Then why should we reject the disease model?
The main reason is this: Every experience that is repeated enough times because of its motivational appeal will change the wiring of the striatum (and related regions) while adjusting the flow and uptake of dopamine. Yet we wouldn't want to call the excitement we fell when visiting Paris, meeting a lover, or cheering for our favourite team a disease. Each rewarding experience builds it own network of synapses in and around the striatum (and OFC), and those networks continue to draw dopamine from its reservoir in the midbrain. That's true of Paris, romance, football, and heroin. As we anticipate and live through these experiences, each network of synapses is strengthened and refined, so the uptake of dopamine gets more selective as rewards are identified and habits established. Prefrontal control is not usually studied when it comes to travel arrangements and football, but we know from the laboratory and from real life that attractive goals frequently override self-restraint. We know that ego fatigue and now appeal [the author's term for delay discounting], both natural processes, reduce coordination between prefrontal control systems and the motivational core of the brain....So even though addictive habits can be more deeply entrenched than many other habits, there is no clear dividing line between addiction and the repeated pursuit of other attractive goals, either in experience or in brain function.
(p. 163)
Some of his evidence for not treating addiction like disease is that people can get over substance abuse without medication--since when do 12-step programs cure cancer? If programs that address thoughts and habits can overcome addiction, then it's not a physical disease the way we usually think of it. 75% of US soldiers using heroin during the Vietnam war came home and kicked the habit once they were back in their usual opportunity-rich environments. Merely changing a person's outward circumstances doesn't heal a "disease."
Also, behavior addictions are often just as severe as substance addictions. Video gaming young men in Asia come to mind. Pornography addiction, sex addiction, gambling addiction, hoarding, compulsive shopping, binge eating, etc. Nearly anything that gives us temporary pleasure can take over our lives, it would seem.
How to beat addiction, according to Lewis? First, protect children from too much adversity early in their development. The more trauma they experience, the more likely they are to grow up and find solace in negative behaviors that give temporary feelings of relief. Second, "redirect" the biology of desire; simple repression is less effective because we get fatigued repressing our desires. People need a long-term perspective that gives them motivation to seek longer-term goals. "Humans need to be able to see their own lives progressing, moving, from a meaningful past to a viable future. They need to see themselves as going somewhere, as characters in a narrative, as making sense. In addiction the relentless preoccupation with immediate rewards carves a small burrow out of the potential richness of time." People need a personal, emotion-saturated story with bigger goals than just short-term satisfaction of an appetite. Cognitive behavioral methods can help people explore their choices and examine and modify their personal beliefs, but they're not enough to beat out desire. Instead, harness the power of desire to serve more ultimately rewarding goals.
One painful conclusion--which the author probably never intended to convey--that I reached from this book is that addicts don't love others enough. The heartbroken family members who cry "You just don't care about us enough to change!" might be right. Is it the addicts' fault that they don't love enough? Are they damaged from traumatic childhood experiences? Should we blame our materialistic, individualistic society that devalues loving service to family and community? What religious beliefs help or hinder the processes of becoming addicted and recovering from addiction?
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