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Addiction & Behavioral Health


This page links to articles, letters, and reviews that demonstrate how naturalism can inform treatment and social policy concerning addiction and behavioral health.
 

Weight Loss Naturalism: Behavior Technology and the Quest for Self-Control

Choosing Irrationality - review of Addiction: A Disorder of Choice, by Gene Heyman, 6/09

Real Diseases: The Moral and Practical Significance of Physicalism 1/09

Worldview Cognitive Therapy 1/08

Choice and Free Will: Beyond the Disease Model of Addiction  9/06

Objectivity in Mental Health: Who Has a Real Disease?, by Ron Pies M.D. 9/06

Causality, Victimhood, and Empowerment:  How to Hold Addicts Accountable, 2/05

Origins of addiction (letter published in the National Catholic Reporter), 10/8/04

Keeping the Streets Mean for Addicts, 4/25/03

Absolution for Addicts, 4/03

Thomas Szasz and the myth of radical autonomy, 4/03

NIDA and Naturalism, 7/01

Addiction: Choices and Cravings, 2/01

Addiction and Responsibility: Review of Jeffrey Schaler's Addiction is a Choice

Seeing Drug Use as a Choice or a Brain Anomaly (by Michael Massing, plus editorial comments) 6/00

The Science of Stigma,  10/98

Related to addiction, see also 3 Boston Globe op-ed pieces on drug policy.

 

 

Causality, Victimhood, and Empowerment:

How to Hold Addicts Accountable

The causal story of addiction gives us control and generates compassion

A shorter version of this appeared in Brown University Digest of Addiction Theory and Application,  V 24 #2, February, 2005

If we knew the entire causal history behind addiction, we would see precisely how in any given instance someone ends up dependent on alcohol, tobacco, or other drugs.  Addicts will sometimes cite this history to claim they are victims of circumstances, and so should not be blamed for their predicament.  This is the strategy of causal victimization, designed to deflect punishment for what would otherwise be considered the moral failure of having succumbed to substance abuse. 

 But the causal history of addiction also shows the route to behavior change by delineating the exact circumstances under which people behave in certain ways.  This is the strategy of causal empowerment.  Understanding why the addict behaved the way he did is crucial in figuring out how behavior might improve in altered circumstances. 

What causal explanations don’t do is change our values about what’s right and wrong, desirable and undesirable.  The addict might say, playing the victim: “Don’t blame me, it was my circumstances that caused the relapse…”, etc., etc.  Nevertheless, however it was caused, the relapse is still regrettable and to be avoided in the future. In addition, understanding the causal story doesn’t mean we can’t still hold persons accountable.  After all, accountability remains an essential tool in achieving sobriety.  But it does mean that accountability should be compassionate, since the addict’s behavior (indeed, all behavior), is fully a function of internal and external conditions.  Both involuntary cravings and the voluntary choice to use drugs are entirely caused phenomena, and compassion follows from the naturalistic insight that we don’t have supernatural, magical, or contra-causal free will.[1] Had we been in the addict’s shoes, with the same history, biochemistry and environmental setting, we would have acted the same way.

In order to forestall complacency and the passive mind-set that sometimes accompanies playing the victim, the conditions of accountability must be made very clear at the outset of treatment.  Both sides (the addict and the therapist) accept a fully causal explanation of behavior, both sides want behavior to change, and so both must also accept that certain conditions and consequences are necessary for that to happen.  If the addict agrees with us that his actions are shaped by conditions, then he must consent to some reasonable set of contingencies that will indeed produce the behavior we all want.  He must agree that, should he not live up to his side of the bargain, it’s proper that certain consequences will follow, and no amount of playing the victim will deflect them (he’s agreed to them, after all).  Should he relapse and plead causal victimization, we’ll simply remind him of our contract.  It’s not a question of blame and punishment, but of behavior and consequences.  We’re setting things up so that eventually he’ll no longer be victimized by addiction, but rather empowered by our common understanding of causality.

If the addict slips up, then he must agree with us that the conditions weren’t right to maintain the right behavior.  So the question arises, what are the right conditions?   The motivation to reduce or end substance use is a function of various factors, so what factors need modification to keep motivation intact and behavior acceptable?  This is an empirical question, answerable (eventually) by research underway at the National Institute on Drug Abuse, Brown University, and other public and private research groups.

The actual conditions and contingencies put in place by addictions programs and the addict’s wider community are inevitably shaped by real world constraints, including assumptions about human nature.  This is why the pervasive assumption of contra-causal free will must be challenged, since it often (but not always) motivates punitive approaches to behavior change, approaches which suppose that persons can simply will themselves to be abstinent, and if they don’t they deserve punishment.  This same assumption prevents using positive behavior-controlling incentives (e.g., food stamps, skills training, decent living conditions, cash) by saying that people shouldn’t be “controlled” or “coerced” by incentives, that they should “freely” decide to get better without such inducements.  But people’s behavior is always controlled by various factors, whether we admit it or not; it’s simply a question of what sorts of controls are in place, which can be either positive or punitive on balance.

If we want to replace drug abuse and dependence with productive behavior, and if people can’t simply choose to change, then we must find the conditions under which they can change.  This is to be empowered by understanding the causal story behind addiction.  Having dropped the myth of free will, we have no metaphysical rationale for supposing punitive contingencies are deserved, so any justification for punishing addicts must be empirical.  We must ask: what actually works to heal addiction, especially for those that have little or nothing to lose?  It turns out that contingency management[2] using rewards often works best, since addicts by and large are all too familiar with and inured to punitive outcomes that demoralize and alienate.  Draconian measures may sometimes work, but are constrained by the humanitarian principles that we should use the least punitive means possible to achieve a given outcome, and that certain outcomes (e.g., the death and disease that can result from withholding harm reduction measures) are simply disproportionate as deterrents – they are worse than addictive behavior itself.[3]  

If we can manage to take science seriously with respect to ourselves, the unthinking blame we assign addicts for their lapses will be attenuated in light of a causal understanding of addiction.  By resolving to hold addicts compassionately accountable, we can reshape the unnecessarily harsh and often counter-productive policies that often drive them out of the treatment system.  To explain addiction is not to let the addict off the hook, but it is to become more humane and effective in our approach to addictive behavior.   

TWC 6/04       

[1] See Clark, T., “To help addicts, look beyond the fiction of free will,” The Scientist, 12[16]:9, Aug. 17, 1998.

[2] See for instance, Epstein DH, Hawkins WE, Covi L, Umbricht A, Preston KL: Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12 month follow-up. Psychology of Addictive Behaviors 2003: 17: 73-82, and  Higgins ST, Wong CJ, Badger GJ, et al.: Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up.  Journal of Consulting and Clinical Psychology 2000; 68: 64-72

[3] See Clark, T., "Keeping the streets mean for addicts," 4/25/03 commentary for Join Together Online.

 

Absolution for Addicts

 Using the causal story behind addiction to combat stigma and discrimination

Join Together is to be congratulated for convening a national policy panel on discrimination and addiction, and for the resulting report, which highlights important changes that should be made in policies involving those in recovery. 

Since unenlightened policies on addiction are often based in stigma against those struggling with dependence, it is important, as the report notes, to communicate that addiction is a chronic illness.  Ordinarily, we don’t punish people for their illnesses, and as the report rightly states, punitive policies such as lifetime bans on access to public housing or receiving other benefits can only perpetuate the conditions that create and reinforce addiction.

Unfortunately, however, the disease model of addiction isn’t sufficient to completely defuse punitive attitudes and policies.  As the report notes, drug or alcohol addiction begins voluntarily, and voluntary acts, if wrong or illegal, are ordinarily thought to merit blame and punishment.  The report quotes Alan Leshner, who says “The recognition that addiction is a brain disease does not mean that the addict is simply a hapless victim. Having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why an addict cannot simply stop using drugs by sheer force of will alone” (my emphasis).  So, while the disease model helps to explain the compulsive nature of addiction, the addict remains fully responsible, and thus morally blameworthy, for having become addicted by voluntarily choosing to use drugs.  The moral stigma attached to addiction, therefore, remains essentially intact on this account.  Those not charitably disposed toward addicts are only too happy to pounce on this chink in the disease model defense against stigma, in which case we’re unlikely to see significant changes in punitive attitudes or policies.

What might help change attitudes, however, is the recognition, amply confirmed by accumulating evidence from the biological and behavioral sciences, that the voluntary choice to use drugs is just as caused – just as necessitated by circumstances – as the compulsive addictive behavior resulting from years of substance misuse.1  The responsibility for having used alcohol or drugs in the first place can’t be assigned to a freely willing, uncaused agent within the addict who could have simply willed otherwise.  There is no such entity.  Rather, the responsibility, in terms of originating causes, lies in the many factors that shaped the choice, such as genetic predisposition to addiction, the availability of drugs and alcohol, community norms sanctioning substance use, poor role modeling by parents and peers, poor education about the risks of addiction, and lack of sufficiently attractive alternatives to substance use, to name a few.

The objection will immediately arise that this sort of “absolution” for addicts goes much too far in denying a central assumption about human nature: that we could have chosen differently even given the exact circumstances (internal and external) in which the choice arose.  But it is precisely this assumption that science calls into question, and it is this same assumption that underwrites moralistic, punitive attitudes and policies towards addicts (“You could have chosen differently, but you didn’t, so you are fully to blame and deserve the consequences.”).  By questioning it, we stay true to the science that is progressively unraveling the etiology of addiction, and we help combat stigma and discrimination.

What we don’t do in questioning it, as many might suppose, is let addicts entirely off the hook.  Holding people accountable and responsible for their choices, even though the choices are fully determined, is part of what helps change behavior.  But, crucially, seeing the causal story behind addiction will ensure that accountability stays non-punitive and compassionate, since we realize that had we been in the addict’s situation with his biology, parents, peers, and neighborhood we would have made exactly the same unfortunate choices.  We will seek to end addiction not by counterproductive jail terms, or permanent bans on receiving public assistance, but by providing adequate treatment, training, job opportunities, and housing, all so that behavior can change.  Once we see improvement, then continued assistance is made contingent on maintaining the improved behavior.2

This is a different slant on Leshner’s point that addicts aren’t hapless victims: depending on the conditions and contingencies we set up (including pharmacotherapy such as methadone and buprenorphine), they *can* behave differently.  But in holding addicts responsible in this forward-looking fashion, we’re not supposing they could have done other than what they already did in a given situation – we’re not blaming them for not acting otherwise (they couldn’t), and we’re not interested in punishing them for punishment’s sake.  They don’t deserve such punishment.  Rather, we’re interested in setting up non-punitive conditions which will reduce addictive behavior and substitute new, productive, self-actualizing behavior. 

The “sin” of addiction, because it’s not ultimately just the addict’s doing, but the result of a network of causes, isn’t something for which he really needs absolution.  Originative, causal responsibility is distributed, in that the choice to use drugs is a function of many factors, factors that must be addressed to prevent similar choices from arising in the future.  But in seeking to create better choices, the addict himself is one such factor.  Therefore he isn’t excused from having to meet some reasonable expectations, since that’s the only way to achieve sobriety or more responsible substance use.  

What’s fundamentally changed on this naturalistic picture is the moralistic, blaming, punitive approach to addiction, an approach based on the pre-scientific view that people have cause-defying free will to transcend their biological and environmental circumstances.  The moral stigma against addicts will persist as long as people suppose they have such supernatural freedom.  But once we drop this supposition, we can start to discern the actual causal story behind addiction, and in its light begin designing compassionate, non-punitive approaches to changing behavior.  

TWC, April, 2003

Notes:

1. See for instance Gene M. Heyman's discussion of voluntary versus involuntary behavior in "Is Addiction a Chronic, Relapsing Disease?" in Drug Addiction and Drug Policy: The Struggle to Control Dependence, Philip B. Heymann and William N. Brownsberger, editors. pp. 101-103.

2. What precisely does “compassionate accountability” mean?   First, we have to create beneficial conditions, for instance stable housing with access to treatment and other services, under which addictive behavior can reasonably be expected to change.  Once change gets underway, compassionate accountability consists in making continued provision of such benefits contingent on a continued minimum level of improved behavior (not necessarily abstinence, since that’s often an unrealistic immediate goal).  This sort of accountability doesn’t ever make an addict’s life *worse* than it was at the beginning of engagement in the recovery process, which is what current punitive policies do by making sure benefits are forever denied, or withdrawing all public assistance when drug use is first discovered, or by jailing someone for using drugs.  Rather, the closest it gets to being punitive is in setting up the contingency that if someone backslides, they might temporarily lose a certain benefit or privilege they originally won on the basis of improved behavior.  But clients are never seen as deserving to be permanently outcast from the continuum of treatment.  The essence of compassionate accountability is to use the least punitive means to effect behavior change (which in practice means using primarily rewards, not punishments), while acknowledging that the threat of losing privileges or benefits plays a role in helping people avoid relapse to unacceptable behavior.  This has much in common, of course, with the treatment technique known as contingency management, but the rewards given or withheld are more broadly conceived, not limited, for instance to vouchers or cash payments. 

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NIDA and Naturalism

This is a friendly critique of a recent statement on addiction by Alan Leshner, director of the National Institute on Drug Abuse (NIDA).  Leshner is 90 percent of the way to understanding addiction naturalistically, but the remaining 10 percent is crucial.  Clarifying our concepts about agency is as important as assessing scientific evidence about the causes of addiction.  Without a clear notion of our place in nature, we will likely ignore or downplay evidence of precisely how our behavior arises from our environmental and genetic situation.

In a recent column in the National Institute on Drug Abuse’s (NIDA) monthly newsletter (V 16, #2, http://www.drugabuse.gov/NIDA_Notes/NNVol16N2/DirRepVol16N2.html) NIDA director Alan Leshner gets close to an entirely naturalistic view of drug abuse. That is, with minor but telling exceptions (which I will discuss), he sees drug abuse as a function of various causes, not a matter of willful misconduct. I’ll quote several paragraphs, emphasizing one sentence. He says that

… [A]ddiction encompasses both voluntary and compulsive behaviors. A person makes a voluntary decision to use a drug, and continues to use it until the repeated drug exposures change the brain's structure and functioning. As a result of these changes, the individual's scope for voluntary acts becomes severely restricted, particularly with respect to drug use. He or she now exhibits the essential features of addiction - compulsive, nearly irresistible drug craving, seeking, and use.

In fact, it even oversimplifies the facts to say that drug abuse is voluntary at first and subsequently becomes involuntary. There are voluntary and involuntary components to every stage of the process that leads from the initial decision to take a drug through addiction and treatment to abstinence. We know, for example, that many factors that people cannot control can either increase or decrease their likelihood of making the initial voluntary decision to use drugs. They include the quality of parenting one receives and whether or not one has undiagnosed or untreated mental illness or is exposed to a good prevention program.

The point that voluntary decisions, external influences, and brain changes all contribute to drug addiction is not just interesting theory. It has vitally practical implications.

Leshner sees that the voluntary component of drug taking is influenced by "factors that people cannot control." He quite properly places voluntary acts within a larger explanatory context, so that it becomes less of a mystery why the initial choice to use alcohol, nicotine and other addictive drugs gets made in some circumstances but not in others.

The question arises, however, as to whether there is any aspect of the voluntary choice to use drugs that isn’t ultimately traceable to factors outside a person’s control. Some factors influencing my choice to use drugs may seem at first glance well within my control, such as who I hang around with, where I go after school, and how seriously I take getting ahead in life. For example, no one is forcing me to consort with the neighborhood drug dealer; it’s just that he’s a cool guy and seems to have a lot of money and girlfriends. If I didn’t want to hang out with him, I wouldn’t have to, but since I do, I do. Being "within my control," then, means that I could refrain from the behavior in question if I wanted to refrain from it. Those with obsessive-compulsive disorder don’t have control over their repetitive hand-washing: as much as they’d like to stop, they pretty much can’t.

But what about my desire to hang out with the drug dealer? Is that within my control? That is, could I refrain from having this desire if I wanted to? Suppose I have some nagging thought in the back of my head that says "Mom said not to hang around with those guys. You’ll be a fool if you do." This bit of nagging surely acts as a motive not to have the desire to hang out with the dealer, or at least a motive to ignore its prompting.

But is it motive enough? Does Mom’s forecast of a bad outcome deter me? The answer to this question lies, clearly, in the relative strength of my attraction to the dealer compared to my inclination to listen to Mom. My behavior is the outcome of this contest of motives, and in the case we’re imagining it turns out that Mom’s injunction loses: I find that I’m hanging out with the dealer, the nagging quieted to an occasional whisper of regret. In other circumstances, or for someone else, it might have gone the other way.

But couldn’t I have exerted an act of will to quell the bad impulse, or amplify the good? Isn’t the outcome of these contests ultimately within my control? Here we reach the heart of the issue, for on a naturalistic understanding of the self, there is no internal, supervisory agent that exists apart from the confluence of motives. I have, perhaps, the rational capacity to anticipate what the outcomes will be if I act one way or the other, and such considerations might end up damping or amplifying one or both motives. But again, there is no agent that independently decides to conduct such deliberations – it either happens or it doesn’t, depending on what sort of person I am or the mood I’m in at the time (or, importantly, the state of my frontal cortex; see the NIDA research on how drug use can affect decision-making capacities at www.apa.org/monitor/jun01/cogcentral.html.) Further, there is no guarantee that rationality will make the good side win out, since nefarious behavior might lead to some pretty attractive outcomes. But this is somewhat tangential to my main point, which is that any agent that existed independently of desire would have no motive to act on either side of the issue, and so would be useless as a controller. Therefore, contests between motives have to work themselves out on their own, in their social and psychological context.

The upshot, from a naturalistic perspective, is that I don’t ultimately choose or control my desires, rather they partially constitute me as a person. This means that even though whether or not I hang out with the drug dealer is within my control (I could refrain from hanging out with him if I wanted to refrain) the desire is not: if a desire is powerful enough, I can’t simply refrain from having it, even if a countervailing motive makes me not want to have it. And I can’t simply choose my desires or their strength ex nihilo, since after all, such choices depend on motives I already have.

What this shows is that voluntary behavior is a function of motives of individuals that they don’t control. But then what does control these motives? What ultimately accounts for voluntary behavior, and more specifically, for the voluntary behavior leading to drug abuse?

The answer lies in the multiple factors, both remote and immediate, which shape a person’s character and desires (and therefore their motives), including the factors Leshner mentions: "the quality of parenting one receives and whether or not one has undiagnosed or untreated mental illness or is exposed to a good prevention program." There are of course dozens or hundreds of other such factors, depending on how you count them, and they include all the environmental influences a person is exposed to growing up, the endogenous, genetic influences which interact with the environment to create an individual, and the current situation in which the addict finds herself.

The crucial fact to keep in mind is that under naturalism there is no third thing, nothing that shapes a person’s character and motives that isn’t found either in the environment (physical, social, familial, peer) or in her genetic endowment. So the voluntary component of drug abuse, just as much as the involuntary, derives entirely from influences that created and currently affect the person. It isn’t a matter of free will.

At one point, Leshner writes as if there were such a thing as a person’s autonomous will, something that they could rally to the cause of beating addiction (if only they wanted to!): "The patient, for his or her part, must focus all the resolve and determination he or she can muster to stick with the treatment regimen and maintain abstinence." Let us imagine a patient, skilled in introspection, who is trying to muster resolve while under observation by a cagey therapist:

Therapist: How’s it going?

Patient: Well, I’m mustering my resolve the best that I can, but it seems like my desire to maintain abstinence is about the same as it was 10 minutes ago.

Therapist: Are you really focusing and mustering as hard as you can?

Patient: Yes, really, I’m trying, but my determination and resolve don’t seem to be increasing. I must be doing something wrong. Maybe I’m just defective in the willing department, sorry.

Therapist: Actually, it’s OK. Despite what some people think, this isn’t something you can really do on your own. What if I told you that if you stay clean for a week, then you’ll get grounds privileges? Feel any change in your resolve now?

Patient: Mmmm…wait, wait….yes, as a matter of fact, it seems like there’s more resolve than there was a minute ago. You mean, I’d actually get to see what’s off my floor?

Therapist: Right, but remember, you’ve got to stay clean. And by the way, there’s nothing wrong with your will. It’s just not something you can will, if you see what I mean.

Patient: Yeah, I think maybe I see what you mean. Doc, you’re a little weird, but you’re OK.

Therapist: No problem. See you in a week – clean!

On a non-naturalistic or what might be called a supernaturalistic understanding of the self, the patient could have bootstrapped himself into greater resolve without help from the therapist or any outside intervention. According to this view, (what is sometimes called the libertarian view of free will) there exists a freely willing agent within the person that could have chosen desires and motives in some crucial respect independently of any influence. Such an agent is above, or outside nature by virtue of being causally privileged: it causes without being entirely caused in turn. In explaining addiction, this means that the voluntary choice to start using drugs (or to stop using them) is ultimately attributable to the person alone. So drug use, at least to some extent, is beyond social or environmental control, with the user finally to blame for the choice.

The policy implications of the naturalistic and supernaturalistic views of addiction could not be more different. Under naturalism, even the first voluntary steps toward drug abuse are understood scientifically, that is, as a matter of contextual cause and effect. Such understanding points the way toward various interventions to prevent and treat addiction, and the drug user’s motives are seen to lie within potential control of policy. As much as we might find the addict’s conduct reprehensible, knowing that it arises entirely from a wider context keeps punitive attitudes in check and encourages compassion, since there but for the vagaries of life go we. Interventions will therefore emphasize attention to the economic, social, and physical factors that cause drug abuse instead of after-the-fact sanctions, while encouraging responsible behavior from addicts via incentives, not punishment.

Under supernaturalism, the person is thought to be self-originating in some respect, and therefore drug use is chalked up to free will, not anything we can control. This encourages a laissez-faire, devil-take-the-hindmost stance, since if it’s the individual’s ultimately free choice whether or not to try drugs, why bother to intervene? And of course punitive attitudes are given free rein, since the addict could have done otherwise in the environmental and genetic situation she found herself when drug use became an option. That is, she could have chosen not to have the desires she had; she could have willed herself, somehow, to be other than she actually was. For the failure not to have done so she deserves our scorn, and social sanctions, not prevention, are indicated.

Given these policy differences, the choice between a naturalistic understanding of addiction - the true view from a scientific perspective - and a supernaturalist understanding is hardly an academic matter. The conceptual analysis conducted above may seem academic, but it isn’t; rather it’s essential in order to clarify our thinking on fundamental topics which underlie attitudes and values. Failure to think through and make explicit our assumptions about self and agency is just as much an omission as to ignore empirical evidence.

As for evidence, research into the determinants of voluntary behavior strongly challenges the supernaturalist consensus on the existence of the freely willing self. See, for instance Gene Heyman’s 1996 paper, "Resolving the contradictions of addiction," in Behavioral and Brain Sciences 19 (4): 561-610, at http://www.bbsonline.org/Preprints/OldArchive/bbs.heyman.html, and his chapter "Is addiction a chronic relapsing disease? Relapse rates, duration estimates, and a theory of addiction," in Drug Addiction and Drug Policy: The Struggle to Control Dependence, Philip Heymann and William Brownsberger, eds., Harvard University Press, 2001. Heyman shows that the voluntary behavior involved in drug use is just as determined, albeit in different ways, as involuntary behavior. Furthermore, it seems as if the neural basis for cognitive functions involved in decision-making may be susceptible to change via exposure to drugs (again, see the NIDA research described at http://www.apa.org/monitor/jun01/cogcentral.html).

In his column, Leshner is 90 percent of the way to a entirely naturalistic understanding of drug abuse and addiction. The above analysis is meant to fill in the remaining 10 percent so that no residual superstitions about the self remain to distort social policy on drug abuse. Since free will is widely thought too precious an assumption to challenge, it’s unlikely that explicit naturalism will find a home at NIDA (or anywhere else, for that matter) for decades to come. Nevertheless, the seeds of a new view of ourselves are being sown in the scientific study of addiction.

TWC - July 2001

P.S. Those who think libertarian free will either exists or is a necessary fiction in running a culture are invited to visit the free will section.

 

 

Addiction: Choices and Cravings

Abstract:  This op-ed takes issue with the disease model of addiction, suggesting instead that addiction is best conceived as a bio-behavioral disorder involving voluntary behavior.  But since the voluntary is equally a function of conditions as the involuntary, this should lead to a reduction in punitive attitudes toward addicts, and renewed attention to the environmental determinants of addiction, in particular how lack of reinforcing life opportunities makes the use of drugs and alcohol more attractive.


Despite concerted efforts by treatment professionals to change public perceptions of drug addiction, stigma against addicts remains widespread. According to the National Treatment Plan Initiative recently released by the U.S. Center for Substance Abuse Treatment (CSAT), stigma can "cause ostracism, shame, and even denial of life’s necessities – such as employment and a place to live – for which the person in recovery is fully deserving."

In the fight against stigma, the primary strategy has been to portray addiction as a chronic, relapsing disease, rooted in bio-chemical changes in the brain wrought by drugs. The logic of those promoting the disease model is simple: people are not to blame for diseases; addiction is a disease; therefore, addicts do not deserve blame or stigma.

Well meaning as it is, this approach has had limited success, and CSAT’s promotion of the disease model is unlikely to have much further impact on attitudes. Why? Because addiction, although certainly a disorder, has characteristics which patently fall outside accepted definitions of disease, and no amount of rhetoric will change that fact.

Unlike most diseases, addiction can bring out the worst in people, including conduct we cannot help but judge reprehensible, and which often generates anger and avoidance. Equally important, addiction involves deliberate, decision-laden behavior, both in the initial choice to use substances and in planning how to obtain them. Asking the disease concept to accommodate such behaviors asks too much, which means the addiction-as-disease strategy against stigma simply lacks credibility.

A better approach would acknowledge that addiction is not a disease, but rather a bio-behavioral disorder involving persons who, although gripped by strong desires, remain rational for many, if not most, of their waking hours. The neural reward system in the "old brain," modified by repeated exposure to drugs, certainly drives behavior, but higher level cortical processes involved in decision making and choice still exist.

This means that addictive behavior has a significant voluntary component, and is sensitive to foreseeable consequences. Addicts anticipating the agonies of withdrawal can and will tailor their actions to suit the exigencies of the moment, including selling drugs to support a habit or hiding bottles to avoid detection. As clinicians will testify, some addicts make the best of their misery with considerable ingenuity.

Researchers in what is known as behavioral choice theory are seeking to better understand the voluntary component of addiction. How, precisely, do the ultimately self-destructive decisions involved in drug abuse arise out of biological, psychological, and social conditions?

Writing in the Brain and Behavioral Sciences, psychologist Gene Heyman at the Harvard Medical School’s Division on Addictions argues that evolution has endowed us with a normally adaptive "biology of choice" that can be victimized by highly reinforcing substances. The powerful, immediate, but short-lived pleasures of drugs take precedence over the more distant, long-term goal of building a meaningful life that avoids the disaster of dependence.

Moreover, Heyman points out, the voluntary behavior of buying and consuming substances is shaped by addicts’ expectations about the consequences of their behavior as it plays out in the social environment. Just as involuntary cravings are determined by exposure to drugs, so too the choices involved in addiction, mediated by some measure of planning and deliberation, are determined by an addict's surroundings, especially by the availability of drugs compared to rewarding drug-free alternatives.

Such an account seems to entail the ultimate destigmatization of addicts. Given their particular situations, those ensnared by addiction chose precisely as they did, and no other choice could have arisen. Even in its earliest stages, addictive behavior unfolds as a complex function of person-environment interaction, and were any of us in the same situation, with the same genetic vulnerabilities, brain chemistry, motives, and options, we would have acted similarly.

The immediate objection will be that such explanations let addicts entirely off the hook, should they behave badly. If their choices were fully determined, on what grounds can we hold them accountable?

The reply is straightforward: since addictive behavior is often responsive to the anticipation of consequences, then holding addicts accountable for their actions can help them change for the better. Just as drugs such as methadone and naltrexone block the effects of and craving for addictive substances, likewise well-designed social contingencies can help channel behavior within acceptable norms. We need not suppose that addicts choose addiction using some sort of undetermined free will to justify interventions which improve their behavior.

The crucial question, though, is what sorts of interventions are appropriate? The traditional view - that addicts have primarily themselves to blame for their fate - underwrites the punitive attitudes which favor criminal sanctions, with prison simply just deserts for willfully consuming drugs. But criminalizing addiction simply creates further shame, alienation, and dysfunction.

On the other hand, recognizing addiction as a bio-behavioral disorder involving both a person and a social context will help defuse resentment of addicts, since choices leading to dependence are seen to arise out of biological and environmental conditions, not a self separate from circumstances.

Furthermore, understanding these conditions points the way toward policies that will likely prove far more effective and less costly than incarceration for possessing drugs (although crimes that addicts commit against persons and property must obviously draw appropriate penalties). Community development, treatment, counseling, job training, and other structured programs can make addictive behavior less appealing by shifting the balance of rewards in favor of healthy alternatives.

Limited personal sanctions for failing to reduce drug use can still play a role in behavior change, but within a non-punitive framework which minimizes the suffering already central to the addict’s experience. As with the mentally ill, involuntary commitment of extremely dysfunctional addicts into treatment may sometimes be necessary, but only as a last resort and strictly for their own safety and rehabilitation, not as punishment.

Like the disease model, a bio-behavioral understanding of addiction will reduce stigma and increase support for prevention and treatment, but it has the key additional virtue of staying true to the facts about this disorder. Although the power of drugs to usurp normal priorities can hardly be overstated, most addicts retain some capacity to respond to social contingencies as well as to medications which control craving. This means that given the right sorts of opportunities and interventions, and given some leeway for mis-steps, they can regain their dignity and learn to behave responsibly.

Requiring personal accountability is part of this process, but in the light of a thorough understanding of addiction we will focus more on creating humane, supportive conditions that permit positive choices, and less on blaming those who were simply in the wrong place, at the wrong time.

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The Science of Stigma

This  essay applies the naturalistic conclusion about the non-existence of free will to the problem of addiction and our attitudes towards drug abusers.  The initial choice to use drugs is often voluntary, but voluntary choices are just as caused as compelled choices, an insight which should lead us to re-evaluate punitive social policies brought to bear against addicts.  For a more complete exploration of these issues, see the forthcoming Materialism and Morality: The Problem with Pinker.  The Science of Stigma was published in The Scientist in the August 17, 1998 edition, under the title "To help addicts, look beyond the fiction of free will." For comments on this essay, see Replies/Stigma.  See also Michael Massing's New York Times article, Seeing Drugs as a Choice or as a Brain Anomaly in Currents.


Ordinarily
, we don’t suppose that people are to blame for their illnesses. That is, prior to discovery, many diseases develop independently of what the sick person does or thinks. This is why the disease model of addiction, widely espoused in the therapeutic community, is so controversial. Commonsense suggests that a person’s choice to start using an addictive substance is often voluntary, and often made with the knowledge, either vague or specific, of the risks of getting hooked. Of course, some people may have a genetic predisposition to dependence, and some are placed in environments in which turning down that first drink or cigarette is nigh impossible, but nevertheless it’s hard to eliminate voluntary choice in our explanations of why individuals become addicts.

This question is now very much central to the current debate on how we should respond to the problem of addiction. Alan Leshner, director of the National Institute on Drug Abuse, urges that dependence is a chronic, relapsing disease and that, therefore, we should treat addicts as sick and not punish them for their illness. Leshner points out that the addict's brain is radically changed by drugs--"hijacked," as he puts it--so that the ability to resist drugs is severely compromised, if not altogether eradicated. Punishment won't help an addict to get clean, while treatment just might. But Leshner also recognizes that the physical, compelling nature of full-blown dependence does not exonerate an addict from having made the choice to start using drugs.

In a recent interview in The Scientist (12[3]:1, Feb. 2, 1998), he remarked: "What do you say to people who suggest that there's a difference between addiction and other sorts of brain disorders, like Alzheimer's disease or schizophrenia, because the latter conditions don't arise from a voluntary act of will? But lung cancer [caused by smoking] does occur from a voluntary act of will, and we still pay to treat people for it. The question is whether you want to fix it or not. Whether you think the person is evil and you hate them is not relevant. ... You need to deal with it as a health issue, even if you hate them while you're doing it."



Is Suffering Deserved?

Leshner says the issue of responsibility should be outweighed by our obligation to cure. But in reality many feel that the disabilities individuals bring on themselves are their just comeuppance. If an addict is to blame for his addiction, doesn't he deserve to suffer for it? Whether or not someone is "evil" and hated is indeed relevant to whether we feel motivated to help them or punish them. So, we can't duck the issue of moral responsibility when talking about addiction, and the disease model alone won't be enough to deflect the opprobrium many feel toward addicts.

But what accounts for "voluntary acts of will"? Most would say that there is something irreducibly personal driving the initial choice to use drugs, something that derives neither from an individual's environment nor his biological endowment. According to what might be called the "standard model" of free will, we all possess the capacity to act, in some important respect, independently of internal and external conditioning factors. It's that capacity that justifies praise and blame, reward and punishment. If the situation were replayed with all factors the same, the addict could have made a different choice, so he bears an inescapable, originative responsibility for his condition.

The problem, of course, is that the standard model is false. Although it is not yet widely appreciated, this sort of free will seems increasingly implausible given the rapidly growing scientific understanding of human biology and behavior. Acts may be voluntary in the sense that they are not compelled (most nicotine addicts don't start smoking with a gun to their heads), but they are nonetheless fully caused, a function of personality, motives, predispositions, and situations, none of which springs full blown from an uncaused agent within the person. Even if we presently lack the skill to track its causal antecedents, the will--the net vector sum of desire--is just as determined as anything else in nature, says science. And you won't find blameworthy free will in the residuum of what's undetermined, since, after all, we are usually only blamed and praised for what we intend to do. Intentional behavior of the sort we can be held responsible for certainly doesn't include random acts that surprise even the actor.

If the standard model of free will is false, it seems as if the addict is completely off the hook and morally blameless; given the governing conditions, things couldn't have turned out otherwise. Indeed, it seems that by challenging the assumption of free will, science threatens the very foundations of moral judgment. In his recent book How the Mind Works (New York, W.W. Norton, 1997, p. 56), cognitive neuroscientist Stephen Pinker confronts this dilemma and reaches a rather startling conclusion, especially for a scientist: We must idealize ourselves as uncaused creatures in order to have morality. In our ethical deliberations we must pretend, contrary to science, that human behavior is in some crucial respect independent of circumstances. For this to work, we must see that, "Science and morality are separate spheres of reasoning. Only by recognizing them as separate can we have them both. ... A human being is simultaneously a machine and a sentient free agent, depending on the purposes of the discussion. ... The mechanistic stance allows us to understand what makes us tick and how we fit into the physical universe. When those discussions wind down for the day, we go back to talking about each other as free and dignified human beings."


Science and Morality Linked

Since Pinker thinks that the "machine" view of ourselves undermines moral agency, naturally he is forced to keep science and morality in separate spheres. But is this dramatic and artificial disconnection of our explanatory powers and our ethical intuitions really necessary? The example of addiction will show that it is not.

First, it's clear that knowing that the voluntary choice to start using drugs is not a matter of uncaused free will doesn't invalidate our judgment that such a choice is bad. After all, addiction destroys lives, rendering addicts unproductive and unhappy. We have excellent reasons for expressing disapproval of drug abuse, since such disapproval can help dissuade those who aren't in the grip of nicotine or alcohol or heroin from taking that first, second, or nth hit. Precisely because the decision to drink or smoke or shoot up is, at first, voluntary--not internally compelled by addiction--stigmatizing that decision can reinforce the resolve to abstain or cut back.

Second, seeing that the traditional notion of free will is false may have an effect on just how much stigma we want to dispense, as well as its timing. Knowing that voluntary choices are just as determined as knee jerks undercuts the moralistic self-righteousness of those who suppose that they would never have succumbed to the temptations of crack or speed: there but for the contingency of life go I. Our anger at moral failure might be tempered, and seeing the causal necessity behind choices to use drugs might lead us to de-emphasize punitive measures with little or no utility (e.g., cutting welfare and health benefits for addicts) and increase our commitment to prevention, treatment, and outreach programs that actually reduce addiction and its harms. At the very least, seeing through the fiction of free will should lead us to re-evaluate the effectiveness of punishment, since it isn't deserved in the traditional sense.

We all know the power of stigma; just ask any youngster if he or she wants to grow up to be a junkie or a crackhead. But, as investigations of what works in treatment have shown, direct shaming of addicts is usually counterproductive: they need to learn that, despite the mistakes they have made, they are worthy of rehabilitation. What brings them and keeps them in treatment is knowing that someone cares, that they possess some kernel of dignity that merits praise and support, not continued condemnation. Stigma may play a useful corrective role in the early stages of drug abuse, but not after addiction has taken hold.



It's a Matter of Degrees

Although a thorough understanding of what causes addiction may lead us to reconsider the utility of stigma, it doesn't change our basic moral stance toward addicts and potential addicts: your choices were bad; do better next time or suffer the consequences. But such an understanding can significantly fine-tune the practical ethics of blame. To repeat: the vehemence of stigmatization will be kept in check by understanding that the choice to use drugs isn't a matter of uncaused free will, and its timing will be informed by how far along in the addictive process the individual has progressed. Such are the virtues of not compartmentalizing science and morality.

The growing scientific consensus that all human behavior lies within the natural realm has implications far beyond the study of addiction, of course. Whenever individuals are given all the blame or take all the credit for who they are and what they do, we can defeat such claims by pointing out the causal antecedents of their faults and virtues. Responsibility for good and bad doesn't inhere within some special, uncaused internal agent, but is distributed over the influences that create character and motive. Nevertheless, we must still praise or condemn an individual's behavior, because that, in part, is how people are shaped. Even though we can't any longer suppose that rewards and sanctions are deserved, in the pre-scientific sense of that word, they must still be applied, judiciously and compassionately. People are moral beings that should be held accountable--that is, be subject to rewards and sanctions--just to the extent that they have the capacity to anticipate and be influenced by them.

This model of morality ensures that, in the event a naturalistic, scientific self- understanding takes hold, excuse-mongering will not flourish. It will be generally conceded that we are all, in all respects, products of environment and heredity, but for that very reason social sanctions (and some hurt feelings, unfortunately) will be deemed essential to bring out the best in us, and inhibit the worst. On the other hand, it is likely that this same understanding will moderate the excesses of our all-too-punitive culture, transmuting our zeal for punishment into a concern for changing the conditions that produce destructive behavior in the first place. In a culture more fully informed by science, it will be a good deal more difficult to become an addict, and a good deal easier to find help, not rejection, should the unfortunate choice to abuse drugs arise.

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