Knowing the Disease

There’s an old Borscht Belt routine where a guy walks into a doctor’s office complaining of a pain in his elbow.

Patient: Doc, what do I do? It hurts when I go like that (bends his elbow).

Doctor: Don’t go like that!


When it comes to responding to addiction, our first and most common response is not too different from the doctor in that corny old bit. After all of our best advice and most rational counsel have been exhausted, what else can we tell a person who still seems hell-bent on self-destruction? “Cut it out already.” “Give it a rest.” Or perhaps a little more emotionally, “Why must you do this to yourself?!”

The truth is that most people, including addicts themselves, have no idea what addiction really is. When being honest, the addict will tell you that he or she has no better an understanding of the problem than you have. Addiction confounds us; it frustrates us; it scares us. This has been the way it’s been since time immemorial. That’s why for millennia the only response to the town drunk was either to lock him up for good or to allow him to run raving in the streets. How else should one deal with a problem that makes no sense?

Most people, including addicts themselves, have no idea what addiction really is.

There is an old Jewish saying: “Knowing the disease is half the cure.” (Yes, the rabbis have been saying that for centuries already.)

So what is the disease of addiction?

Let’s examine a few popular approaches and see where they fall short of offering a complete explanation.

The Biological Model

Ask the average man or woman to define addiction, and they will tell you in so many words that it is a chemical dependence. A person becomes used to relying on a substance, and their bodies crave more and more of the same until they’re hooked.

That is actually a nice nonprofessional’s description of the physical phenomena of chemical tolerance and withdrawal. It has little, however, to do with addiction.

If addiction were chemical dependency, then the solution for addiction would be detox. Once you can get through the drying-out period, you’re home free. However, if this were the case, rehabs wouldn’t have so much return business, and drunk tanks would sober-up people for life.

No, if that were what addiction really were—a mere dependency of the body—then addicts wouldn’t baffle their friends and families by getting clean, starting to put their lives back in order, then tragically—inexplicably—relapsing for no apparent reason at all. No, if addiction were synonymous with physical dependence on a substance, we still wouldn’t understand why the addict, even after long periods of chemical sobriety, is drawn like a moth to the flame, to be burned again. Furthermore, if addiction were really just chemical dependence, why are some people addicted to sex, gambling, and other processes that have nothing to do with introducing a foreign chemical into the body’s system at all?

Chemical dependence is a physical problem, and it has a physical solution. Medical doctors can cure a patient of a chemical dependence. Heck, the deputy at the county jail can, too. If your body is dependent on a chemical, then hold tight and get ready to feel real sick for a while, until your system regains its natural equilibrium.

But addiction doesn’t work like that. Addiction stays with a person—indeed, it works harder—even when the body is no longer physically dependent on his or her drug of choice.

The Mental Health Model

Why hasn’t modern psychology developed an effective method for curing addiction?

Given all of the above, we may feel compelled to classify addiction as a mental health issue, an illness of the mind. If that were our conclusion, we would be getting slightly closer to a better understanding of addiction, but we’d still be left with a plethora of inexplicable facts. Most pointedly, why hasn’t modern psychology developed an effective method for curing addiction or, at least, treating it into remission? Addicts have been thrown into asylums since asylums first existed. They’ve been given medication, electroshock, psychotherapy, and a multitude of other treatments. Yet the typical addict will continue to confound mental health professionals with relapse after relapse, despite having benefited from even the most prodigious and harrowing efforts that the field of mental health has to offer.

We should be honest in fully disclosing that there certainly are people for whom psychiatric or psychological treatment has been effective in curbing their substance abuse problem. Indeed, there are people for whom completely physical means of treatment are effective as well. But then there are that curious and peculiar lot who can’t seem to keep sober for any significant period of time no matter what medications they are prescribed, no matter what kind of therapy they undergo, no matter how long they’ve been clean, no matter this, no matter that, no matter what. They change jobs, change cities, change spouses. They try to work more, work less; relax more, relax less; be more assertive, less assertive; more expressive, less expressive. They try anything and everything, and eventually are right back where they left off—only, in almost every case, even worse off.

Is the addict a sociopath? Why are most addicts so full of remorse?

The Moral Argument

Some will argue that the addict’s problem is a moral one. He or she simply lacks the moral fiber or willpower to straighten up and fly right. In other words, the addict’s problem is a lack of decency. The addict knows what he or she is doing and could really stop, but hasn’t the decency to do so.

But is the addict, then, a sociopath? Why, then, are most addicts so full of remorse? Why do they, as a rule, suffer from self-loathing and depression?

Zealous clergy who lecture about the demon of addiction may very well have their success stories to tell about the addict who, upon one day hearing a fiery sermon, made a resolution to turn over a new leaf and kicked the habit. But how do we explain all of the earnestly religious folks who sit and listen to such preaching and nod their heads, and yet still continue to be slaves to addiction? In what way can we understand the plight of the otherwise upright and ethical man or woman who can withstand many other kinds of temptation, but when dealing with his or her drug of choice, seems to lack any semblance of free will? The addict is usually aware of this paradox better than anyone, and suffers a great deal of confusion and emotional torment because of it. “I’m not a bad person,” the addict argues. “You’ve got me all wrong.” But go tell this to someone who takes the high and mighty view that addiction is not a disease but a repeated series of immoral choices.

To be fair, we should say that religious types are not the only ones apt to misconstrue addiction as no more than an unconscionable lack of willpower. There is the secular willpower argument as well. Adherents of this position will tell you that most addicts eventually recover spontaneously, without any treatment at all. This proves, they argue, that an addict will quit if only he or she finally makes a decision to do so. In answer to this argument, we must concede that many people who abuse substances or compulsively engage in other dangerous behaviors will eventually kick the habit on their own. That is indisputable, and it is wonderful for those who can do so. But when we speak of addicts, we are not speaking about habitual users who can ultimately quit on their own. We’re speaking about another breed entirely. We’re speaking about the people who spend their lives getting clean, building up everyone’s hopes, and then defying all logic as one day they jump, not fall, right off the wagon. Who are these people, and what is their problem?

Addiction is their problem. Addiction, not chemical dependence; addiction, not mental illness (although they certainly may suffer from both of these as well).1 Addiction, and not even lack of willpower: an insidious, misunderstood, mysterious syndrome called addiction.

What all addicts have in common is the incomprehensibility of their seemingly willful descent into oblivion.

Addicts may be addicted to a substance or to a behavior. Their drug may come in a bottle, a syringe, over the Internet, or in many other forms. Nevertheless, what all addicts have in common is the incomprehensibility of their seemingly willful descent into oblivion. Over any significant amount of time, their condition gets worse, never better. They are the ones whose bizarre behavior can be just as—if not more—insufferable during periods of abstinence than during active use. They are the ones who are, in some way, easier to deal with when they are indulging in their drug of choice than when they are staying straight. They are the ones who will eventually sacrifice everything that is dear to them, in order to hold on to their disease. And the tragedy is that their disease is completely treatable.

Problem or Solution

Please know that whenever we use the terms addict and addiction in this book, it is to this mysterious condition that we refer—an incurable, progressive and most bewildering malady that defies categorization by conventional terms.

But if all of these varied misconceptions fail to define addiction, is there any way to understand what it is?

We may start to get a better idea of what addiction really is if we consider one aspect of addiction that is most always overlooked. It’s something that even addicts themselves are usually unable to articulate unless it is pointed out to them, and even then it’s something that’s likely to be terribly misunderstood. What is this overlooked aspect of addiction? It is the fact that the addict’s drug of choice is not, as we would think, his or her problem; it’s a solution.

Yes, it sounds strange. So we’ll say it again. For an addict, his or her drug of choice is not a problem, but a solution. If it were their problem, they would eventually give it up. But because it is their solution—as a matter of fact, their only solution—they haven’t any real choice of going without it.

What makes addiction “abnormal” is that the addict no longer uses his or her drug of choice for fun or recreation, but from necessity.

Consider. Most people who wantonly engage in drinking, drugging, overeating, or other forms of physical pleasure are not addicts. They may overindulge; they may do so habitually, even recklessly; but they do so for a basically normal reason. They like it. It feels good. That may not sound like a very compelling reason to engage in irresponsible behavior, but it’s the truth. They do it for fun. And when it stops being fun, they stop doing it.

An addict, on the other hand, does not use his or her drug of choice for pleasure. Yes, in the very beginning, the addict settles on a particular drug of choice because of the pleasurable effects that it provides, but indulging for pleasure does not set someone apart as an addict. Seeking pleasure is normal. What makes addiction “abnormal” is that the addict no longer uses his or her drug of choice for fun or recreation, but from necessity. By necessity we do not mean chemical dependency, because, as we said, addicts will relapse even when they are completely detoxified. The addict uses his or her drug of choice because it serves a crucial, even vital, function. It actually allows them to live, just as food, air and sleep allow normal people to live. If you don’t get enough sleep, you become less productive, moody, even depressed. If you don’t get enough sleep long enough, your body will force you to go to sleep.

Never mind the fact that sleep is necessary for the body to function, and mood-altering chemicals are not. The fact is, for reasons we shall explain very soon, that if the addict could function without his or her drug of choice, then he or she wouldn’t be an addict.

That’s what we mean when we say that for the addict, his or her drug of choice is not a problem but a solution—a poor solution, a destructive solution, a costly solution, but the only solution that works. That’s why, when you take away an addict’s drug of choice, they don’t get better; they get worse. You haven’t helped them get rid of their problem; you’ve just taken away their solution. And that’s why, left without a solution, the addict will always go back to his or her drug of choice. Not because they want to, but because they need to.

I once heard an old-timer in AA make an interesting distinction: “For some people, drinking is a hobby. For me, it’s a job. Social drinkers are amateurs. I am a professional.”

Life and Death

A teacher of mine once told us a story about a group of Jews assembled at a farbrengen, a typically informal Chassidic gathering where stories are told, songs are sung, and there is almost always a bottle of schnapps to go around. At this particular farbrengen, which took place in Russia many decades ago, the participants had carried on late into the night. As they were about to toast each other l’chaim, they noticed that their bottle was empty. It was late and the stores were closed, so they went out into the street to look for someone from whom they could buy liquor. It wasn’t long before they spotted a drunken peasant, bottle in hand, hobbling down the street.

“How much for that bottle?” they asked.

“What, this?” asked the drunk.

“Yes, we’ve run out of vodka. How much for yours?”

“Money?” the drunk cried, sounding very much offended. “No one pays Ivan to save a life!”

It was a long time ago, back in yeshiva, when I heard this story, but I’ve thought about it many times since then. By now, I have made three conclusions. All are just hunches. None can in any way be proven.

• Judging from his answer, the drunk was definitely not just a peasant on a bender, but a real alcoholic.

• The Jews who went looking to buy the bottle late at night might themselves have been alcoholics.

• If this story really happened, it is absolutely certain that, if the peasant didn’t have another bottle on him, then he had one very close by.

At any rate, true or not, the story’s punch line says it all. The addict is not out to have fun. The addict is trying to stay alive the only way he or she knows how, by using the only thing he or she has found that works.

Pick Your Poison

But why can’t the addict live any other way?

What is the problem that the addict cannot find any other way to solve?

Addiction is a pre-existing condition that drives a person to use.

What condition is it that the addict is so desperately trying to treat by self-medicating with his or her drug of choice?

The condition is addiction.

That’s right. Addiction.

Using does not cause addiction. Addiction is a pre-existing condition that drives a person to use. The addict actually uses in order to relieve the symptoms of addiction.

What are the symptoms of addiction?

They are many and varied, but they can be summed up as an overall and pretty much constant feeling of extreme discomfort and uneasiness. The addict is someone who just doesn’t feel right in his or her own skin. The addict feels isolated, scared, frustrated and hurt. These feelings are the addict’s default setting. This is how an addict goes through life. Then, one day, the addict finds a “medicine” that will make those feelings go away for a while. This wonderful medicine does for the addict what nothing else can do. Once the addict has discovered the medicine, he or she can no more discontinue its use than a diabetic can go off insulin.

Dr. William D. Silkworth, the specialist who treated AA co-founder Bill Wilson in the hospital, noted what he considered the common characteristic of those alcoholics who were untreatable by medical means:

To them, their alcoholic life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks . . . (Alcoholics Anonymous, pp. xxviii–xxix)

Of course, Silkworth had no idea what made this so; all he knew was that (a) alcoholics generally feel miserable all the time, and (b) they briefly experience almost total relief by becoming intoxicated. This double-bind makes someone an addict.

As a longtime member of OA (Overeaters Anonymous) once told me, “I don’t qualify for OA membership because of all the problems that food caused me. I qualify for OA because of all the problems I fixed with food.”

Of course, you can’t really fix a problem with food or with booze or with drugs or with gambling or with sex. However, for the addict, the momentary relief from existential suffering is the closest he or she can get, and is a great enough payoff to justify any and every expense. As the Satan remarked in the Book of Job (2:4): “Only skin for skin, but a person will give everything for his life.”

What was the Adversary saying? A person will give up only some skin, something superficial, to save skin, some other extraneous thing. For instance, if you are falling, you might put your hands out to break your fall, and scrape the skin on your hands in order not to scrape the skin on your face. But you wouldn’t risk your life in order to avoid getting a scrape on your face. That’s what it means, “Only skin for skin.”

A person will give up only some skin, something superficial, to save skin, some other extraneous thing.

That’s why a non-addict with a substance abuse problem will stop using when the consequences become too costly. A non-addict might be willing to make certain sacrifices for the sake of having a good time, but will not want to play for keeps. An addict, on the other hand, will not stop no matter what the stakes, for a person will willingly risk any sacrifice in order to live.

Of course, the irony is that the addict’s drug of choice is actually causing death. But for the addict, it doesn’t seem so. It seems the opposite. We mentioned this point earlier and said that it would be explained, so here is an explanation.

Consider the following analogy. A person, God forbid, is suffering from an incurable disease of the body. The doctors say that they cannot make it go away, but they may be able to force it into remission with chemotherapy. Now, the doctors admit that the chemotherapy has dangerous side effects; it may even kill the patient before the disease does. But if they do nothing, the disease will surely be fatal. That is precisely the dilemma that the addict faces in using or not using his or her drug of choice.

Excerpted from God of Our Understanding—Jewish Spirituality and Recovery from Addiction, by Rabbi Shais Taub.