Featured Article: How much choice is there in addiction?
By Nick Heather and Gabriel Segal
Image credit: Medications, cure, tablets by frolicsomepl. CC0 public domain via Pixabay.
There is much that we agree about in our understanding of addiction and what can be done about the harm it causes. However, unusually perhaps for collaborators, we disagree about some important implications of suggesting a rethink of the relationship between addiction and choice.
First, what do we agree on? We agree that the relationship between addiction and choice needs rethinking. More specifically, we both reject two polarised views of this relationship – one, that addiction involves no choice on the addict’s part whatsoever, and the other, that it involves a completely free choice, just like any other choice that humans normally make. We believe that the truth lies between these unhelpful extremes and that disputes between adherents of these positions have hampered theory, research and practice in the addiction field for too long. Addicts are clearly not the automata depicted in some “disease” accounts of addiction, neither are they the free agents depicted in traditional “moral” accounts. Rather, addicts’ choice-making is disordered in some way and addiction is therefore a disorder of choice.
Studies of addiction are best approached with the questions ‘What is the nature of the impairment?’and ‘How is it acquired?’ in the lead. Questions about management, treatment, law, and social and philosophical matters follow. All of these matters can be dealt with without first deciding whether addiction is a disease, except perhaps those relating to public health expenditure and insurance.
I do believe that addiction is a disease. It consists in a particular type of impairment to the choice-making systems in the addict’s mind and/or brain. It is specific to an addict’s relationship with their substance, and cannot be accounted for in terms of any other psychological, social, or further condition. It is like a software bug in a chess-playing computer, which causes the computer to sacrifice all other goals to that of taking its opponent’s pawns. And the more successful it becomes at this, the higher it values that goal and the more its computational resources become dedicated to it.
Addicts normally use because they choose to, but the disease affects how choices are made and acted on. Addicts choose to use even when they believe that using is against their own best interests. Even when they know they are, without any sensible justification, breaking their own prior firm and thoroughly justified resolutions and even when they have a strong desire not to use, they still use. In these ways addicts often use against their own wills. And, often, either by sheer force in the moment or by relentless persistence over time, the urge to use breaks the will as easily as a wrecking ball might break a brick wall.
There is much to agree with in what Gabriel has just said. I agree that the problem in addiction is tounderstand why addicts behave in ways that they are fully aware are against their best interests andwhy they repeatedly break prior resolutions to desist from the addictive behaviour. If we identify “will” as the resolutions made under conditions of cool and rational reflection and judgement, it is in this sense that in breaking their resolutions they act against their “will”.
However, I don’t agree that addiction is best viewed as a disease. Diseases are things that happen to people, over which they have little or no control and for which medical treatment is usually seen as the only resource. By contrast, addictive behaviour is what people do and over which they can have control. There is a huge amount of research to show that, while addiction involves involuntary, automatic urges and desires to use substances or engage in addictive behaviours, volition can always be exercised to decide whether or not those desires are complied with or resisted, however difficult this may be. Although professional or mutual aid assistance is often helpful, the public needs to be clearly informed that breaking free from addiction is possible and told how it can best be accomplished. This is less likely within a language of compulsion and disease. This is not an argument for blaming people for addictive behaviour; blame can be withheld without resorting to the language of disease. It is, however, an argument for a more enlightened societal response to addiction.
As a clinical psychologist who has been concerned in his career with responding to people who ask for help with their addictive behaviours, it follows from what I’ve said above that advances in understanding addictive behaviours will come from better understanding of the normal processes of self-regulation and how those processes go wrong in addiction. Improvements in treatment will result from research on ways to improve self-control training. I think there is a renewed interest among clinical psychologist in the addiction field in research and treatment applications of improved self-control training, with very interesting possibilities.
Someone in active addiction suffers from persistent and powerful desires, cravings, urges and feelings of need to use. The key to long-term recovery is not learning how to resist these motivational forces, but learning how to prevent them from arising in the first place. I believe they all arise in response to stress caused by turbulent emotions, such as anger, fear and elation. Good recovery requires the adoption of new methods of life- and mind-management that keep emotions under control.
I agree that, as well as finding ways to deal with temptation and avoid relapse, lifestyle and wider cognitive-affective changes are essential to long-term recovery.
Disease or not, compulsion or not, addicts’ cognitive and emotional responses to events in their own minds and in the external world, and their consequent choices, are disordered and, typically, detrimental to their well-being. A better and more nuanced understanding of the nature of the disorder is well overdue.
Addiction and Choice: Rethinking the relationship is available now.
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