Tuesday, March 16, 2010

Do addicts have self-control?

This book review about "addiction and freedom" is worth reading, and it's a good companion to the book review about medicating children that I blogged recently. The book is Addiction: A Disorder of Choice by Gene M. Heyman, a Harvard psychologist. The reviewer is a psychiatrist, Sally Satel.

Both this review and the one about children illuminate the same fallacy, which I'd paraphrase like this:

1. A certain behavioral/mental problem -- call it "X" -- is associated with brain activity in ways that can be observed and predicted.  
2. Therefore, the solution to "X" must take the form of psychiatric/medical assistance; the solution cannot be individual free choice. (Indeed, even invoking that concept may be detrimental.)
There's a lot that could be said about why this is a fallacy and why it's so common. The question of free will lurks under the surface of the discussion, though Satel understandably sticks to talking about science, policy, and history, and hardly touches the philosophical problem. Here's what she says about the fallacy:
[M]uch of the public, and a dismaying number of psychiatrists, psychologists, and neuroscientists, mistakenly believe that if a behavior is influenced by genes or mediated by the brain then the actor cannot choose his actions. While every behavior has a biological correlate (and a genetic contribution) and every experience that changes behavior does so by changing the brain, the critical question, Heyman wisely says, is not whether brain changes occur (they do) but whether these changes block the influence of the factors that support self-control. . . .

Heyman uses the phenomenon of addiction to make a profound point about neuroscientific progress in general. "The implication is that as we learn more about a disorder," he writes, "the more likely it is to be thought of as a disease" -- and, consequently, as a condition whose course cannot be modified by its foreseeable consequences. Indeed, reconciling advances in brain science with their meaning for personal, legal, and civic notions of agency and responsibility will be one of our next major cultural projects.

Progress in brain science will also force a confrontation with the fact that the common interpretation of pathological behavior is often informed by a primitive form of dualism. If biological roots can be found, then we reflexively think “disease”—as in the obliteration of choice-making ability. The mechanical “brain disease” rhetoric is a symptom of the growing tendency to privilege neuroscientific explanations as the most authentic way of understanding human behavior.
In addition to logically explaining why that's a fallacy, Satel also says that the people who came up with the idea that addiction is a disease and is incompatible with self-control were motivated by political and financial concerns (and probably emotional impulses):
In fairness, the scientists who forged the brain disease concept had good intentions. By placing addiction on equal footing with more conventional medical disorders, they sought to create an image of the addict as a hapless victim of his own wayward neurochemistry. They hoped this would inspire companies and politicians to allocate more funding for treatment. Also, by emphasizing dramatic scientific advances, such as brain imaging techniques, and applying them to addiction, they hoped researchers might reap more financial support for their work. Finally, promoting the idea of addiction as a brain disease would rehabilitate the addict’s public image from that of a criminal who deserves punishment into a sympathetic figure who deserves treatment.
Those concerns may be admirable. But having good intentions behind your account of reality hardly ensures that your account will be accurate.

Finally, I had never heard of this incident (which begins the review), and I'm surprised it isn't better-known:
In 1970, high-grade heroin and opium flooded Southeast Asia. Military physicians in Vietnam estimated that between 10 percent and 25 percent of enlisted Army men were addicted to narcotics. Deaths from overdosing soared. In May 1971, the crisis exploded on the front page of The New York Times: “G.I. Heroin Addiction Epidemic in Vietnam.” Spurred by fears that newly discharged veterans would ignite an outbreak of heroin use in American cities, President Richard Nixon commanded the military to begin drug testing. In June, the White House announced that no soldier would be allowed to board the plane home unless he passed a urine test. Those who failed could go to an Army-sponsored detoxification program before they were re-tested.

The plan worked. Most GIs stopped using narcotics as word of the new directive spread and the vast minority who were detained produced clean samples when given a second chance. More startlingly, only 12 percent of soldiers who were dependent on opiate narcotics in Vietnam became re-addicted to heroin at some point in the three years after their return to the states. “This surprising rate of recovery even when re-exposed to narcotic drugs,” said the epidemiologist who collected the data, “ran counter to the conventional wisdom that heroin is a drug which causes addicts to suffer intolerable craving that rapidly leads to re-addiction if re-exposed to the drug.”
Satel says our ignorance of this real-life experiment represents a case of "generational amnesia." It's easy to keep believing in a dogma if you don't look at any of the evidence that goes against it.

(Photo by Daniel Modell, a.k.a. dM.nyc.)


LemmusLemmus said...

Another facet of the motivations-for-seeing-addiction-as-desease topic: My father (a legal scholar) told me that here in Germany (where health care is practically universal and highly regulated), the most important consequence of this interpretive switch was legal: Now your health care oranization paid your rehab, before they'd only pay the treatment of the symptoms you might develop as a consequence of your drug abuse (e.g., cirrhosis of the liver). Who knows, this might even have been a cost-effective move in purely monetary terms; would like to see a study on that.

Jason (the commenter) said...

This sort of thing reminds me of Nietzsche and his attack on the idea of free-will.

If addicts are slaves to their brain chemistry, then a reasonable way of making them change their behavior is with things that will have a strong impact on their brain chemistry, such as harsh punishments. It is only the insane, people entirely outside the purview of cause and effect, who it makes no sense to punish for their actions. It doesn't matter if people want to call a tendency towards a criminal activity a sickness or not. The punishments handed out by courts ARE a form of treatment.

The only thing I would recommend to help addicts, would be places where they could have themselves forcefully held, like sanitariums, to dry out. It might be helpful for lots of people and lots of things.

Anonymous said...

That Vietnam story was really interesting and helpful. The part about only 12% becoming re-addicted reminded me of some studies from college- I don't remember the details, but a really large number of college students meet all of the defined criteria for alcoholism. Thing is, once they get out of college, they by and large lead normal lives; the incentives to drink heavily simply aren't there anymore.

The "disease" model really understates how much of this is situational and incentive-based.

To build on Jason's comment about giving people with chronic problems a place to dry out, we should add something (counseling? Guidance?) that leads them to a new place afterwards, perhaps even geographically new, that would keep them literally away from the social forces that encouraged them to use. If that means cutting off certain family and friends, so be it.
- Lyssa

Kylos said...

I hate to open the can of worms, but the same logical fallacy seems to apply when discussing homosexuality. In the case of addictions, we agree (mostly) that they are harmful, so the issue is mostly the cure.

But if this fallacy equally applies to reasoning about the nature of homosexuality, then it's not so simple to conclude that homosexuality is not a matter of free choice. It would then come down to the individual's feelings about their own sexuality, whether they find it natural and healthy, or destructive. The ability or desire to change one's sexual desires through free will does not then seem at all an affront to nature.

John Althouse Cohen said...

Kylos: Even if sexual orientation is a choice, that doesn't settle the question of what society's attitudes should be toward sexual orientation. Those who think homosexuality is harmful to society will presumably think so regardless of any evidence that it's freely chosen or not freely chosen. Those (like me) who think homosexuality is a fine thing will also presumably believe this whether or not there's evidence showing that homosexuality is or isn't a choice. After all, even if I believe homosexuality isn't a choice, I at least have to admit that bisexuals get to choose whether to have male or female mates (though not which people to feel an initial attraction to). But that fact is of no consequence from my point of view since I don't see anything wrong with a bisexual person (or a gay person) choosing to be in a romantic relationship with someone of the same sex. If homosexuality actually had a deleterious effect on society, then we might justifiably insist that gays simply not act on their sexual desires at all, just as we insist that pedophiles refrain from acting on their sexual desires (without needing to first determine whether pedophilia is innate or freely chosen). I have little interest in debating anyone about whether "homosexuality is a choice"; what I am interested in debating is how society should view the fact that two people of the same sex are sometimes going to be attracted to each other, fall in love, raise children together, etc. If it's their "choice" to do these things, well ... great! Those are good things to choose to do, whether the configuration happens to be female/male, male/male, or female/female.

One thing I wonder about the idea that sexual orientation is a choice: if you're heterosexual, do you believe you could decide tomorrow to start being gay? I find that rather implausible. I'm straight, and I can't think of anything I could have ever done in my life to turn myself into a gay person.

Jimmy said...

One comment on the Army heroin addiction anecdote:

With high-stakes testing like urinalysis and going home, many people probably were trying to cheat the test. So it would be interesting to have some discussion on cheating attempts, and whether the epidemiologist and the program commander try to proctor the testing.

Kylos said...

John, you're right, it doesn't settle the question. My point is to say that claiming that sexuality is a biological imperative tries to avoid the question by using a logical fallacy. We might have more useful discussions of the question if this fallacy is rejected.

Kylos said...

Please note, John, that I am not saying that you employ this fallacy, just that I have seen it argued enough that I think it is somewhat common.

I'm no neuroscientist, but as I understand, the human brain is able to train and rewire itself, so that what may be interpreted as a 'gay' region of the brain (or a region of some such other proclivity) is not proof of lack of choice, but rather could be the result of a series of choices, reinforcing a particular behavior. In others words, as you increasingly pursue certain behaviors and rationalities, your brain reconfigures itself to expedite these processes, until it seems that there is little choice or thought left in the process. This gets into the nature vs. nurture debate, but I'll cut this post off here unless you'd like to discuss it more.

John Althouse Cohen said...

Yeah, you make a good point that people who leap to the conclusion that "homosexuality isn't a choice" may be making the same fallacy. Personally, I don't consider sexual orientation to be a choice -- but that's just my hunch, and I don't see any need to be dogmatic about it. I was just adding tangentially that I think it's often overstated how important the hardwired-vs.-freely-chosen debate is with respect to sexual orientation. In contrast, the "Do addicts exercise choice?" question is highly relevant to how we should treat addiction.

Jason (the commenter) said...

JAC: I was just adding tangentially that I think it's often overstated how important the hardwired-vs.-freely-chosen debate is with respect to sexual orientation.

If sexuality were a choice that would put it in the same class as religion.