A summary of the disease model of addiction
In our last blog, we discussed the advantages and disadvantages of the disease model of addiction in both chemical and behavioural addictions, including sex and porn. The primary advantage was how it shifted society’s view of addiction from being a moral failing or a weakness to a recognised health condition. The disease model of addiction meant the government and the health service began to take the issue more seriously and offered treatment that focused on recovery, rather than shame.
However, we also highlighted the disadvantages of this model, namely that it disregards the concept of choice and created a new kind of stigma and shame that said addicts were powerless and stuck with their unwanted behaviours. Furthermore, the disease model oversimplified the problem, focusing on physical symptoms and ignoring deeper psychological issues and thus offered simplistic treatment options that include abstinence (which of course, does not work for sex). Finally, we concluded that it was primarily these problems with the disease model of addiction that fueled the ongoing controversy and debate surrounding sex and porn addiction, and when we move away from this model towards a more biopsychosocial one, those tensions and conflicts are lessened substantially.
What is a biopsychosocial model of addiction?
The biopsychosocial model was first theorized by George Engel in 1977 and since then, it has gained popularity amongst addiction professionals. As can be surmised by the term, it is an approach to medical understanding and treatment that covers a wider range of human experience beyond just the biological aspects like brain structure and heredity. When assessing health issues, it also considers underlying psychological factors, the individual’s socio-cultural context and how these all intertwine when it comes to choosing the right treatment approach. In this sense, the biopsychosocial model offers a much clearer picture of an individual’s condition and opens up the potential for more varied and client-centred treatment approaches.
However, whilst a biopsychosocial model is a vast improvement from a pure disease or medical-based lens, it isn’t sufficient when it comes to sex and porn addiction as it doesn’t address crucial psychosexual aspects. Sexual health is incredibly broad, nuanced and unique to the individual. It is also rife with moral implications, politics and hugely dependent on an individual’s personal context. Therefore, it’s crucial that the ‘psycho’ and ‘social’ aspects of the biopsychosocial model are explored fully and within a sexological context. The BERSC model which is an expansion of the biopsychosocial model resolves this.
The BERSC model of sex and porn addiction
The BERSC model (see image below) addresses everything that the biopsychosocial model does but crucially, it also considers the ‘psycho’ and ‘social’ elements in more depth as they are broken into two connected but distinct categories. Additionally, it uses bidirectional arrows to acknowledge the importance of correlation versus causation, meaning these factors can be both a cause of the addiction and a consequence of it (and indeed, both simultaneously).
The biological part of the model addresses the neuroscientific aspects of addiction including how chemicals or behaviours change our brain structure. Equally, it also takes into consideration those who may be genetically predisposed to addiction problems and neurodiversity. As we know, addiction does change the brain but as discussed in our previous blog, this does not necessarily equate to it being a disease as many other things cause brain change.
The emotional part includes all significant psychological issues that may have caused addiction such as childhood trauma, as well as mental health problems like depression and anxiety which may be both a cause and consequence of the behaviour. As therapists and counsellors, it is vital that these factors are addressed alongside behaviour change otherwise the probability of achieving long-lasting recovery will be significantly lower.
The relational part, a distinct, addition to the ‘psycho’ element of the model, acknowledges that both the cause of addiction, and the perception of them, can be significantly influenced by someone’s relationship status and satisfaction. Like emotional factors, these relational issues should be addressed and understood in both assessment and treatment. Sex and porn addiction commonly have a negative impact on relationships, whether that’s forming relationships in the first place or maintaining them. Additionally, attachment issues may often predispose someone to addictive behaviours, but it should be recognised that they are also a common consequence.
Finally, we come to the ‘social’ element which is separated into ‘social’ and ‘cultural’ in the BERSC model. Whilst society and culture are intrinsically linked, separating them provides space to consider the individual beliefs and mores of distinct groups within society. There is little doubt that society’s attitudes to sexuality have changed considerably over recent years as has its access to sexual materials and services through the internet, but within the broader picture of society we also need to consider the cultural influence of, for example, sexual orientation, gender identification, religion, race and work environment. The definition of healthy sexuality will vary hugely for certain individuals depending on these factors. The bidirectional arrows of the BERSC model indicate how demand for sexual resources reconstructs social norms and how the ongoing dialogue around porn addiction changes cultural perceptions and reactions. For many of those opposed to the label of sex addiction, acknowledgement of cultural difference and the subsequent moral perceptions of healthy sexuality versus compulsive sexuality is a crucial missing piece.
Conclusion
Many of the moral objections to sex addiction and porn addiction that keep us trapped in controversy and academic debate can be alleviated if viewed through the lens of the BERSC model of addiction as opposed to a disease model. The model provides an emotional path that acknowledges addiction is often a response to deeper psychological needs, rather than being about biological sex. It also explores relationship satisfaction and how that contributes to sex or porn becoming their mode of addiction. BERSC also provides clear routes to understanding and exploring sexuality from a culturally sensitive perspective, both in terms of why someone might consider their behaviours problematic and what healthy sexuality means to them. This expanded conceptualisation can provide a guide that ensures an integrative and holistic assessment, formulation and treatment approach that focusses on ‘why’, rather than ‘what’.
Moving away from a disease model of addiction and towards a biopsychosocial one also opens more avenues for research, for example focusing on other recognised components of addiction such as salience, mood modification, tolerance, withdrawal, conflict and relapse, rather than the current emphasis on brain studies. Updating the lens applied to sex addiction would inevitably change the picture and by addressing the moral objections, energy can be focused on other essential areas of research such as assessment and treatment efficacy.
Some argue that the label of sex addiction or porn addiction is, in itself, stigmatising and people who self-identify with the label experience psychological distress, not because of their behaviours, but because of the label. That would not be the case if a biopsychosocial model was used, and professional communities developed an integrative, inclusive and compassionate response. In fact, this objection raises further, separate questions as to why an addiction label is stigmatising in the first place and whether there is work to be done by health professionals to reframe this view of addiction, regardless of whether it is chemical or behavioural… However, this is for another blog! Ultimately, it is our duty as clinicians to ensure that the client remains central to the treatment process and our methods and practices do not contribute to this idea that issues with addiction are something to be ashamed of.
If you’re a therapist or counsellor who is interested in training in how to treat CSBD and sex addiction with a sex-positive and culturally inclusive approach, take a look at our diploma. Our next Tutor Tuesday, an online, open afternoon all about our diploma, takes place on 25th February from 1-2pm. If you’d like to join us, learn more and ask tutors some questions, sign up using the button below.
