By Nick Heather & Gabriel Segal –
Unusually perhaps for collaborators, we disagree about some important implications of suggesting a rethink of the relationship between addiction and choice.
There is much that we agree about in our understanding of addiction and what can be done about the harm it causes.
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.
Gabriel: 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.
Addicts normally use because they choose to, but the disease affects how choices are made and acted on.
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 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.
Nick: There is much to agree with in what Gabriel has just said. I agree that the problem in addiction is to understand why addicts behave in ways that they are fully aware are against their best interests and why 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”.
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.
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.
Both: 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.