Framing addiction as a compulsive brain disease lowers readiness to change addictive behavior in alcohol consumers, in two exploratory experiments
Research article
Background
The brain disease model of addiction (BDMA) is widely endorsed by scientists and clinicians including psychiatrists and addiction treatment practitioners. The BDMA emphasizes individual biological risk factors (e.g. genetics), drug-induced brain abnormalities, cognitive deficits, and the strengthening of compulsive/habitual drug-seeking behavior.
Critical addiction theorists have challenged the brain disease model on epistemological grounds, arguing that when disseminated publicly, such discourse might function as an iatrogenic diagnosis serving to harm substance users by reducing their motivation and beliefs concerning their capacity to modify their behavior (psychological recovery capital) and promoting public stigma.
Iatrogenic refers to any illness, injury, or adverse effect that is unintentionally induced in a patient as a result of medical treatment, diagnostic procedures, or the actions of a healthcare professional.
Arguably, the BDMA encourages essentialist beliefs across stakeholder groups (public, clinicians and clients) that addiction is caused by largely unmodifiable constitutional factors inherent to the individual which encourages prognostic pessimism and perceived otherness inviting stigma.
Although this critique has strong rhetorical force, it is empirically weak – being based on a handful of experimental studies with substance users testing iatrogenic effects of disease framing on a small set of recovery capital constructs.
The most reliable iatrogenic effect of brain disease framing is on recovery confidence. Four online experimental studies have demonstrated that framing addiction as a compulsive brain disease versus psychosocial choice reduces problematic substance users’ confidence in their capacity to reduce their addictive behavior. This corroborates studies showing that framing mental health and addiction as biologically determined increases observers’ prognostic pessimism regarding sufferers’ chances of recovery.
As confidence in actioning recovery-oriented behaviors (often labeled self-efficacy) predicts actual recovery outcomes dissemination of the brain disease model might actually impede recovery from addiction, independently from its validity as a scientific theory.
Motivation or readiness to change is another key recovery capital construct which is linked with actual recovery outcomes.
Whether the brain disease model has detrimental effects on substance users’ motivation to reduce their addictive behavior remains unclear. Given the importance of motivation to change as the first step toward recovery, it is crucial to test whether framing addiction as a brain disease versus value-based choice undermines this construct.
The current article reports two exploratory experiments which randomized alcohol consuming students to read and hear direct quotes from scientific papers describing addiction as a brain disease versus a value-based choice (using between-subjects designs). Then, their confidence (self-efficacy) and motivation (readiness) to reduce alcohol consumption or unwanted habits, their choice and desire for alcohol, and their sense of general self-control were measured.
The researchers hypothesized there would be significant iatrogenic effects of framing addiction as a compulsive brain disease on these measures of psychological recovery capital.
Findings and Meaning
The research reported about two studies that used different procedures but were consistent in demonstrating a harmful effect of framing addiction as a brain disease versus value-based choice on readiness to change.
- Study 1 found that exposure to disease versus choice framing statements was linked with lower readiness to change alcohol consumption behavior in students who consume alcohol hazardously.
- Similarly, Study 2 found that exposure to disease versus choice framing statements was linked with lower readiness to change unwanted habits (which included alcohol consumption, smoking, other drug use, gambling and overeating), in students who consume alcohol weekly.
No other outcome measure was significantly modified by the framing manipulation, including alcohol choice, alcohol craving, alcohol self-efficacy, self-control over unwanted habits or general self-regulation, suggesting the framing effect was specific to readiness to change.
Given that readiness to change is reliably linked with recovery outcomes in clinical samples, the current findings elevate the concern that brain disease discourse might harm substance users’ motivation for behavior change relative to choice addiction narratives, producing real-world consequences.
- It is theoretically possible that the brain disease frame encouraged the essentialist belief in participants that their unwanted habits stem from relatively unmodifiable constitutional risk factors (genes, brain structure, temperament etc.), which decreased their motivation for change, but this mechanistic account of the framing effect needs to be formally tested.
The framing effects on readiness to change has mixed support from other studies.
- Some studies show that
- disease versus psychosocial addiction framing lowered substance users’ estimated likelihood that they would pursue supportive counseling and cognitive-behavioural therapy for their drug or alcohol addiction;
- exposure to framing material which characterized alcohol problems as a binary disease versus falling on a continuum, was linked with lower alcohol problem recognition.
Although these framing effects are broadly consistent with the present findings, it remains unclear to what extent problem recognition and readiness to change constructs are comparable.
In contrast to these results, other studies found that brain disease versus choice framing did not lower high-risk alcohol users’ desire to reduce their substance use rated on a 3-point scale from ‘no’ to ‘strong desire’, or readiness to change measured in a subsample at the end of the study (although these null effects could be explained by the low sensitivity of the 3-point scale and rapid decay of framing effects over time respectively).
One might conclude from these mixed results that the BDMA does reduce some dimension of readiness to change in some substance users, although the optimal framing manipulation, outcome measures and participant sample required to reliably demonstrate this effect remains to be clarified in future work.
There is also uncertainty about the optimal method for detecting any iatrogenic (harmful) effect of brain disease framing on self-efficacy. Some researchers found that disease versus choice framing lowered high-risk alcohol users’ confidence that they could reduce their substance use (generally, i.e. in no particular context), and this effect has been confirmed in treatment-engaged substance users.
There are several weaknesses in the two experiments reported in this study:
- The sample size of study 1 was small, and although study 2 had a larger sample it was conducted online which is notorious for producing low quality data.
- Both studies recruited predominantly psychology students, so the effects on readiness to change could be demand effects, i.e. participants complying with the perceived aims of the study.
- Against this, the researchers employed a between-subjects framing design to limit participants’ knowledge of the other manipulation condition and thus mask the purpose of the study.
- Another concern is that the brain disease frame and the readiness to change index may have had limited relevance for the study participants as they had relatively low alcohol problem severity (hazardous and weekly alcohol users in study 1 and 2, respectively).
- Against this concern, the researchers’ previous study found that brain disease framing produced a statistically comparable iatrogenic effect on self-efficacy in hazardous and dependent alcohol users, both of whom differed from low-risk alcohol consumers.
- Motivation to reduce alcohol use is prospectively linked with reduced alcohol use in both hazardous and more severe alcohol users. These findings suggest that even for alcohol consumers at the lower end of the severity spectrum, brain disease framing and motivation for change may be relevant for their real world alcohol consumption behavior.
- Another weakness of the current studies is the absence of a neutral control group, so the researchers cannot determine whether readiness to change was reduced by disease framing, or increased by choice framing, or both. Either way, clinical and educational discourse should favor choice over disease narratives if intended to promote readiness to change.
- A key limitation of the work concerns the substantive methodological differences between the two experiments, which is both a weakness and a strength. Between Study 1 and 2, the total set and order of questionnaires was changed, the testing protocol shifted from in-lab to online, and participants changed from hazardous to weekly alcohol users, all of which might have affected responding.
These limitations should be addressed in future studies, especially regarding the exact construct measured by the readiness to change index.
Despite these procedural differences, the studies were consistent in demonstrating a disease framing effect on readiness to change supporting the robustness of the effects.
A final uncertainty is to what extent the iatrogenic framing effects reported here operate in the natural environment. Although health messages do produce significant behavior change, effects sizes are often small or short-lived and the dissemination pathway between scientific publications and different stakeholder groups are obscure ‘(Brann, Citation2024; National Academies of Sciences, Engineering, and Medicine, Citation2017). Nevertheless, the current work does suggest that clinicians and educators might consider avoiding BDMA discourse to avoid undermining behavior change in their client groups.
In conclusion, both studies found that framing addiction as a brain disease versus value-based choice was linked with lower motivation to change alcohol consumption behavior and unwanted habits in students who consume alcohol hazardously and weekly.
These findings raise the credibility of the epistemic critique that scientific framing of addiction as a brain disease is iatrogenic for psychological recovery capital in substance users, thus impeding recovery from addiction, independent of the validity of the BDMA as a scientific theory.
Language guidelines around addiction terminology might be extended to recommend eliminating brain disease discourse from both scientific and lay-communications where possible to minimize potential harms.
Abstract
Background
It has been argued that framing addiction as a compulsive brain disease rather than a value-based choice might harm substance users’ motivation and beliefs concerning their capacity to modify their behavior (so called psychological recovery capital, e.g. readiness to change) but few experiments have tested this proposal.
Methods
In study 1, students who consume alcohol hazardously (N = 63) were randomized to read and hear quotes from scientific publications describing addiction as a compulsive brain disease versus a value-based choice (between-subjects, in-laboratory), before reporting readiness to change their alcohol consumption behavior, alcohol choice, craving and self-efficacy.
In study 2, students who consume alcohol weekly (N = 155) were randomized to receive the same framing manipulation (online), before reporting readiness to change their unwanted habits, self-control and self-regulation.
Results
In both studies, participants reported lower readiness to change following exposure to scientific quotes that framed addiction as a compulsive brain disease versus a value based choice.
There were no significant framing effects on other outcome measures.
Conclusions
These findings provide preliminary evidence that scientific discourse describing addiction as a compulsive brain disease rather than a value-based choice is iatrogenic (in the sense of being a harmful diagnosis) in reducing readiness to change alcohol consumption behavior and unwanted habits in students who consume alcohol hazardously or weekly.
These findings provide a foundation for further research into the downstream epistemic consequences of scientific addiction narratives on psychological recovery capital.