How to Hold Addicts Accountable

The causal story of addiction gives us control and generates compassion.

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

Causality, Victimhood, and Empowerment: How to Hold Addicts Accountable

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, June 2004

[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. Attached here:

Keeping the Streets Mean for Addicts

This spring, the city of Baltimore will join Chicago and New Mexico in giving heroin users access to Narcan, the opiate antagonist naloxone,[1] that can reverse the sometimes fatal effects of overdose.  Now, who in their right mind would oppose such a potentially life-saving intervention, one that might have prevented some of the 109 heroin overdose deaths in Baltimore county in 2002?   Some ex-addicts, it turns out.  Michael W. Gimbel, a former heroin user and past director of the city’s department of substance abuse services, reportedly commented that “The Narcan program sanctions heroin addiction.  It’s like the city has given up.”  

Such a response will come as no surprise to those familiar with the debate over harm reduction, the philosophy that if we can’t end drug use altogether, we can at least take steps to minimize harm to drug users.  Giving addicts Narcan is quintessential harm reduction, in that it accepts the reality that some individuals will use heroin or other opiates, that some of these will overdose, and, crucially, that it’s more important to save lives than to keep the threat of death as a disincentive to use drugs. 

Like Gimbel, those who oppose harm reduction sometimes argue that measures such as providing Narcan or sterile needles simply encourage drug use.  By protecting addicts from the negative consequences of their behavior, harm reduction wrongly reduces the motivation to avoid drugs.  The implicit calculus here is that drug use is somehow worse than death, disease, or injury, such that keeping fatal overdose or brain damage or HIV infection as disincentives is a legitimate, even moral tactic. If a drug user refuses to get clean and incurs such harm, well, that’s his comeuppance, and besides, it just might deter others. 

Now why, one wonders, is drug use so morally bad that death and disease are justifiable deterrents, and that therefore we should forego measures which could easily (and cheaply) save lives, as well as the cost of treating AIDS, Hepatitis C, and other diseases?  Why is preventing heroin use via the threat of death worth the lives lost when the threat fails to deter?  As it must, of course, for fear of overdose rarely stops someone who’s “dope sick” – that is, in withdrawal – from using heroin. 

The roots of moral objections to drug use lie in culturally transmitted attitudes about the proper pursuit and limits of pleasure, the virtues of honest toil over indolence, and the perceived dangers of altered consciousness.  Without exploring the pros and cons of such beliefs, suffice it to say that those who see death as a justifiable deterrent to injecting heroin are at one end of the attitudinal spectrum.  For them, succumbing to the evil of drugs is a failure of will, and harm reduction simply stays the harsh but nevertheless just hand of mean streets retribution.  Harm reduction thwarts the moral, disciplinary purpose of the pain addicts would otherwise suffer, and so is itself immoral by their lights.

As a subset of those who oppose harm reduction, some ex-addicts harbor the most hard-line attitudes about addiction, perhaps because they overcame their habits without the “crutch” of methadone or the safety net of needle exchanges or Narcan.  They see immediate drug-free abstinence (methadone included) as the only acceptable route to sobriety, and anything that reduces the risks of drug use is construed as “enabling.”  And of course many who’ve never struggled with addiction feel much the same way, supposing that had they grown up in similar circumstances, they would have had the strength of will never to have tried drugs.

It’s this assumption that often underlies the punitive attitudes that characterize some (but certainly not all) harm reduction opponents.  It says that addicts, if they had only chosen to abstain, wouldn’t have got themselves into this mess in the first place.  And since the choice to use was ultimately up to them, they don’t deserve to be protected from the harmful consequences of addiction.  They made their bed, now let them lie in it.

But as the science of addiction progresses, there is less and less reason to suppose the choice to use drugs and alcohol (and tobacco, for that matter) is explained by anything that’s ultimately up to the individual.  It’s becoming clear that a person’s character and choices are produced by the interaction of genetics, environment, and upbringing, and it’s this causal story, not the exercise of uncaused personal willpower, that explains why some people end up addicted and others don’t.  As Alan Leshner, former head of the National Institute on Drug Abuse said, “We know…that many factors that people cannot control can either increase or decrease their likelihood of making the initial voluntary decision to use drugs.”[2]  

If voluntary decisions to take drugs are just as caused as anything else in nature, this should prompt us to question the notion that addicts essentially “make their own bed,” and so deserve the harm that befalls them.  If opponents of harm reduction accept scientific explanations of addiction, they must say precisely why those in its thrall should face a prevention regime that deliberately maintains the threat of disease and death.  If, on the other hand, they don’t accept scientific explanations, how do they account for the fact that some people have and use willpower, and others don’t?  Absent such an account, appeals to willpower lack credibility and utility.

They don’t lack for a motive, however: to place blame solely on the addict, thus justifying punitive or laissez-faire policies on substance use and addiction.  Once we understand the choice to use drugs as caused, not a failure of will, it will become considerably more difficult to justify such policies.  And in light of the causal story, we’ll devise more compassionate and effective approaches to reducing addiction and its harms.


When he wrote this, Tom Clark was a research associate at Health and Addictions Research, Inc. in Boston.  

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