Seven perspectives on addiction

'Addicts' get a pretty mixed press. As a researcher and practitioner focusing on the treatment of addictive behaviours, and someone who has experienced addiction myself, the language of the public debate about addiction has always felt consequential. It's also disputed and often contentious.

Is addiction a disease? What kind of a disease? What consequences does this have for how we think and feel about those affected? How should we respond?

This conversation has grown more open in recent years, and names as big as Kate Middleton have entered into it. Her campaign's key message is that 'addiction is not a choice'. She characterises it as a 'serious mental health condition' which demands 'compassion and empathy'.

These sentiments are, on the face of it, laudable and gravely needed. Sadly though, we'll see that on closer inspection they show that we're still at a loss about how to speak about addiction and mental health as a society.

Far too often, our framings of distress, disease and who deserves help in recovering from it reduce to simplistic, binary notions of causation, responsibility and blame. This inevitably leads to bad policy, but it also constrains our ability to think and respond differently. And we are certainly not meeting the scale of the challenges we face.

How did we get here? Drawing on my own work on addiction, both clinical and conceptual, I will introduce seven perspectives and a range of characters from across the debate. Some of the viewpoints – a Victorian novelist, for example – may be unexpected. But I hope that some of their answers will suggest a way out of our current ideological trap.

Professor Dame Carol Black

On 8 July 2021, the Department of Health and Social Care published the phase two report of the government's 'major independent review' of drugs. It was written by Professor Dame Carol Black, a rheumatologist by training, and a former President of the Royal College of Physicians. Its calls for more funding and training for services were welcomed by the statutory treatment sector, andGovernment also made positive noises.

Soon after in August, the Office for National Statistics published the figures on drug-related deaths in England and Wales for 2020. They were the highest on record, a feat that was repeated in 2021, and have risen every year for the last nine (funding was cut every year between 2010 and 2020). Deaths in Scotland dropped in 2021, but by a single digit amount, and the country still has easily the highest drug death rate in Europe.

By December 2021, a long-term drugs strategy had emerged – From Harm to Hope: A 10-year drugs plan to cut crime and save lives. Dame Carol's recommendations were adopted in full and the stated ambition is to 'deliver a world-class treatment and recovery system' within a decade. While we can only hope this successful, the £780 million committed over three years always seemed unlikely to deliver it.

Just as important as the targets in these documents is the language about what addiction or substance misuse actually is, and therefore how we should think about it. Black makes her view explicit: 'addiction is a chronic health condition, like diabetes, hypertension or rheumatoid arthritis'. Her point in context is about normalising relapse, but her choice of comparators is significant, and not surprising given her frame of reference. Diabetes and arthritis are uncontroversially thought of as diseases, and the word 'mental' is absent from her categorisation.

Instead, 'trauma and mental ill-health are the drivers and accompaniment of much addiction'. While there might be important psychosocial top notes, the overall flavour of the report is the broadly biological and she stops short of advocating any serious shake-ups of the system.

Addiction is a framed as public health issue (like obesity, perhaps), no administrative or ideological boats were rocked, and acres of political wiggle room are left for assigning responsibility for the problems, either at a personal or societal level.

Boris Johnson

Former Prime Minister Boris Johnson did his best to claim that ground in his foreword to the government strategy. Running alongside (and without needing to depart from) Black's biological framing, his argument was essentially a moral one. There was blame and condemnation for 'vile county lines gangs' and pity for their 'vulnerable victims'. There was an eye-catching estimated total cost of £20 billion (which makes the headline spending commitment seem like small change), but he is also at pains to stress the 'human toll': 'innocent' families and small businesses are juxtaposed with the (presumably less innocent) addicts who commit crimes and the criminal gangs who supply them.

Self-evidently, these addicts must 'properly punished' as the 'serial offenders' they often are, but they will also be graciously afforded more and better chances to recover and reform themselves, mostly because it will save other, more upright people money and hassle.

For Johnson and subsequent governments, this issue seems fundamentally to be one about choice and responsibility, and the state's response to those affected is dependent on the choices they make and the way they behave. Their reading of Black's work is that addiction might be a biological 'disease', but it's one that people largely bring on themselves by drinking and taking drugs.

Johnson did acknowledge that the 'old way isn't working' and he's right: the UK has the third largest prison population in Europe, roughly a third of which consists of people incarcerated under the (largely unamended) Misuse of Drugs Act, 1971. But having spent several years working in substance misuse services in the prison system, it quickly became clear to me that the rigid binaries of guilt and innocence, health and disease that he doubles down on are precisely the problem with the 'old way'.

Kate Middleton, Princess of Wales

Middleton is patron of The Forward Trust, a prominent charity and service-provider, and the leading partner of a public awareness campaign called Taking Action on Addiction. This national campaign has promoted Addiction Awareness Week for the last two years, which Middleton has fronted with well-publicised speeches. Speaking at its inaugural launch event in 2021, Middleton's choice of language framed addiction in a subtly different way to the Black report.

In addition to the quotes we saw earlier, she said:

No one chooses to become an addict. But it can happen to any one of us. None of us are immune. Yet it's all too rarely discussed as a serious mental health condition. …. by recognising what lies beneath addiction, we can help remove the taboo and shame that sadly surrounds it.

At first glance, this appears to be a starkly different moral argument to Johnson's rooted in a similar scientific account to Black's. Addiction is a mental health issue and sufferers deserve compassion because their situation (and the bill that goes with it) is not really their fault – at least as far as it didn't stem directly from their intentions. In fact, it's in everybody's interest that treatment should be improved, because you or someone close to you could need it any minute.

Explicit reference to 'disease' is gone for now, but the language of immunity shows that the influence of Black's biological thinking isn't far below the surface. Instead, addiction is assertively positioned – more clearly than ever before – under the 'mental health' umbrella.

To understand the implications of this shift, we need to look next at other similar awareness campaigns. What they have in common is the idea that mental health issues can be understood in disease-like ways, which serves an important rhetorical purpose.

'It's OK to talk' campaigns

There have been a wide range of these kinds of programmes over the last 15 years, but a good example is Heads Together, another royal initiative and also led by Middleton along with her husband Prince William. Dr Lucy Foulkes gave a more thorough review and critique in these pages in 2022 but in summary, they frame mental health conditions (now including addiction) as common, blameless and treatable. Like a chest infection or diabetes, they get better or can be managed, so it's ok to talk about them. Just talk to your peers, contact your local services if needed, get a diagnosis and then get fixed.

But how easy is this to do in practice? In 2021 NHS England estimated that, over and above the official waiting list of 1.6 million, a further 8 million people were unable to access specialist mental health services because they were considered not to meet services' thresholds of severity. I've often had clients' referrals to residential treatment turned down because they weren't 'complex' enough to be prioritised. It's OK to talk, but be prepared to wait a long time and get really bad.

For those who are under services, navigating them effectively can be almost impossible, even for the well-informed. And if you're unfortunate enough to have a substance misuse issue as well as other mental health problems, you can expect to be denied access to help for one until you've addressed the other, depending on how services happen to be organised and commissioned in your area. (This issue is addressed to some extent in the Black report, but there are no plans for the fundamental separation in mental health and substance misuse service provision to be changed.) It's OK to talk, but make sure you talk to the right people, in the right order.

By adopting the rhetoric of disease in this way, there's a danger that these public campaigns can serve to shift the responsibility onto sufferers and their communities and let government off the hook. And below the surface, the campaigns remain trapped by the same rules and moral assumptions as Johnson's policies: how deserving someone is of empathy is dependent on how responsible they are for their problems.

Samuel Butler: A perspective from Erewhon

First published in 1872 by Samuel Butler, Erewhon is a fantasy travel novel with a strong moral message. It depicts an inverted society in which crimes and 'moral' failings are treated therapeutically, while biological illnesses are harshly punished.

This reversal of Victorian thought was intended to encourage a more moderate approach by showing that either version, taken to its extremes, could produce perverse and shocking outcomes. This is exemplified by a character who is pretending to be an alcoholic (then viewed in a purely as a moral failing) in order to avoid punishment for her physical ailments. Her friends suspect she is trying to 'win a forbearance… to which she is not entitled.'

The 'It's OK to talk' perspective on addiction and mental health is the mirror image of this – we're encouraged to see them as disease-like, justifying a therapeutic rather than punitive response. But, yet again, the question being answered is the same: who is entitled to compassion? Butler would probably have argued that neither society had the correct answer.

James: a prisoner's perspective on choice

How we think about choice is pivotal to understanding these perspectives, with Johnson and Middleton representing two ends of a spectrum. Middleton is probably right that no one directly chooses or intends to enter states of addiction, but would it matter if they did, and why? Some choices are sure to have contributed to their eventual situation, so which ones (if any) should we judge them by?

Samuel Butler's lesson for us is that the context in which we behave and make decisions really matters. I had the pleasure of working for several months in a London prison with a man who had struggled with crack, heroin and spice use. James [not his real name] was a large, imposing man who was doing time for manslaughter. He had long periods of clean time both in and out of jail and was detoxing from opiates when we met. He was also using regularly using spice and wanted to stop but found that he couldn't. Was this because he had a 'chronic health condition', a moral failing, or a "serious mental health condition"? What choices was and wasn't he making, and why?

Getting to know James further it emerged that he was, at certain times and in certain contexts, incredibly anxious. And for understandable reasons – he had worries about how he was perceived, which had implications for his safety. Thoughts about his future raced in his mind and he found it difficult to manage his emotions. Sometimes this left him drenched in sweat in his cell, and often he felt desperate and suicidal.

This context is essential to understand his 'choice' to use substances, even when the consequences for him and those around him were horrific. Drugs had a clear function for him: to allow him to regulate his thoughts and feelings and feel safe in his own skin. Crucially, his environment and personal history meant that he did not feel he had access to less problematic ways of coping.

Gradually though, and working with colleagues, we found ways of helping him deal with his anxiety and his cravings, and his using stopped. However we understand the choices James made about drugs, he needed (and surely deserved) help, and he took it when it was offered in a way that he could engage with.

A radical alternative? Treat people, not pathologies

James shows us that there's lots of messy nuance when it comes to thinking about responsibility and agency in addiction. As Butler suggested in Erewhon, trying to create clear and universal distinctions between physical or mental (dys)functioning, or between states of health and disease, will always be arbitrary, if not entirely meaningless. Using those distinctions to judge a person's level of responsibility and shaping our responses along those lines inevitably produces the cruel, violent systems and poor outcomes we see today.

So what is the alternative? Many psychologists would agree that 'what has happened to you?' is a more fruitful line of enquiry than 'what is wrong with you?' or 'what have you done?' for facilitating change. James certainly did. This universally empathic starting point for engagement was perhaps most famously articulated by Dr Eleanor Longden, an expert by experience and researcher in psychosis, in a TED talk in 2013.

Her argument is that people in distress are best responded to as just that – people, rather than pathologies or charge sheets. Our ability to empathise with them and the state's willingness to help them shouldn't change based on their biological, medical or legal status. And we need neither to make them wholly responsible for their situation nor explain away their agency to understand their frame of reference.

In the meantime, demand for services continues to soar and it's a fantasy to think it can be met without huge increases in investment and training, well beyond the government's commitments. Breaking down stigma on its own will not be enough, and campaigns which reinforce the conflation of distress with disease, disease with innocence, and innocence with the right to empathy, may not be as helpful as they appear, however well-intentioned their patrons.

The key question that all seven perspectives challenge us to think about is, in Butler's language: 'who is entitled to forbearance?' Our answer should be: everyone, equally.

• Dom Merchant is a PhD Researcher in addiction psychology in the Centre for Addictive Behaviours Research at London South Bank University, where he studied Addiction Psychology and Counselling and now teaches on undergraduate and masters level counselling courses.
  Dom is a BACP registered therapist and Addictions Professionals Advanced Practitioner working in private practice, specialising in metacognitive approaches. He worked for several years in substance misuse services in the men's prison estate, both therapeutically with clients and facilitating reflective practice, self-care and resilience workshops for staff.