MEDICALIZATION AND ADDICTIONS: Markers and Psychosocial Issues

Author(s): Amnon Jacob Suissa

Source: Canadian Social Work Review / Revue canadienne de service social, Vol. 26, No. 1
(2009), pp. 43-58
Published by: Canadian Association for Social Work Education (CASWE)
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MEDICALIZATION AND ADDICTIONS

Markers and Psychosocial Issues

Amnon Jacob Suissa

Abstract:Medicalization ofaddictivebehavioursis an increasingly

privileged
modeofsocialcontrol. Howdoesa conditionlikeaddictive changefrom
behaviour
and ideologicalbasisdoes the
a socialconditiontoa disease?On whatscientific
discourseon medicalization allowus to makethesebehaviourssociallymore
acceptable?As an analysisofthephenomenon ofaddic-
reveals,thedefinition
tionhasconstituted groundformultiple
a fruitful and controversial
interpreta-
tions.The 12-stepphilosophy, oftenconsideredto reduceharmbyoffering
mutualsupport, infactplaysa majorideologicalrolein thetrendtowards med-
ofaddictionand doesnotattacksocialdependency
icalization problems their
at
root.Byassociatingaddiction medicalization
withpathology, againstthe
militates
achievement ofhumanpotential, hinderingchangeand labellingpeopleas dis-
easedforlife.
Abrégé: La médicalisation des comportements toxicomanogènes estun mode
de plusen plusprivilégié de contrôlesocial.Commentun étattelqu'un com-
portement engendrant unedépendancese transforme-t-il d'unecondition sociale
en une maladie?Sur quellebase scientifique et idéologiquele discoursde la
médicalisations'appuie-t-ilpournouspermettre de rendreces comportements
socialement plusacceptables? Comme le révèle
une analysedu phénomène, la
définitionde toxicomanie estsujetteà des interprétations multiples et contro-
versées.La philosophieen 12 étapes,souvent réputéeréduirelestortsen offrant
un soutienmutuel, joue en faitun rôleidéologiqueimportant dansla tendance
de la toxicomanie
à la médicalisation sanss'attaquer aux problèmes sociauxde
fondde l'accoutumance. En associantla toxicomanie à la pathologie,la médi-
nuità la miseen valeurdu potentiel
calisation humain,faisant obstacleau chan-
gementetétiquetant les genscommemaladesà vie.

To PLAY OFF Freud'sreflectionson the last centuryin Civilization and

(Freud, 1929), one mightwonderwhetherthe twenty-first
itsDiscontents
centurydoes not conceal an even greaterdiscontent,broughton byglob-
alization.Economic,political,and social globalizationexertextraordinary

in theschoolofsocialwork
JacobSuissaisprofessor
Amnon du Québecà
at Université
Montréal.

CanadianSocialWorkReview,Volume 26,Number de
1 (2009)/Revuecanadienne
26,numéro
social,volume
service 1 (2009)
inCanada/Imprimé
Printed au Canada

43

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44 Revue canadienne de servicesocial, volume 26, numéro1

pressureson everycountryto compete and to perform.Accordingto

Saul (2006) and Chossudovsky(1998), the impactof globalizationpro-
duces certaininjuriouseffectson the social and economic conditionsof
citizens around the world, in particular,a major increase in poverty.
Althoughincomeis not a directindexofwell-being,economicconditions
have a huge impactnot onlyon the natureand frequencyof social and
familyproblems,but also on means ofconflictresolution.Fromthisper-
spective,we findthat,themorefamilyincomerises,thefewerbehavioural
problems,cases ofaddictionand childplacement,and manifestations of
violencewe find(Suissa, 2005b).
For betteror forworse, these changes have shaken up our way of
lifeat thebeginningof themillenniumand createdothersocialproblems.
Amongmanypossible examples,considertheprevalenceofworiienand
children among the poor, the.aging of the population with the con-
comitantincreasein socialand healthcare costs,familiescopingwithseri-
ous diseases such as AIDS, and the increasedrecourseto addictionsand
medicalization.Insofaras most problemsrelated to addictionsare the
resultofindividualreactionsto structuralsocialproblems(suchas poverty
and weak social relationships),takingthe social contextthatgivesrise to
the problemsin question into accountwhen we workwithindividuals,
families,and networksdealingwithaddictionsallowsus to identify poten-
tiallydurable solutions.
Medicalizationof addictivebehavioursis an increasinglyprivileged
mode of social control.How does a conditionlike addictivebehaviour
change froma social conditionto a disease? On whatscientificand ide-
ological basis does the discourse on medicalization allow us to make
thesebehaviourssociallymore acceptable? Based on a reviewof the lit-
erature,thisdiscussionfocuseson the social trendtowardsmedicaliza-
tion in the fieldof addictions.
Far frombeing a naturalelementof our existence,recourseto med-
icalizationrepresentsa mode of social controlthatfitsintoa dynamicof
socialpowerrelationshipsoccupiedbyindividualsand groupswithdiver-
gentinterests.The workof Horwitz(1990, 2002) on social controlstyles
and mental health,of Lloyd, Stead and Cohen (2006) on the medical-
ization of young people's behaviour,of Beaulieu (2005) on the various
modes of social controlaccording to Michel Foucault,and the classic
studiesbysociologistsConrad and Schneider(firstpublishedin 1980) on
the médicalisationof deviance and addictionsare good illustrationsof
this constructivist approach to a range of social problems,described
under the umbrellatermof medicalization.
Althoughthe process of medicalizationapplies to all social groups,
citizenswho are the most sociallyexcluded are more likelyto be sub-
ject to medicalization of their behaviour since theyare more visible
and perceived as less desirable in the public social space (Beaulieu,
2005; Lloyd et al., 2006). The case of drug-addictedpeople who are

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Canadian Social Work Review,Volume 26, Number 1 45

excluded in the contextofAIDS and addictionis a good example of this

medicalization of the social. Worried about a potential epidemic of
AIDS and hepatitisC, Canadian public health authoritiesopted fora
harm reductionapproach (Suissa, 2007b). Needle exchanges, hepati-
tis treatment,and specialized clinics offeringheroin under medical
supervisionare combined withthe supply of substitutedrugs forpsy-
chotropicopiates such as buprenorphine (Subutex) and methadone.
The studiesin thisfieldby Morissette,Alary,Roy,Parentand Blanchette
(2006) and by Roy,Nonn, Haley and Morissette(2003) shed consid-
erable lighton these practices,whichfallwithinan essentiallymedical
publichealthresponseto a social problem.These medicalizationmodes
primarilymanage the social distancingof groups perceived as being
deviant,as havingweak social ties,and thus as being more difficultto
integratesocially.The medicalizationof addictions thereforeoccupies
a dominantrole as a mode of social control(Pharo, 2006). In point of
fact,we are witnessingwhat Saint-Onge (2005) calls the emergence of
a new-stylejunkie,who can be medicalizedwithoutdisruptingthe social
order.

The concept of medicalization: Definition and context

In attemptingto definemedicalization,let us considerthe viewof Zola
(1983), who definesthe concept as "a processwherebymore and more
aspects of dailylifehave come under the control,the influenceand the
supervisionof medicine" (p. 295). Other researchersdescribemedical-
ization as a processwherebyprimarilysocial problemsare definedand
treatedas medical, and even pathological,problems (Beaulieu, 2005;
Cohen & Breggin, 1999; Conrad, 1995; Saint-Germain,2005; Saint-
Onge, 2005). Accordingto theseresearchers,certaincontextualfactors,
includinga declinein religion,an unshakablebeliefin science,an increase
in individualism,a weakeningof social ties,insistenceon rationalityand
progress,and, finally,the increased power and prestigeof the medical
profession, have favouredtheriseofmedicalizationas meansofmanaging
social problems.
Historicallymedicine has takena centralrole in the medicalization
of behaviours. Di Vittorio(2005) notes thatthe professionalizationof
physicianstook place withinthe frameworkof public health policy at
a timewhen a need was seen fora technical apparatus to manage the
social body. In a remarkable essay on Foucaulťs work, Di Vittorio
shows that,in the name of public health, a body of "medical-admin-
istrative"knowledgewithinmedicine developed to manage social dan-
ger as a pathological risk. Insofar as the discourse was centred on
danger, this science of social danger was the springboard for med-
icalization or,as Castel (1983) would put it,the social controlof unde-
sirable behaviours.

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46 Revue canadienne de servicesocial, volume 26, numéro1

Gori and Volgo (2005) do not hesitate to use the term "patholo-
gizationof existence,"in whichmedicine takesover,throughmedical-
ization,to manage more and more of our daily lives. Consider the use
ofmedicalizationthrough"happy pills" as a means of controllingsocial
groupswithless power in society.In thiscontext,we mightthinkof the
elderly,who consumean averageofmorethansix prescriptiondrugsper
day (Pérodeau, Forget,Green-Demers,Préville,Savoie-Zaic & Suissa,
2005), or of adolescents prescribed Ritalin (Lloyd et al., 2006).
Researcherswho have drawnattentionto the phenomenon of medical-
izationas a formofsocialcontrolincludePersons(1951), Friedson(1970),
and Zola (1972). Accordingto Conrad and Schneider (1980) and Con-
rad (1995), we mustavoid limitingmedicalizationto the applicationof
a singlelevel of controlsince the processaffectsthreelevels:conceptual
(in the formof discourseand the adoption of an ideologythatstrength-
ens its social acceptance), institutional(in termsof physicians'roles in
organizationsand themanagementofpsychosocialproblems),and inter-
active(the privaterelationshipbetweendoctorand patient).
In lightof these observations,one can say thattwoimportantfields
constitutepreferentialtargetsin the processofmedicalization.The first
is whatone mightcall themedicalizedsocialcontrolof thenormalevents
of life(birth,adolescence, infertility,menopause, menstruation,death,
forexample). The second is relatedto themanagementofcertainbehav-
iours or problemsconsideredto be deviant,includingaddictions.
The workof Midanik (2004, 2006) contributesto demonstratingthe
ideologicalshiftsin whatshe calls thebiomedicalizationprocessofaddic-
tions.Withreferenceto alcohol in the United States,Midanik succeeds
in illustratingveryclearly how the reduction of alcohol problems to
genetic and biological processes leads to biomedicalizationof behav-
iours and social problems.Among heî arguments,we note the move,in
1992,oftheNationalInstituteon AlcoholAbuseand Alcoholism(NIAAA)
to the National Institutesof Health, the inclusionofbiomedicalgoals in
NIAAA's five-year strategicplan, and finallythe increasedNIAAAfund-
ing of biomedical researchfrom1990 to 2002. Accordingto Midanik,this
biomedical approach by which alcohol problemsare framedcreates a
more individualisticvision and solution to addiction social problems
that therebyomits importantenvironmentalstructuralfactors.In the
same logic, Midanik (2006) denounces the partnershipbetween bio-
medicalizationwiththe disease model in alcohol researchand givesthe
example of Sweden in the biomedicalizationof more and more social
condiions. She finallyinvitesus to remain alert to the application of
potentially thesame paradigmbythesocialsciencesto humanbeingsand
social problems.

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Canadian Social Work Review,Volume 26, Number 1 47

Emergence of new addictions

Cyberaddiction
Since the late 1980s,we have witnesseda technologicalrevolutiondur-
ing which cyberaddictiongraduallyinfiltratedmost societies and cul-
tures(Suissa,2007a). The manymanifestations ofcyberaddiction - Inter-
net addiction as well as pathological, problematic, excessive, and
compulsiveInternetuse- reflectthedifficulty ofreachinga consensuson
a definitionor the social constructionof thiscondition,whichchanges
over timeand in different contexts.
In the fieldof cyberaddictions, Young (1996) was a pioneer,identi-
fying fiveof the best-known behaviours: cyber-sexual,cyber-relational,
excessiveWeb surfing,net gaming,and computergame addiction.More
recently, Dufour(2003) pointsout that,althougha pathologicalInternet
user experiences feelingsof competencyon the Internet,he or she is
sociallyisolated but also less inhibitedwhen online. Meanwhile,addic-
tionto onlinegames ofchance and gamblingformoneyhas boomed due
to virtualcasinos, electronicstock markets(day trading), and multi-
playergames on the Internet.The casino maybe virtual,but the money
spent is real forthe player,who attemptsto recreatethe atmosphereof
a gaminghouse in completeanonymity. The drama thereforetakesplace
in the intimatesettingof the home or office,shelteredfromthe public
gaze, thusremovingone possible agent of dissuasionand social control.
Griffiths, a well-knownexpert on cyberaddiction,definesit as "an
addictivebehaviorthatdoes not involvethe consumptionof substances
but is focusedon thehuman interactionwithmachines"(Griffiths, 1999,
p. 212; 2000, p. 414) . He also calls on privateindustry as well as social
and healthcare policy-makers to considerthe devastatingnatureof this
social problem and assess the harmfuleffectsof thiskind of addiction
(Griffiths, 2002). For purposes of illustration,in 2003 the Britishspent
an astronomical£3.5 billionon online gambling,whichcorrespondsto
morethan$7 billionin Canadian currency, forthatyearalone (Edwards,
2004). The same trendcan be seen worldwide.It is estimatedthatthe
popularityof online poker games, forexample, increased the amount
wageredfrom£8.5 millionto £53.9 millionper day byDecember 2003
(Edwards,2004). In the United States,the latestfiguresshowthatthere
are morethan 1,500 networksofwebsitesdedicated to gamblingaround
the world and that theygenerated, in 2003 alone, more than $5 bil-
lion,ofwhich70 per centcame fromAmericangamblers(Smith,2004).
In this social trend,individualismholds sway,to the detrimentof
social networksand connections,whichbecome increasinglyweak. As a
consequence of increasingindividualism,this new addiction conceals
the veryreal psychosocialsuffering of userswho are dependent on the
Internetand raises importantethical, social, and political questions.
Insofaras 12-stepanonymoussupport groups historicallyshare major

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48 Revue canadienne de servicesocial, volume 26, numéro1

stratégieand ideologicalallianceswiththemedicalprofessionand thedis-

course associatingaddictionwithdisease, one can say thatthese groups
play an ideological mediation role in the process of medicalization.It
should be noted thatonline 12-stepmovementsdo indeed existunder
the name of InternetersAnonymous,in whichthe higherpowerof God
is replaced by the almightyWebmaster.

Plastic surgeryand themedicalizationofhappiness

In recentyears,we havewitnessedan unprecedentedfascination withthe
recourse to cosmetic surgeryas a means of meeting the increasingly
socialized, and increasinglystandardized,criteriaof beauty.Television
showssuch as Extreme Makeoverin United Statesand SOS Beautéin Que-
bec illustratethisextraordinary enthusiasmforthe beautifying, or total
transformation, of the body. Although the body is a prioria physical
object,one mustalso speak ofthesocialbody,sincethesocial gaze on the
body is a determiningfactorin the processofjudging whatis acceptable
and whatis less so.
In consideringhow recourseto surgerycan constitutean addiction,
it is usefulto note thatPeele and Brodsky(1975) were among the pio-
neeringresearchers,ifnot the veryfirst,to apply the term"addiction"
notonlyto theabuse ofmind-altering substancesbutalso to otherbehav-
iourssuchas obesityand addictionto love.Applied to plasticsurgery, the
concept of addiction refers primarily to a search outside oneself for
something thatis lacking on the inside. It is a of
way filling a void or sti-
fling a fear by means of a product or an action thatprocurestemporary
reliefand response(Le Breton,2004). In otherwords,thecycleofaddic-
tion to plasticsurgeryis part of a reactionto personal suffering includ-
ing weak self-esteem or self-image and an attempt respond social
to to
contextsoffragility or anxiety.Amongthe othersocial factorsthatinflu-
ence addiction to cosmeticsurgery, Lorenc and Hall (2005) mentionat
least three:
L exposureto television,special programming,Hollywoodspokesper-
sons, artisticrepresentations, and fashion;
2. the huge technological strides in medical procedures, such that
patientsrequireless anaestheticand post-operativerecoveryis much
faster;
3. the socializationprocess thatincreasesthe acceptabilityand desir-
abilityof surgeryin a societythathas become more and more toler-
ant of the idea.
The issue of the medicalizationof behavioursin general and cos-
metic surgeryin particularsheds lighton the importanceof the stan-
dardization and social normalizationof the criteriaof beauty (Blum,
2003). This increasinglyfavouredtreatmentfor"image disease" reflects
a truediscontentofcivilization.Someone who is dependenton an image

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Canadian Social WorkReview,Volume 26, Number 1 49

of oneselfand vulnerableto ageism uses surgeryas a means to anaes-

thetizeemotions and poor self-esteem,as well as to respond to social
criteriaand norms.

The concept of addiction: The heart of the debate

Historically,the verydefinitionof the termaddictionhas constituteda

fruitful ground for multipleand controversialinterpretations(Room,
1995). Accordingto Room (1995), frequentchanges in the definitionsof
addictionduringthe 1960s and 1970s mustbe understoodas the med-
ical establishment'swayofadjustingto a seriesofsociologicalarticlescrit-
icizing the concept of disease. For example, in 1980 the AmericanPsy-
chiatricAssociation,the InternationalClassificationof Diseases, and the
Diagnostic and StatisticalManual (DSM-III) adopted the definitionof
addictionas a substitute foralcoholismand intoxication.Whiletodaythe
termused in the DSM- IV is more oftendependence, thesevariationsin
the definitionof addictionare concretereflectionsof developmentsand
adjustmentsbased on changingsocial, economic,cultural,and political
contextsand relationsof power.
The sociologyofprofessions also teachesus thateverysocialdiscipline
has itsown versionof the concept of addiction.Pharmacistshave a ten-
dency to understandthe phenomenon as a series of reactionsto sub-
stancesand thebody'sincreasingtoleranceofa product;physiologists as
a dysfunction of the organsand metabolism,geneticists as a failureof a
specificgene, psychiatrists as a biomedical disorder or neurochemical
problem,psychologistsas a symptomof underlyingproblems or self-
esteem,sociologistsas a reactionto the processof social regulationand
the constraintsinherentin social relationships.Consequently,the vari-
ous professionalsactivein thisdomain continueto failto reach anycon-
sensusregardinga commonperspectiveon standardsrelatedto ideas and
the kind of treatmentto be applied. In the face of thispanoply of pos-
sibleversions,whichillustratesthemultifactorial ratherthanone-dimen-
sional natureof addiction,the model based on pathologycontinuesto
play a predominantrole in the discoursethatassociates addictionwith
disease.
The definitionof addiction is thereforenot neutraland in factrep-
resentsa crucialissue,both scientifically and socially.Depending on the
statusone holds in the hierarchyof power and the interestsat play in
social relations,the choice of definitionfor the term "addiction" will
varygreatlyfromone historicalperiod to anotherand in different social
and culturalcontexts(Conrad & Schneider,1980; Peele, 2004). Some
researchersand clinicianssee the question of addictionin moral terms,
othersin biomedical,cultural,or psychosocialterms.
Far frombeing a merelysemanticdebate, the concept of addiction
is a fundamentalsocial issue insofaras the waysin whicha conditionis

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50 Revue canadienne de servicesocial, volume 26, numéro1

perceived and defined have a directimpact on our understandingof

the phenomenon and on the typesof servicesand treatmentsthatare
favoured.Althoughhistorically theconceptofdisease has primarily been
in
associatedwithalcoholism,the dominantdiscourse thefieldofaddic-
tions is based fundamentallyon the four classic argumentsmade by
Jellinek(1960), whichare the cornerstoneof the approach associating
addictionwithdisease: predisposition,the progressivenatureofthe dis-
ease, loss of control,and the necessityof abstinence.
Regardingthepredispositioncharacteristics thatdifferentiateaddicts
fromnon-addicts,theresultsofa numberofstudiesdo notappear to sup-
portthehypothesisthatthereis a specificpersonalitytypeassociatedwith
these conditions(Chevalier 8cAllard,2001; Peele, 2001, 2004). In fact,
we can saythat,apartfromthesubstanceor activity thatlinksaddicts,no
twoindividualshave developed the abuse forthe same reasons.
The hypothesisthataddictionconstitutesa process thatprogresses
in a numberofwell-identified stepsis likewisefarfromconvincing.Most
people suffering fromaddictionsuse the substanceor activity reactively,
thatis, as a balancing strategyto deal witha stressfullifeevent(Castel-
lani, 2000; Peele, 2004; Valleur8cMatysiak,2003). In lightofthisunder-
standing,one mightask whethertheconceptof "progressive, inexorable
process" is not part of a determinist
vision thatobliterateshuman beings'
potentialto change or to adopt a particularbehaviour.
The concept of loss of controlis verycontroversialsince it is the
basis forthe idea that,ifan abstinentaddict resumesthe substancesor
activitiesin question,he or she willnot be able to stop. On the contrary,
the scientificevidence showsthatpeople are able to exerta certaincon-
trol over theirconsumptionor reduce the frequencyand intensityof
their addictive activities(Hodgins, Mararchuk,El-Guebaly 8c Peden,
2002; Peele, 2004; Sobell, Leo, Agrawal,Johnson-Young8c Cunning-
ham, 2002).
Finally,abstinence,which is considered desirable in intervention
withaddicts,can be a real obstaclewhen it is imposed as a precondition
fortreatment.By claimingthata potentialrelapse is the directresultof
the subject's abstinence problem,we eliminate intentionalityand the
manychoices made by people in the decision-makingprocess,whereas
these in factrepresentthe cornerstoneof personal and social change.
Weil emphasized, as earlyas 1983, thatit is not the addictiveactiv-
ity such thatdeterminesthe level of riskor suffering,
as but the nature
of the relationshipone establisheswithit. By emphasizingthe relation-
shipbetweentheindividual,theactivity or substance,and the social con-
text,Weildefinesaddictionnot as a permanentdisease condition,but as
a multifactorial continuumof psychosociallearning.Accordingto Weil,
thereare no good or bad activitiesor substances;thereare onlygood or
bad relationshipswiththese activitiesand substances.In otherwords,
althoughseveralfactorsmaycorrelateto explain thenatureofaddiction

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Canadian Social WorkReview,Volume 26, Number 1 51

(discoursefocusedon pathology,economic imperatives,promotionand

socializationof theideologythroughanonymoussupportmovements,or
culturalrealities,forexample), these factors,taken separately,cannot
fullyexplain the complexityof the phenomenon.
Complementingtheseremarks,Peele (1989, 2001, 2004) enrichesthis
definitionbyframingitmoreas a wayofliving,a wayofdealingwiththe
worldand oneself,a lifestyle.Whiledenouncingthepredominanceofthe
medical model and the deterministicvision of addictive behaviours,
Peele maintainsthatsocietyis themain mechanismforproducingemerg-
ing addictions.In thiscontext,one can thinkof the surgein casinos in
NorthAmericaand aroundtheworld,thedominanceofbig corporations
sellingalcohol or tobacco, the role of privateand public institutionsin
bolsteringthe discourseof medicalization,and the socializationby 12-
step movementsof theirphilosophy,whichis applied to more and more
behavioursto be medicalized. Fromthispointofview,the phenomenon
of addiction allowsus to situateit not as a problemattachedsolelyto a
person, but as a psychosocial problem (Perkinson, 2003; Valleur &
Matysiak,2003).
Despite theimpressivenumberofstudieson addiction,thedominant
view of this condition is based primarilyon pathologyand sets aside
macrocontextualexplanatoryfactors - political,historical,cultural,and
psychosocial - in the construction of such a discourse. In fact,if the
pathology/disease of addictionexisted, people who have theseproblems
should manifesta distinctivesyndrome.However,population studies
showthatdifferent people displaydifferent kinds of problemsand the
numberand severity oftheseproblemsfallalong a continuumratherthan
formingseparate profilesforaddicts and non-addicts.

Philosophy of 12-step anonymous groups:

An intermediary ideology in the medicalization of addictions

Althoughanonymousmovementsare sometimesconsideredto be harm-

reductionspaces, the factremainsthattheirdiscourseis based on a cer-
tain ideologythatpromotesmedicalization.Allergy,progressivedisease
of the will,moods, loss of control,or impulse disorder- this labelling
excusesindividualsand theirenvironment, morallyand socially,fortheir
actions,by offeringa space in which theycan find social solidarity,a
friendlyear, an absence ofjudgment, and mutual support(Peele, Bufe
& Brodsky, whichseem positive,simul-
2000; Ragge, 1998). These effects,
taneouslysituatemembersof such groups on a particularsocial trajec-
tory.More specifically,
responsibilityfortheiractionsis generallyremoved
fromthe individualand assigned to the disease, even ifthe person has
been abstinentfor several years. In addition, this labelling generally
applies to familymembers,commonlycalled co-dependents,who are
also requiredto adhere to the principlesunderlyingthe movement:the

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52 Revue canadienne de servicesocial, volume 26, numéro1

addictionis biological in origin;the addict has to acknowledgethathe

or she has a disease; he or she mustsurrenderto a higherpower(God);
the treatmentexpertis an ex-addict.
Anothereffectof thisideologyis the increasinglycommon applica-
tionof theselabels to a numberofbehavioursnow consideredto be dis-
eases: habitualgambling,divorce,obesity, depression,shopping,depend-
encyon affectionor love, the difficulties encounteredby adult children
of alcoholics,and drug use, forexample. We are witnessingthe social-
ization of labelling,which militatesagainst the potentialforpersonal
and social change.
The strikingthingabout thismovementis thatit succeeds in creat-
ing significant connectionsbyincludingmembersin a groupand break-
ing through their social isolation,but it simultaneouslyexcludes them
fromthewidersocietybylabellingthemas being sickforlife.This social
differentiation and secondaryadaptation (Spector,1972) betweensick
people and the restof societyhas twomajor consequences. First,strong
social solidaritydevelops, cemented by the principlesunderlyingthe
discourseof disease. In thiscase, the solidarityreproducestherapeutic
social control.Secondly,thousandsof individualswho are labelled as so-
ciallyill are excludedfromthewidersocialarena,whichis whyanonymity
is a necessaryrule.
Contraryto a harm-reductionapproach in which people are con-
sidered to be able to exerta certainamount of control(Suissa, 2007a),
the 12-step philosophy continues to oppose the concept that control
mayeverbe possibleforpeople who have developedan addiction.In fact,
abstinence constitutesan indispensable condition for the individual's
successin the processofrehabilitationand becomes a benchmarkforhis
or her successor failure,in accordancewiththe slogan of "one day at a
time"or the "24-hourplan,"whichdoes not allow the addictto envisage
more than 24 hours of abstinence.A systemof recognitionof the dura-
tion of the period of abstinencehas been establishedwithinthe move-
mentto encourage and rewardthosewho have succeeded in remaining
sober (forexample) forthe longesttime.
A numberof questionsremain.How can we claim to transferpower
and autonomyto people suffering fromaddictionswhenwe simultane-
ously confine them within a permanentindividualconditionofloss ofcon-
trolfor the rest of theirlives? How can we demand a certainlevel of
controlwhen the firststep in the 12-stepmovementclaims exactlythe
contrary, namelythe admissionof not havingcontrolover one's addic-
tion? What role do people's strengthsand competencies play in the
process of intentionalityand personal and social change? In point of
fact,severalresearchersin thefieldofaddictionhave shown,on thecon-
trary,thatthousandsof individualsaround theworld succeed in break-
ing the cycle of addiction withoutany treatmentat all (Peele, 2004;
Sobell, 2002; Sobell et al., 2002; Toneatto,2000).

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Canadian Social Work Review,Volume 26, Number 1 53

Conclusion and prospects for social work

The phenomenonof medicalization,or over-medicalization, constitutes
a preferredchoice formanagingsocial problems.The perverseeffectsof
thisdiscourseofmedicalizationinclude theeliminationof anyreference
to psychosocialand culturalfactorsand an attemptto prove thataddic-
tionis an impersonaland non-discriminatory - a questionof dis-
reality
ease. In a well-documentedarticle, Maddux (2002) gives a masterly
demonstrationofhow the disciplineofpsychology, forexample,has his-
torically backed up the social construction of the ideologyofdisease and
the individualizationof social problems. managing "diseases of the
In
soul," Maddux suggeststhatwe turntowardsa so-called positivepsy-
chology,in whichemphasis is placed on strengthsand skillsratherthan
on shortcomingsand deficits.In the face of the expansion of medical-
izationas a formof social control,the issue of social tiesremainscentral,
since it spearheads the modes of controland measuresto be favoured.
On an etymologicallevel,it is worthnotingthatthe concept of mal-
ady comes fromthe Frenchwordsmalà dire, whichmean the inabilityto
name or pinpoint the source of a person's sufferings and emotions.In
the same logic,theworddisease findsitsoriginin thewordsdisforpain
and the Frenchword aise, mal aise then constitutingthe condition of
being ill, a lack of ease, and thereforemalaise as the source of the dis-
ease concept. If the medical paradigm explains the pathologyor the
disease of addictionmainlybyreferingto a physicalpain disturbingthe
homeostasyof thebody,the main questionremains:to whatextentdoes
a behaviourlike addictionconstitutea disease, a pathology?
Today, we should question the results of the pathology/disease
approachto thephenomenonofaddictions.Likemanyotherresearchers,
authors,and practitioners, I sharethefollowinghypothesis:the morewe
label people as havingor suffering frompathologies,the morewe mul-
tiply theirnumber. It is true with alcoholism and otheraddictions,includ-
ing gambling. This sad reality is the clear illustrationof the govern-
ment'sfailureto findalternativesolutionsto thesocial problemsin terms
of how to integratecertain social categories and lifestylesconsidered
undesirableand deviantto the social mainstream(Suissa, 2005a).
In thesame vein,Le Bossé (2007) denouncesthedichotomyin which
social workersand practitionersoftenfindthemselvescaught. On one
side, the focusis on deficiencies:ifa person is.experiencingproblems,
itis because he or she is personallydeficienton one or morelevelsofper-
sonality, functioning, learning,or otheraspect.The dominantidea ofpeo-
ple suffering from addiction due to a physical,chemical,or psycholog-
ical deficiency,even a disease, is a good example. On the otherside, the
focus is structural:social change is needed to forcethe collectivesys-
temsof dominationto change course. Problemsare a symptomof diffi-
cult social and power relationships,and so people mustbe directedto

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54 Revue canadienne de servicesocial, volume 26, numéro1

solidarityand social action networksto reduce the structuralgaps that

fuelsocial problems,includingtheirown. In the case of 12-stepgroups,
theemphasisis on storiesofpersonalsuffering; althoughthesecreatecer-
tainsocialbonds,theydo not attacksocial dependencyproblemsat their
root,and the underlyingreasons are leftout altogether.
In responseto thisdichotomy, Le Bossé (2003, 2007) proposesdevel-
opmentof thepowerto act,whichmakesitpossibleto act specifically on
what is meaningfuland importantfor a person. By power to act, Le
Bossé means the exercise of greatercontrol over one's personal life,
one's family,and the community, whilerestoringone's own agencyand
relationto theaction.Accordingto Le Bossé,helpingdoes notmean alle-
viatingor curingsuffering, or even denouncingthe underlyingcauses;
rather,helpingshouldbe understoodin termsoffreeingoneselffromsuf-
fering,in thiscase fromaddictions.
In otherwords,intervention shouldbe centredon thecreationofpro-
pitious conditions so thatpeople are able to actindividually or collectively.
By concentrating on the here and now in the context of intervention,Le
Bossé remindsus, we can recognizethe importanceof remainingflexi-
ble, while not losing sightofwhatis urgentand what is less urgentand
keeping the followingthreeguidelinesin mind: take time,because the
problemhas probablydeveloped over a long period; share power and
expertise;and, finally, worktogetherwiththe people concernedwitha
focuson findinga solutionand not merelyidentifying deficienciesand
problems.
The resultsof a studybySuissa and Bélanger (2001) on social work-
ers' representation of thephenomenonofaddictionshowthat,although
social workerssay theypromoteempowermentand preventionin their
discourse,theyveryrarelyinclude family,social, and communitynet-
works (Suissa, 2005b). Paradoxically,theycooperate with the 12-step
anonymoussupportmovements,mostlybyreferring clientseven though
they claim to recognize the contradictions between empowermentand
power transfer and the 12-step model. The dominant disease model,
whichviewsaddictionas an individualmedicalproblemratherthana psy-
chosocial problem,goes beyond the purelyconceptual level and raises
the question of citizenparticipation.
When it comes to a transferof power to citizensin the case of gam-
bling, forexample, whywould we not include, in the process of treat-
ment,thestateor thegamblingprivateindustry as a principalactorin the
problems created? One could ask such questionsas, how do you feelas a
persondispossessed of his or her financialand familyproperty bya casino
or a video lotteryterminal?Do you feelentirelyresponsibleforyourcur-
rentsituation?If you had the possibilityof changing somethingabout
thecurrentsituation,at the social or collectivelevel,whatwouldyou sug-
gest? Is it possible to move froma psycho-clinicalapproach to a psy-
chosocialone,withoutanyhyphenbetweenthe"psycho"and the"social"?

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Canadian Social Work Review,Volume 26, Number 1 55

In termsofsocial ties(Suissa,2001), we seriouslyquestionthe 12-step

ideology as it produces certain social ties in which pathology can be
stoppedbut notcured:once an addict,alwaysan addict;yourpermanent
disease conditionis here to stay.While 12-stepself-helpgroupsrespond
to basic needs in termsof breakingsocial isolation,providingsupport,
activelistening,and some solidarity,these organizationsdisseminatea
certainconceptionof thehuman being in whichpeople are seen as inca-
pable ofexercisingcontrolovertheirliveseven iftheysucceed in chang-
ing theirlifestylesor habits.
The richnessoftheconceptofaddictionresidespreciselyin itsglobal
applicationto a betterunderstandingofan impressivevarietyofhuman
behaviours,includingcyberaddiction, gambling,druguse, and all kinds
ofactivities thatmaybe harmfulto thedevelopmentoftheindividualand
society.It is appropriateto emphasize thatthousandsof people succeed
in breakingthe cycle of addiction or reducing theiractivitieswithout
being labelled as sick forlife.These citizensregularlystop consuming
tobacco, reduce their alcohol consumption, lose weight, and create
healthyrelationshipswithoutany interventionby an outside group or
expert.By associatingaddictionwithpathology,medicalizationmilitates
against the achievement of human potential, hindering change and
labelling people as permanentlydiseased. Should we not investmore
in the strengthsoffamilyand social networks,ratherthanacceptingthe
verdictof once dependent, always dependent (Juhnke& Hagedorn,
2006; Suissa, 2005b)?

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