived. But looking back on it, wow, I had my driver’s license for less than a year. And there’s all of these warning signs about taking these curves slowly. But I thought it was a roller coaster and I thought it was awesome.
Lisa: There, but for the grace.
Gabe: I don’t know. But this doesn’t matter. Does it matter? Let’s talk about how substance use disorder impacts your brain, because it sounds like we both agree on that. It sounds like we both agree that once you start down the road that these substances impact your brain differently because, for example, I was able to quit. But perhaps if my brain chemistry was different, if my DNA was different, if my genes were different, I would still be addicted to drugs and alcohol to this day. So I didn’t do anything special except inherit good genes, no doubt, from my mother’s side.
Lisa: Well, I have wondered about that, too, because I’m completely on board with the idea that mental illness is not a choice. You can’t convince yourself not to be psychotic. Your brain just does this to you. You can’t control it. So should I be seeing the same thing going into, hey, I have to drink? I can’t control it. I don’t know. But it’s not just an existential crisis. It also has practical implications for our society. Now, that isn’t necessarily the way we should decide whether or not this is not a disease, but, think about it for a minute. If it is, in fact, a disease, what do we do with people who have it? What are we going to do with people who get drunk and kill someone? Do drunk drivers get to go free? Because after all, they have a disease?
Gabe: Yeah, would they be? Would they be not guilty by reason of insanity?
Lisa: Exactly. Are you willing to accept that world? I’m not
Gabe: Well, no,
Gabe: But that’s how come I don’t want to consider it a mental illness. When I think of a mental illness, I think zero choice, literally zero choice says mental illness to me. You have no control whatsoever. It is a medical condition that needs medications and therapy and coping skills. And on and on and on. And just I think of, you know, severe and persistent mental illness. You know, psychosis, you don’t even know your name. Of course, somebody would argue that if you drink enough, you don’t know your name either.
Gabe: One of the things that we learned along the way is how substance use and alcohol can change your brain.
Lisa: I was surprised.
Gabe: I understand that you love the social consequences. And I get it. I understand what you’re saying. But let’s talk about hard core science. Again, like I said, I have good genes from my mom. When I did all the drugs and alcohol, I was able to quit. When other people did drugs and alcohol, it all the sudden started changing things. I believe the exact way that it was worded by the study was that we all like dopamine. Dopamine is a wonderful thing that tells our body that we are enjoying something. We believe that it came from this biological need to survive. So, for example, eating makes us feel good, which encourages us to.
Lisa: Not starve to death.
Gabe: Right. Not starve to death. So that’s good. So let’s say that everything is on a scale of 1 to 10 and eating gives us a 2. So zero is our resting point. We eat, we feel a 2. Now, let’s say that that sex gives us a 5. All right, because most people like sex more than food. So that gives us a 5. Now, you know, let’s be a smart ass for a moment. If you incorporate food into your lovemaking, that’s a 7.
Lisa: And this is how the species propagates and survives.
Gabe: Right. So now enter drugs and alcohol. See drugs and alcohol, they’re a 10. But from my understanding and from the research understanding, it’s actually a little bit worse than that. Not only is it a 10, which, of course, is what makes you addicted to it, because you want that 10. You want to “chase that high.” But not only does it give you a 10, but it does something else that’s rather insidious. It stops sex from being a 5 and it stops food from being a 2.
Lisa: That’s not exactly accurate. It’s not so much that it stops other things from still giving you those neurotransmitters. And I was really surprised at how robust the science is on this. The thinking is that it makes your brain become accustomed to always getting that 10. So now 10 is the only thing that will do. Two, five, six, that just doesn’t cut it anymore. You have to have 10. And so, it becomes that they’re no longer drinking to get the high level of satisfaction, the high level of neurotransmitters. They have now established that high level as their baseline. So, when addicts say, oh, I don’t shoot up to get high, I do it to feel normal. Yeah. Because their brain has been altered by the chemicals to require a new baseline. So, if they do not get that chemical, they don’t feel normal.
Gabe: And, Lisa, in layman’s terms, this is like tolerance, right?
Gabe: So, using alcohol as an example, when I first started drinking, I needed 2 shots. Now I need 10 shots. Or when I first started doing drugs, I needed a little bit of drugs and now I need more drugs. And it just, it builds on itself until your body can’t handle it anymore. And you’re constantly chasing a better and longer and deeper and a more satisfying high because your brain keeps squelching it down.
Lisa: Because your brain is no longer finding satisfaction in the lower levels. These changes are definitely long term and there’s some thought that they might be permanent if you are a habitual user of alcohol or other drugs for a long enough period of time. The science is fascinating and very well established, much better established than I would have thought.
Gabe: I still fall back on does this really matter? Does it matter if it’s a mental illness or if it’s a disease?
Lisa: Yeah, it does actually matter because that will tell us how to treat it. If it is a disease, and not a choice or a moral failing, why don’t we treat it medically? Why is the treatment for this medical condition a set of spiritual steps?
Gabe: Because that’s not the treatment. That’s a peer support group. That should never be the medical model. We should treat it medically.
Lisa: But almost nobody does. Even if you do get help from professionals, you know, therapists, psychologists, psychiatrists, you’re not just counting on support groups or 12 step programs. Even if you do that, almost all recovery or treatment programs are abstinence based. And they’re all just about, hey, stop doing it. There’s not much else there. This isn’t medical science. It’s all about making a decision to change your behavior. There are drugs, etc. available, but almost nobody uses them. Which is strange because apparently, they work like way better than I thought. Apparently, they work really, really well. Which is also something that kind of convinces me this might in fact be a disease, because otherwise why would this work this way? But almost nobody is offered them. And we as a society don’t want people to be offered them. We as a society have chosen to not do it.
Gabe: It crushes my will to live. It literally crushes my will to live that people who are addicted to drugs and alcohol can’t get better than peer support, like for real. That is reprehensible. People with eating disorders get more support. Oh, but everybody has to eat. Not everybody has to eat a sheet cake, Lisa. But notice, that’s the one I couldn’t beat on my own. Can we agree? And it’s just, this is Gabe and Lisa talking. Can we agree that people that find themselves in this place need help? They cannot do it on their own.
Lisa: There’s plenty of people out there who need help. Why should the people who have made the poor moral decision be the ones who get the help? There’s not an infinite amount of help. You could argue that there should be an infinite amount of help. But as of right this second, there’s not.
Gabe: I detest that argument with every fiber of my being. You know what this reminds me of? Why do I need health insurance? I’m perfectly healthy. Well, one, you don’t know that you’re going to be healthy for the rest of your life. And I can’t help but notice that as soon as you find yourself on the unhealthy side, all the sudden the GoFundMe page goes up on Facebook and you’re begging everybody to help you. This is nonsense. It’s just, you know what I hate more than anything? People that say, well, all this bad stuff happened to me and I turned out OK, so that’s why I don’t think we should fix it. Look, you did not, in fact, turn out OK. If something bad happened to you and you got through it and you’re OK with that bad thing happening to other people, that is not the definition of OK. The definition of OK is you wanting to fix the bad thing that happened to you. You’re right, the majority of people will not become addicted to drugs and alcohol and therefore won’t need help. Does this really matter? The majority of people won’t have a blood clot at 22, Lisa. The majority of people won’t have bipolar disorder. The majority of people won’t have all kinds of things. What nonsense are you spewing? Also, it’s just you used a word and I love you so much. But you say it all the time. People who made the moral decision, why should they not get. Really? It’s now a moral decision?
Lisa: Well, yeah.
Gabe: You don’t know why people started drinking. You don’t know why people started doing drugs. Look at my case. I had severe psychosis and bipolar disorder. The only reason that I am not a drug addict, the only reason I’m not an alcoholic is because I have different genes than other people. In other words, I did nothing. I didn’t make a moral decision. I didn’t make an ethical decision. I did all the drugs and alcohol and then I got lucky. I got so lucky that my brain was different. But this is always tabled as everybody who is addicted is somehow morally reprehensible and deserving of our scorn.
Lisa: But that’s part of the thing we’re debating, right? Over whether or not it was just luck or whether you had the conscious choice, that you had the ability to not choose it. And we shouldn’t really base anything on morality because everyone’s morality is different. And who’s to say. But.
Gabe: You did not answer my question. You did not answer my basic question of why are you tabling this as a moral or ethical decision? Can’t sometimes moral and ethical people just make mistakes and not be morally and ethically reprehensible? I’m very uncomfortable with the idea that this is a moral and ethical thing because, one, what was the exact words that you use? These are social constructs? Morals and ethics are social constructs.
Lisa: Yes. Yes. That’s disturbing.
Gabe: I can’t help but notice that you and I have had more sexual partners than we’ve had marriages. So
Gabe: To some people, we are morally and ethically reprehensible.
Lisa: Right. Which is why we should not form public policy on this basis. Because, yeah, where’s that going to stop?
Gabe: This is a public show, and you just tabled this under morals and ethics. You don’t think that the population thinks like you think?
Lisa: Well, that’s my point.
Gabe: I don’t think it’s moral or ethical. I don’t think it is at all. That’s just incredibly offensive because you’re pretending that everybody had the same life as you. It could be. It could be a moral and ethical decision. Absolutely. But to state unequivocally that it is, that pretends that everybody had Lisa’s life. Everybody had Gabe’s life. Everybody had, you don’t know.
Lisa: We’re having two separate conversations.
Gabe: Well, but I’m winning. If we’re having two separate conversation, mine is the better one.
Lisa: You’re saying it doesn’t matter if this is a disease or a choice and we should love everyone, that we should take care of people regardless. That we should give these people help, support, what they need to get better. We should try to solve this problem, consider all the social ills of drug and alcohol addiction, and we should try to fix them. And it doesn’t matter, we should give everyone the support and care that they need regardless. But I’m saying from a practical standpoint, it does matter because it tells us what type of care and support they require. And I do agree with you. Yes, obviously, we should care for everybody regardless. Morality or virtuousness doesn’t have anything to do with it. We should care for all people because who are we to decide? So, yes, obviously, I agree with you. But I do think it matters because it determines what happens next.
Gabe: I understand that there’s no consensus and that that’s really a problem. But that just shows you that the stigma is there. Look, I don’t care. I just don’t care. You know, I really hate this. And one of the reasons I hate it is because I know damn well that if tomorrow, I get it in my head that I want to go skydiving. There is no earthly reason that a 43-year-old man needs to skydive. Other than I just want to. So, I get on that plane, I go skydiving and I land in a tree and break every bone in my body. I didn’t have to go skydiving. There’s no reason for me to go skydiving. I didn’t need to. But you know who’s going to pay for my recovery? My health insurance, 100%. So that’s what, a million dollars? But wait, there’s more. I’m stuck in the tree. Who’s going to get the man with every broken bone in his body out of the tree? I’m assuming that there’s going to be some like police, paramedics. Does this matter?
Lisa: No, I agree with you, it’s the equivalent of I smoke five packs a day and have a heart attack. Or if I fall off a ladder later today, no one is going to say, oh, no, don’t send an ambulance to that woman. What was she doing on a ladder? What kind of fool falls off a ladder? Let her go. But we do hear that when people overdose. We do hear that when people are addicts. Well, I mean, he chose it. Should we really? Should we spend all this money trying to save addicts from themselves? And that is very disturbing. This idea that we are going to make moral decisions of who receives care, of who deserves to live and die.
Gabe: Let’s pick on politicians because they are public figures. They say all lives matter, but they vote against health insurance. They say all lives matter, but they have just extreme poverty in the states that they represent. They say all lives matter, but they’re not doing anything to help people in crisis from the opioid epidemic or people with severe and persistent mental illness that can’t get help. There’s homelessness. People are dying from exposure. Why don’t their lives matter? I’m sorry. I wish that the people who were loudly proclaiming that all lives matter actually believed it and would get together and save all of the people that we’re talking about in this show. It’s just so incredibly frustrating because not only is the all lives matter movement, just it’s a retort. It’s a racist retort to an actual social problem that we have and that needs to be addressed. But what’s even worse is that the people who are saying it, they don’t believe it. I wish to God they believed that all lives matter because the people who are saying that they have influence and power. At the at the very lowest level, they can vote. At the very highest level, we’re hearing politicians say it. I do, in fact, believe all lives matter. And that’s why we need to address the systemic issues that our society has. We’re ignoring vast amounts of people and I’m watching them be ignored under the umbrella of all lives matter. When are we going to fix this? All of us are at risk. One hundred percent of the people are at risk of something bad happening to them that they cannot afford or control. And frankly, one hundred percent of us are at risk of doing something stupid and finding ourselves needing help. Because I’m sorry. Nobody’s perfect. I am not going to go skydiving. But make no mistake, I could run my car into a wall accidentally eating a cookie. I could fall into a hole. My dad fell off a deck. Who falls off a deck? I just, ack! I’m just so tired of this debate. I’m just so tired of it. You know why we should help everybody? Because they are a person. They are a person. And they are deserving of help.
Lisa: But that’s not how thing work, Gabe. Society decides who is worthy of help and resources, and who’s not, all the time.
Gabe: I’m just so sick and tired of society thinking that they have an opinion on what happens in another person’s life. Like, they don’t. They just don’t. I don’t know what it is. I’m just as guilty. I want to be very, very clear. I am just as guilty on wondering if this is a disorder. Is it their fault? Do they have any culpability? Is it a mental illness? Is it a disease? I am guilty as well. I would like to think that I’m going to do better after all of the people that we talked to and all of the research we did for this episode. I am certainly not claiming that Lisa and I, notice how I threw you in there, Lisa.
Lisa: Yeah. Thank you. Thank you.
Gabe: I am certainly not claiming that we are perfect. But I got to tell you, I live with bipolar disorder. That is a mental illness. I have gotten lucky. I have gotten help. There are other people with bipolar disorder that don’t have the same options that I have. I didn’t earn those options. I didn’t pick my family. I didn’t pick you. I just got lucky. I just want everybody to get lucky.
Lisa: It’s not that you want people to be lucky, you want luck to not have anything to do with it. You want people to be able to get better and not need luck.
Gabe: Yeah, yeah. I want people to know what to do. I want it to be like a house catching on fire. We all know what to do. Call the fire department. They’ll come put it out.
Lisa: They won’t ask you on the phone if one of your kids was playing with matches before they decide if they’re going to come.
Gabe: Yeah, they don’t. They don’t at all. And you don’t have to know somebody. You don’t, oh, my house is on fire. Oh, call Larry. He’s got a pickup truck that’s filled with water. No, we all have access to this, which is amazing since the majority of our houses will not, in fact, catch on fire.
Lisa: Obviously, yes, Gabe, all of that. Very well said. But did we really answer the question?
Gabe: No, no. Of course, we didn’t answer the question. All of society can’t answer the question. What are the chances that Gabe and Lisa are going to answer the question?
Lisa: That’s fair.
Gabe: The reality is that we are just as confused as everybody else because we cannot get good data. We cannot get consensus. We cannot get good research. And we’re so busy trying to judge each other and maintain our own traumatic events surrounding drugs, alcohol, mental illness and people who are addicted, etc., our own biases. And it’s just an absolute nightmare. And I wish to God the Not Crazy podcast could solve this problem, but it’s just one of those things where there just is no answer yet.
Lisa: Maybe society and science will catch up. In the future, maybe we will get an answer to this.
Gabe: I hope that we do, because this is not a semantic argument. This is a people argument. All of these terms connect to people. And we have to do better because people’s lives are at stake. Lisa, did you have fun this week?
Lisa: I don’t know that fun is the right word, but good episode.
Gabe: Whether you agree with us or disagree with us, we love hearing from you. Hit us up. It’s show@PsychCentral.com. Wherever you listen to this podcast, please subscribe. Please rate, rank and review. Love us. Hate us. We want to hear from you. Share us on social media. And wherever you go, use your words. Don’t just randomly share us. Tell people why they should listen. All right, everyone, we will see you next week.
Lisa: We’ll see you then.
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This article originally appeared on Psych Central as Podcast: Is Addiction a Disease?