Medicalization and the Behavioral Addiction Model

“Medicalization” is a sociological term critiquing the process by which medical models produce an epistemological shift in the way we view human behavior, typically by pathologizing it. Using biomedical etiologies to reconceptualize behaviors that are largely socially determined tends to decontextualize and depoliticize social problems. By focusing causation on individual-level pathology, medicalization obscures community-level and structural solutions.^{Reference Conrad2} “A behavioral addiction model of revenge-seeking and violence” fits squarely within this frame. It redefines violent behavior in terms of neurobiological causation, thereby abstracting it from social context.

The scientific validity and clinical utility of “behavioral addiction” models are controversial among experts.^{Reference Sinclair3} Only one so-called “behavioral addiction” (gambling) is classified as such in the Diagnostic and Statistical Manual of Mental Disorders.⁴ Some wellrespected experts, including professional associations, adamantly reject addiction models of behavior as empirically unsupported and unduly pathologizing.⁵ Critiquing the empirical conclusions underlying Kimmel and Rowe's model is beyond the scope of this commentary, which instead scrutinizes their model's societal implications. But the considerable scientific skepticism about “behavioral addictions” nevertheless accentuates doubts about the value of modeling violence this way.

Oppressive History of Medicalization

Because low-income, predominately-minority urban communities have the highest rates of gun violence^{Reference Aufrichtig6} — and are therefore disproportionately implicated by Kimmel and Rowe's model — we must consider how medicalization has historically oppressed poor people of color in the United States. During the Civil War era, fleeing enslavement was hypothesized as a mental illness, called “drapetomania.”^{Reference Metzl7} Early-twentieth-century eugenicists medicalized poverty and criminality as rooted in heredity, leading to involuntary sterilization of poor women of color.^{Reference Roberts8} During the civil rights movement, psychiatrists medicalized civil unrest by reconceptualizing schizophrenia as a “Black disease” and institutionalizing Black protesters.⁹ Medicalizing substance use has followed similar patterns. A 1985 medical report on prenatal cocaine exposure spawned the now-discredited, racist notion of “crack babies.” The ensuing moral panic motivated an onslaught of fetal protection laws, which are still used to prosecute predominantly poor women of color for using drugs during pregnancy.^{Reference Goodwin10}

Addiction Model and Carceral Investment

A behavioral addiction model of revenge-seeking and violence may appeal to reformers who believe the “brain disease model of addiction” subverted the War on Drugs and expect that Kimmel and Rowe's model could have similar decarcerating effects for violent crime. However, while treatment for substance abuse is essential, the addiction model has failed to elevate medical over carceral responses. In fact, it has fueled new investment in the criminal legal system. The carceral system has become America's primary infrastructure for managing substance abuse since deinstitutionalization began in the 1960s,^{Reference Pan11} and the addiction model follows this trend.

Between 1999 and 2004, as the “brain disease model of addiction” gained traction, drug treatment courts (DTCs) more than tripled in number, with over 3000 now operating in all fifty states.^{Reference Sacco and O'Hear12} Despite modestly reducing convictions, DTCs are an unmistakably carceral response. For example, even successful graduates of Santa Clara's DTC spent an average of 51 days in jail due to sanctions. Failure results in enhanced prison sentences (judges disproportionately fail poor and nonwhite participants). DTCs may even widen carceral control: drug cases in Denver nearly tripled in the two years after it established a DTC, likely due to well-intentioned police and prosecutors making more arrests and filings to get people into court-ordered treatment.^{Reference Walsh13}

The addiction model has also motivated jail expansion. While jail populations are declining in our largest cities, they are increasing throughout most of the country due to a boom in jail construction, driven in part by jail officials' desire to build specialized substance abuse treatment facilities. County jail systems have received state funding to expand existing facilities to increase treatment capacity and build new “therapeutic” detention centers. They have also diverted existing funds from social services to jail construction.^{Reference Mai14}

Similar investments have been made in policing. For example, as Congress increasingly asserts that opioid abuse is a disease, it is doubling down on funding for police: in fiscal year 2018, Congress appropriated over $300 million (an approximately 12% increase from the previous year) for law enforcement efforts to combat the opioid crisis.¹⁵ Department of Justice-administered grants, as well as private foundation money, fund traditional drug interdiction, along with police initiatives to administer naloxone and refer people to treatment after arresting them.¹⁶ While lifesaving first-responder initiatives are essential, police are poorly suited to this role. However, because we have built our crisis response infrastructure around police and eviscerated social services, policies that aim to address addiction as a medical problem slot effortlessly (albeit perversely) into this extant carceral infrastructure.

These investments not only bolster a bureaucracy that devastates poor communities of color; they also detract from investment in community infrastructure that can prevent substance abuse or provide treatment that does not hinge on arrests, criminal charges, or jail stays.

Risks of Medicalizing Violence

Applying the addiction model to violent behavior may produce similar investments in the carceral state: expanding jail systems to treat “revenge addiction,” investing in treatment courts for “violent criminals,” and funding police first-responder initiatives to diffuse “revenge cravings.” Any further investment in carceral infrastructure, however well-intentioned, will disproportionately harm communities of color. Moreover, ill-intentioned carceral investment seems equally likely because those most affected by violence are poor people of color. That is, the notion of “innercity violence addicts” seems more likely to spark fear that would exacerbate over-policing and mass incarceration than to elicit empathy that would motivate public health interventions. As history reveals, medicalizing violence could easily become a tool of oppressive social control.

Furthermore, an addiction model that motivates carceral investment would detract from funding to redress structural failures that are empirically linked to high rates of violence — including inadequate social spending, low social mobility, residential segregation, and failing public infrastructure.^{Reference Culyba and Kim17}

More broadly, when social problems are redefined in medical terms, policymakers tend to prefer medical solutions because they are “less elusive” than reforming social policy; also, because medicalization locates problems in individual pathology, it can obscure the need for such reform.¹⁸ Thus, an addiction model of violence may reduce political accountability for structural change — either through racial bias, which will favor a naturalized explanation of inner-city violence, or through political weaponization that characterizes these populations as victims of apolitical pathology rather than systemic government neglect that warrants remediation. This may be especially likely because addiction is highly stigmatized — research shows that Americans hold significantly more negative attitudes about people with addiction than people with mental illness (an already stigmatized group), including strong opposition to social policies aimed at helping them.^{Reference Barry19} Notwithstanding Kimmel and Rowe's assertions that their model is not a substitute for social reform, their model's normative force, as well as the cognitive effect of shifting focus from a social to a neurobiological etiology of violence, may actually subvert such reform efforts. Moreover, it is not clear why this highly pathologizing and potentially stigmatizing model is needed to support clinical interventions to reduce violent behavior, such as cognitive behavioral therapy, motivational interviewing, or Kimmel and Rowe's own Nonjustice System.