Addiction: The Disease Model vs. The Health Model
Moving beyond judgment, understanding the purpose of substance use, and building a foundation for lasting recovery.
How we understand addiction matters. What we believe about why someone develops an addiction shapes how we respond to them, how we approach treatment, and what we think recovery should look like.
For generations, people who struggle with substances have been seen through a lens of judgment. They are described as undisciplined, irresponsible, or simply lacking willpower. Families become frustrated. Professionals become discouraged. And the person who is struggling often absorbs those messages and begins to believe they are fundamentally flawed.
I have spent more than twenty years working with individuals and families affected by addiction, in hospitals, residential programs, family interventions, and private practice. Over that time I have come to believe that one of the most powerful things we can do is change the question we start with.
Instead of asking, "What's wrong with this person?" I begin by asking, "What has happened in this person's life, and what purpose is their substance use serving?"
That shift changes the entire conversation.
The comparison above is intentionally simplified. In practice, the two models overlap, and good treatment draws from both. To understand why a health model matters, it helps to understand where the disease model came from and what it accomplished.
Where We Started: The Moral Model
For most of recorded history, heavy drinking and drug use were viewed as moral problems. A person who drank too much was considered weak, sinful, or lacking in character. The assumption was simple: if they really wanted to stop, they would.
The response followed the belief. If addiction was a moral failing, the answer was shame, punishment, religious correction, or exclusion. There was little room for treatment because there was nothing to treat, only a person who needed to try harder.
We have not fully left that thinking behind. Many of the people I work with still carry it, sometimes from their families, sometimes from their communities, and very often from inside their own heads.
How the Disease Model Took Shape
The idea that addiction might be a medical problem rather than a moral one is older than most people realize.
In about 1784, Philadelphia physician Benjamin Rush, a signer of the Declaration of Independence and often called the father of American psychiatry, published An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind. In it, he described chronic drunkenness as a disease, catalogued its symptoms, described how it progressed, and called for dedicated institutions to care for people who suffered from it. Around the same time, Scottish physician Thomas Trotter was making similar arguments in Britain, and in 1849 Swedish physician Magnus Huss coined the term "alcoholism."
The modern disease concept took shape in the twentieth century:
1935: Alcoholics Anonymous was founded, bringing the idea of alcoholism as an illness into the lives of ordinary people.
1940s: Marty Mann, one of the first women in AA, launched a national public education campaign, working with the Yale Center of Alcohol Studies, to convince Americans that alcoholism was a disease deserving of care rather than condemnation.
1956: The American Medical Association formally recognized alcoholism as an illness that deserved the attention of physicians.
1960: E. M. Jellinek, a researcher at Yale, published The Disease Concept of Alcoholism, which described different patterns of problem drinking and the progressive stages of the condition. It became one of the most influential works in the history of addiction treatment.
1970: Congress passed the Hughes Act, championed by Senator Harold Hughes of Iowa, a man in recovery himself, which created the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and established alcohol problems as a public health issue rather than a criminal or moral one.
The Brain Disease Era
In 1997, Dr. Alan Leshner, then director of the National Institute on Drug Abuse, published an influential paper arguing that addiction is a brain disease. Advances in brain imaging and neuroscience showed that repeated substance use changes the brain's reward, motivation, stress, and self-control systems. Those changes help explain why people continue using even when they desperately want to stop.
In 2011, the American Society of Addiction Medicine (ASAM) formally defined addiction as a chronic brain disease. In 2019, ASAM updated that definition to read: addiction is "a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences."
That last phrase matters. Even the medical field's own definition now recognizes that addiction does not develop in a vacuum. Life experiences are part of the picture.
What the Disease Model Got Right
I want to be clear: the disease model was an important step forward, and I do not dismiss it.
It moved addiction out of the courtroom and the pulpit and into the doctor's office. It helped create treatment programs, insurance coverage, research funding, and medications that save lives. It gave countless individuals and families language that said, this is not simply a character flaw. For many people, hearing "you have an illness" was the first time they felt anything other than shame.
The disease model also reminds us that addiction has real biological roots. Genetics, brain chemistry, and the physical effects of substances matter. According to NIAAA, genetic factors account for roughly half of a person's risk of developing an alcohol use disorder. Withdrawal can be medically dangerous. Some people need detox, medication, and a high level of care. None of that changes under a health model.
Where the Disease Model Can Fall Short
While the disease model reduced some forms of judgment, it can leave us with an incomplete picture of the person.
When the focus stays narrowly on diagnosis, symptoms, and management, some of the most important questions never get asked:
Why did this person begin using in the first place?
What was happening in their life at the time?
What needs were they trying to meet?
What experiences, emotions, or circumstances made substances appealing, or even necessary?
What has kept the pattern in place?
The disease model has also faced thoughtful criticism from within the scientific community. In 2021, a group of leading addiction researchers published a review titled Addiction as a Brain Disease Revised. They defended the core idea that addiction has a neurobiological basis, but they also acknowledged that some criticisms have merit: that the model can feel deterministic, that it does not fully explain why many people recover, and that it can overemphasize compulsion. Their conclusion was that the field needs to integrate neuroscience with behavioral, clinical, and social perspectives.
In other words, the brain matters. So does the life the brain is living in.
There is also a very human cost when the disease framing is applied rigidly. When people hear over and over that they have an incurable disease that will define them forever, some begin to feel powerless. A label meant to reduce shame can, for some, become a new source of it.
Introducing the Health Model: Understanding the Person Behind the Behavior
The health model offers a different starting point. Rather than beginning with the assumption that something is broken inside the person, we get curious about what has happened throughout their life and how those experiences shaped their development, relationships, coping strategies, and behavior.
This way of thinking has deep roots in clinical practice. In 1977, psychiatrist George Engel introduced the biopsychosocial model, which argued that health and illness are shaped by biological, psychological, and social factors working together, not biology alone. In 1985, Harvard psychiatrist Dr. Edward Khantzian published the self-medication hypothesis, which proposed that many people are drawn to particular substances because those substances relieve painful emotional states they have not been able to manage another way. Khantzian encouraged clinicians to ask a simple question: "What did the drug do for you?"
That question is at the heart of the health model.
Many people develop maladaptive coping strategies in response to difficult experiences: chronic stress, trauma, emotional pain, loss, disconnection, unmet needs, or circumstances they did not have the resources or support to navigate. Those strategies usually begin by serving a purpose.
For some, alcohol or drugs provide temporary relief from anxiety, depression, loneliness, grief, or overwhelming thoughts. For others, substances offer confidence, belonging, connection, escape, sleep, or simply the ability to function in an environment that feels unbearable.
The strategy works, at least for a while. That is exactly why it is so hard to give up.
But something that once helped a person cope can gradually become the very thing that prevents them from living a healthy, fulfilling life. The strategy that once offered relief becomes a source of additional suffering.
Understanding Without Oversimplifying
I want to be careful here, because this is where the conversation can go wrong.
Not everyone who develops an addiction has experienced trauma. Not every instance of substance use can be traced to a single painful experience. Some people carry a strong genetic vulnerability. Some started using socially and found that the substance itself took hold. Some grew up in families or communities where heavy use was normal. Many have a combination of all of these.
The research on self-medication is also mixed. It is a powerful way to understand many people's experience, but it is not a universal explanation, and it should never be used to explain away the addiction itself.
Human behavior is complex. Biological, psychological, social, environmental, and developmental influences all contribute. The health model does not replace those factors. It makes room for all of them, and then adds one more question: what purpose has this served?
From Managing Symptoms to Understanding the Purposefulness of Use
One of the most important distinctions between these two approaches is the difference between focusing on symptoms and focusing on the purposefulness of use.
When we focus only on symptoms, the primary goal is to stop or reduce the behavior. Progress is measured by whether someone is using, how often, and whether they are following the treatment plan. Those things matter, especially when safety is at stake. But they do not tell us whether the underlying issues have been addressed.
Consider someone who drinks every evening to quiet racing thoughts and manage anxiety. Stopping the drinking may be an essential first step. But if we never explore the anxiety and what is driving it, we may have addressed the behavior without addressing the need. The need does not disappear. It looks for another outlet, or it waits.
The question becomes: What is this person getting from their substance use that they are not currently getting anywhere else in their life?
Is it relief? Connection? Confidence? Escape? Emotional regulation? A sense of control? The ability to sleep? A break from painful memories?
When we understand the purpose a behavior serves, we are far better positioned to help someone build healthier ways of meeting that same need. This is not about justifying harmful behavior or minimizing its consequences. It is about understanding what we are actually trying to change.
Addiction, Identity, and Seeing the Whole Person
Addiction can become deeply intertwined with how a person sees themselves.
When someone repeatedly hears that they are "an addict," that they have a disease, or that they will always be defined by their addiction, those messages shape their identity. Over time, the label can become the whole story.
A diagnosis has value. Identifying a substance use disorder helps guide treatment, determine the right level of care, and open access to resources. But a diagnosis describes a condition. It is not a person's identity.
This is one reason the Substance Abuse and Mental Health Services Administration (SAMHSA) has encouraged healthcare providers to pay close attention to the language and attitudes they bring into treatment. Shame keeps people from seeking help, and stigmatizing language can keep them from even being honest about what they are going through. Saying "a person with a substance use disorder" rather than "an addict" is not just political correctness. It keeps the person in front of the problem.
People are more than their substance use, their past decisions, their trauma, or their coping strategies. They have strengths, abilities, relationships, values, interests, and potential that may have been overshadowed by their struggles. Recovery should include rediscovering who someone is, not only managing what they have been through.
Relapse: Failure, or Opportunity to Learn?
How we interpret relapse reveals which model we are working from.
Through a strict disease-management lens, relapse is often understood as a recurrence of symptoms or a setback. In many settings, and in many families, it is also experienced as failure, proof that the person did not try hard enough or cannot be trusted.
Through a health-oriented lens, a return to use is also opportunity. It may tell us that certain needs are still unmet, that a particular environment or relationship is hard to navigate, that current coping skills are not yet strong enough, or that something in the recovery plan needs attention. Federal treatment guidance now often uses the word "recurrence" for this reason: it describes what happened without passing judgment on the person.
Instead of responding only with disappointment, shame, or punishment, we can get curious:
What was going on before the return to use?
What emotions, circumstances, relationships, or stressors were involved?
What was the person seeking or trying to manage?
What can be learned, and what needs to change going forward?
This does not minimize the risk. A return to use can be medically dangerous, especially after a period of abstinence when tolerance has dropped and the risk of overdose is much higher. Appropriate assessment, support, and intervention remain essential.
But treating a recurrence as information rather than proof of personal failure creates room for learning, adjustment, and renewed engagement, rather than the shame spiral that so often makes the next return to use more likely.
Recovery Beyond Abstinence
Stopping substance use can be an essential milestone, and for many people it is a non-negotiable one. I take that seriously.
But abstinence by itself is not the same as a life worth staying sober for. If someone stops using but nothing else changes, the original needs, the pain, the isolation, the lack of purpose, are still waiting.
SAMHSA describes four dimensions that support a life in recovery:
Health: managing physical and emotional well-being and making informed, healthy choices.
Home: a stable and safe place to live.
Purpose: meaningful daily activities, such as work, school, caregiving, or creative pursuits, and the resources to participate in them.
Community: relationships and social networks that provide support, friendship, love, and hope.
That is the health model in practice. The goal is not simply to become someone who no longer uses. It is to become someone who has the capacity, resources, and support to live a healthier and more purposeful life, so that the old coping strategy is no longer needed.
Compassion and Accountability Can Coexist
I want to be direct about something, because it is often misunderstood.
Understanding why a behavior developed does not excuse the harm it causes. People in active addiction can damage relationships, break trust, put others at risk, and hurt the people who love them most. Those consequences are real, and taking responsibility for them is part of healing.
The health model is not an argument for removing accountability. It is an argument for making accountability possible.
It is very hard to take responsibility for a pattern you do not understand. Shame tends to produce hiding, defensiveness, and more of the same behavior. Understanding produces insight, and insight gives people something to work with. Genuine accountability becomes far more meaningful when people have the awareness, skills, and support to actually make different choices.
The goal is not to remove responsibility. It is to move beyond blame and create the conditions in which real change becomes possible.
Bringing the Two Models Together
I do not believe we need to throw out the disease model to embrace a health model.
The disease model moved addiction away from a purely moral interpretation. It established that addiction has real medical, biological, and psychological dimensions, and it opened the door to treatment for millions of people. That contribution matters.
The health model expands the conversation. It asks us to consider a person's history, experiences, environment, relationships, emotional needs, and learned patterns of behavior. It allows us to acknowledge that people develop maladaptive coping strategies without defining them by those strategies. And it shifts the focus of recovery from managing an ongoing problem toward building the capacity to live differently.
One approach manages the behavior. The other works to transform the conditions that sustain it. The best care does both.
A Different Way Forward
When we approach addiction with curiosity instead of judgment, a different kind of conversation becomes possible.
Instead of asking only why someone keeps using, we explore what their substance use has been helping them manage.
Instead of defining people by their diagnosis, we recognize their capacity for growth and change.
Instead of focusing only on controlling behavior, we work to understand its purpose and build healthier ways of meeting the needs underneath it.
And instead of viewing recovery as a lifelong process of managing symptoms, we see it as an opportunity to build capacity, strengthen relationships, develop healthier coping strategies, and create a more meaningful life.
People are not their addiction. They are individuals who developed patterns of behavior in response to a complex combination of life experiences, biological influences, and environmental circumstances. Those patterns can change.
That is where I believe meaningful recovery begins.
At Benson Family Services, recovery is about more than stopping a behavior. It is about understanding the individual, addressing what is underneath, strengthening the resources that support change, and helping people build a life in which they no longer need the coping strategies that once served them.
Recovery is possible. And it can be about so much more than simply managing an addiction.
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