The Disease of Addiction: A 21st-Century Understanding and Beyond
A Q&A with Joseph Caravella
This Q&A, facilitated by Jeremiah Gardner of the Hazelden Betty Ford Foundation, was originally published for Hazelden Betty Ford’s monthly Recovery Advocacy Update. If you’d like to receive our advocacy emails, subscribe today.
Joseph Caravella is a throwback of sorts to the days when addiction treatment counselors were wise philosopher-poets. Charismatic, fascinating in their own right, and uniquely skilled in helping others think about life in new ways, they and their yarns were unforgettable. Caravella naturally carries on that tradition at Hazelden Betty Ford in Center City and St. Paul, Minnesota, where he has been a counselor, speaker and educator since 2013. His patient lectures are frequently requested. Now his book is in high demand, too, by both patients and fellow counselors who want their patients to read it.
Written in 2019, The Disease of Addiction: A Twenty-First Century Understanding and Beyond correlates the modern biology of addiction with the wisdom of Alcoholics Anonymous. It’s a captivating read, drawing from his own lived experiences, professional clinical experiences, and his master’s degree from the Hazelden Betty Ford Graduate School of Addiction Studies — not to mention an insatiable thirst for knowledge that keeps him reading multiple books a week and spending his spare time with neuroscientists. We now eagerly await Caravella’s second book on the science of recovery — specifically, he says, on “the undergirding principles of the Twelve Steps and the mechanisms whereby the craving response is arrested through community support, empathy, and loving-kindness.”
You can download his first book for free at Researgate.net, or purchase a physical copy at Amazon.com and other major online retailers.
Q — You are refreshingly open about your own lived experiences — thank you for that. Could you start by sharing what recovery looks like for you, what it means to you, and how it has empowered different aspects of your life?
On our recovery coins Shakespeare waxes, “To thine own self be true.” My first sponsor and home group taught me the importance of honesty; in particular, veracity in how I talk about my life as a recovering person. Also, being autistic, I have a strong proclivity toward honesty and directness. Taken together, since getting sober, it’s been an imperative to me to be authentic when I share about myself — the good and the painful — in a radical but measured manner.
I got sober on the North Side of Chicago, in a young people’s fellowship of Alcoholics Anonymous, 15 years ago this month. The fellowship literally saved my life, as I had nearly died from acute alcohol poisoning and a suicide attempt two weeks prior. Not only did they save me, but they also gifted me everything — unconditional love, acceptance, a program to arrest my disease of addiction, the principles and community support to self-actualize and pursue my dreams. Everything that is good and meaningful in my life can be traced back to the program of recovery imprinted on me all those years ago. It means everything to me.
What does recovery look like today? I pray and sit in meditation for an hour every morning. I practice yoga and exercise and try to eat healthy. I manage my mental illness. I have a community of recovering people and I love them unconditionally. I have a relationship with a Higher Power, and it’s literally the most important thing in the world to me. As Dr. Bob famously prescribed: pray, clean house, help others.
Q — What inspired and motivated you to write your book, The Disease of Addiction, how has it been received and utilized, and what have you learned from the feedback? (Were your patients the specific audience you had in mind?)
Around 2015, while working as a residential counselor at Hazelden Betty Ford in Center City, I was asked to take over Bruce Larson’s classic Disease of Addiction lecture series. Over the next couple years, patients increasingly asked if I had any written material beyond the lectures. At that point, due to longstanding challenges with a learning disability and attention deficit (and despite having a graduate-level education), I never considered myself a strong writer. So, honestly, writing a book was not something I would have initiated on my own. It was 100% my patients’ requests that inspired me to sit down in 2018, while on vacation in Winter Park, Colorado, and crank out the first draft of the book.
My initial goal was to write a pamphlet, as inspired by the longstanding line of educational pamphlets by Hazelden Publishing which, to this day, are popular tools for the person in early recovery. Pamphlet-size materials are perfect for the newly sober person whose dopamine — which regulates attention span, motivation and energy levels— are approximately 40% lower than baseline — making reading and learning an extra-arduous task. The Disease of Addiction ended up being around 50 pages — a bit longer than a pamphlet, but short enough that it’s still digestible.
I love hearing from newly sober people who read the book and experience an ah-ha moment of understanding about their illness. Another satisfying bit of feedback has been from patients who had their families read it and reported back that it helped legitimize the disease for everyone — i.e., yes, it’s a real brain disease, and thus the afflicted person deserves treatment and respect, patience and support, as they recover.
Q — You are a voracious reader from what I understand. What are you reading and thinking deeply about at the moment?
Oh my gosh. I love to read. I love to study and learn — about addiction, recovery, spirituality, neurology, stress physiology, PTSD, anthropology, sociology, primatology, autism, philosophy, mindfulness/meditation, Zen Buddhism. I think one of my gifts is consuming large amounts of information and then connecting the dots in novel and elegant ways.
Right now, I’m reading a book by Stanford neuroscientist Robert Sapolsky called Behave. It has prompted me to meditate on the following the past couple weeks: It only takes 50 milliseconds of exposure to the face of someone of another race to activate the threat center of the brain — the amygdala. Whoa…so there’s the science of implicit bias — our alarm system activates within 1/20th of a second of seeing someone of another race. Interestingly, and sadly, I also know that seeing a picture of a person who is addicted or homeless — say, hooked on fentanyl, and panhandling for money — tends to activate the insular cortex or insula, not the amygdala — producing a reaction of disgust. Ouch. Look, we all have biases. They’re in many ways grounded in biology. What we do with them — how we respond to these reactions — however, is what’s important.
Q — As a counselor working with people from all over the country, you get keen insights into trends around human struggle. Do you think America is in need of a spiritual revolution, as actor Rainn Wilson from The Office writes in his new book? Why or why not? And what could that look like?
Over the years, there are a few questions that I’ve asked hundreds of patients during my lectures. The first question is whether technology, as in cell phones and social media, has made us more or less connected overall. The resounding answer has been “less connected and more isolated.” The second question is whether we’re making more/less/the same amount of eye contact (the main mode of sensory connection in our species). Again, the emphatic response has been “less eye contact.” The last question is whether anyone waited until they were 25 or older before initiating substance use. Approximately 98 out of 100 people for whom I provide care report that they started using chemicals well before their 25th birthday. (Research suggests if people, even those with a genetic predisposition toward addiction, wait until 25 to use substances, their chances of becoming addicted drop substantially.)
Taken together, this is revealing of our social zeitgeist. Despite being the “richest” country on the planet, our social capital — defined in part by our sense of connectedness, of community and institutional support — is lower than ever. This aligns with the Surgeon General’s recent report on how loneliness has reached an “epidemic” level. As a populus, if we’re not engaging in rewarding relationships, then I assume we’re suffering, to some extent, in our isolated spaces of abstractions — status, wealth, achievement, physical appearance/image, ideology. Then there’s the dissonance from income inequality (of the G7 nations, the U.S. has the highest income equality), which adds to the overall sense of discontent and disenchantment for the average person. Research suggests that feelings of isolation can be worse than physical isolation. So many recovering people relate to that — i.e., isolating in plain sight. I wonder if all this — in addition to all the other typical influences — drives people to numb out or cope with chemicals, and at an earlier age? It certainly doesn’t help that alcohol and other drugs are more potent and deadly now than at any other point in our history.
A spiritual revolution? In short, I think we need to revolutionize our priorities as a society, such that they are more conducive to collective investment — in education, healthcare, community. We need to teach young people skills like emotional intelligence and conflict resolution; the kind of intrinsic investment that doesn’t necessarily have a financial return as much as a human one. We also need to determine how we can optimize digital technology to mediate analog connection — eye contact, friendship, love, reciprocity. I think the pendulum will swing the other way. People, on average, will learn to move beyond the craving to isolate, tune out and polarize in order to connect, collaborate, and achieve something together that surpasses their individual contribution. That’s spiritual.
Q — Almost every week, it seems new studies validate more of the wisdom at the heart of Twelve Step recovery — like the health benefits of forgiveness or social connection, for example. But some still say there’s no place for the Twelve Steps or spirituality in addiction care or any other kind of health care — arguing that it alienates atheists and crowds out other solutions. What do you say?
A 2021 study by Dr. John Kelly of Harvard Medical School (who now serves on the board of governors for my alma mater, the Hazelden Betty Ford Graduate School) identified that roughly 22.3 million Americans — more than 9% of adults — are living in recovery from substance use disorder. In 2020, Alcoholics Anonymous estimated its worldwide membership to be over 2 million, with 75% of those in the United States and Canada. Thus, A.A. and other Twelve Step groups hardly have a monopoly on recovery from addiction. That said, in 2020, Dr. Kelly and Dr. Keith Humphreys of Stanford University completed a Cochrane Review that found a person is up to 60% more likely to sustain their recovery from addiction through Twelve Step facilitation treatment and A.A. participation than they are through other evidenced-based approaches.
Over 200 mutual aid organizations — a.k.a. “fellowships” — with a worldwide membership of millions have adopted and adapted A.A.’s Twelve Steps and Twelve Traditions. I think the proof is in the pudding. It works. It’s a tried-and-true pathway to unlearn one’s addiction and to learn to handle life on its own terms. Regarding the spiritual component (the “God problem”), tens of millions of people — including theists, agnostics, atheists; and people with all kinds of conceptions of a Higher Power (or lack thereof) — have recovered using the Twelve Steps. My formal research and personal experience have helped me understand that it’s far more important what we do in recovery than what we believe. The Twelve Steps are a vehicle for recovery/change behavior, and, crucially, a pathway to comprehensive integration of the euphoric imprints/memories, physiological stress, and trauma caused by addiction into the constitution of a recovering individual. What blows my mind is how not only do the Twelve Steps help arrest addiction, but how they open a person to resilience and freedom in the face of suffering — equanimity.
To be sure, the Twelve Steps are not the solution to all the problems in my life. Nor were they ever promised to be. And I’m obviously biased because they saved my life. But with seriousness and humility, if someone finds a different solution that helps them attain the health and life they want, that’s great. Those of us with substance use disorders need all the help we can get.
With deaths of despair (i.e., addiction and suicide) higher than ever; 50% of Americans meeting criteria for a mental health condition at some point in their life; and addiction, loneliness, gun violence, and obesity at epidemic levels, we need to investigate all pathways to health and healing. We should validate and replicate tried and true methods and discover new ones.
We’re all in this together, trudging the road to happy destiny. Let’s act like it.
