Addiction as choice — responsibility without blame

…by Hanna Pickard

Hanna faceHanna is one of several addiction researchers who wrote commentaries about my book and my theory of addiction. Here she explains how we can view addiction as guided by choice without the extra baggage of blame, shame, and stigma. Following are segments of her revised commentary, which can be seen in full here.

Hanna and I have discussed her viewpoint in detail, and we are largely in agreement. However, she sees me as rejecting a “choice” model of addiction. I don’t agree with that. I think that addicts do have choices, but they are not simple choices. They are difficult, effortful choices to struggle against years of habit formation and the conditioning that goes with it — especially since habitual behaviours become wired in our brains, at least for a while. This makes choice difficult — but certainly not impossible.

Despite our disagreement about what I think of choice, Hanna’s essay makes some excellent points. Here’s what she has to say —

……………………….

Drug use and drug addiction are severely stigmatised around the world. Cross-cultural studies suggest that social disapproval of addiction is greater than social disapproval of a range of highly stigmatised conditions, including leprosy, HIV, homelessness, dirtiness, neglect of children, and a criminal record for burglary… Our common language also expresses stigma: people who use drugs are “junkies”, mothers who use drugs are “crack moms”, and abstinence is called “getting clean” — implying, of course, that when people use drugs they are dirty…

Why are drug users and addicts subjected to stigma and harsh treatment? No doubt a full explanation depends on a variety of complicated historical, socio-political and economic forces. But…we must also recognise how much these attitudes and policies resonate with the moral model of addiction which was dominant in the first half of the Twentieth Century.

The moral model of addiction has two distinctive features. First, it views drug use as a choice, even for addicts. Second, it adopts a critical moral stance against this choice. Addicts are considered people of ministerbad character with antisocial values: selfish and lazy, they supposedly value pleasure, idleness and escape above all else, and are willing to pursue these at any cost to themselves or others. In contemporary Western culture, we typically hold people responsible for actions if they have a choice and so could do otherwise, and we excuse people from responsibility if they don’t. Because the moral model of addiction sees drug use as a choice, it views addicts as responsible — deserving of the stigma and harsh treatment they in fact receive.

brain disease2For those who recoil from the attitudes embodied in the moral model, the disease model of addiction can appear by contrast to offer a desperately needed [alternative]. “When addiction specialists say that addiction is a disease, they mean that drug use has become involuntary.” According to the disease model, addiction is a chronic, relapsing neurobiological disease characterised by compulsive use despite negative consequences. Repeated drug use is supposed to change the brain so as to render the desire for drugs irresistible: the disease model maintains that addicts literally cannot help using drugs and have no choice over consumption.

I agree with Lewis that addiction is not a disease — at least given the typical meaning and implications of that concept. And I believe Lewis is correct to emphasise the central importance of a sense of agency, empowerment, and personal growth and self-understanding, in overcoming addiction. But I do not agree [with Lewis] that we must reject a choice model of addiction.

There are two straightforward reasons why. The first is that the evidence is ever-increasing that, however hard it is for addicts to control their use, and however important it is for others to recognize and respect this struggle, addicts…have choice over their consumption in many circumstances. To briefly review some of this evidence: Anecdotal and first-person reports abound of addicts (including those with a DSM-based diagnosis of dependence) going “cold turkey”. Large-scale epidemiological studies demonstrate that the majority of addicts “mature out” without clinical intervention in their late twenties and early thirties, as the responsibilities and opportunities of adulthood…increase. rat park cozyExperimental studies show that, when offered a choice between taking drugs or receiving money then and there in the laboratory setting, addicts will frequently choose money over drugs. Finally, since Bruce Alexander’s seminal experiment “Rat Park” first intimated that something similar might be true of rats, animal research on addiction has convincingly demonstrated that…cocaine-addicted rats will…forego cocaine and choose alternative goods, such as saccharin or same-sex snuggling, if available. In short, the evidence is strong that drug use in addiction is not involuntary: addicts are responsive to incentives and so have choice and a degree of control over their consumption in a great many circumstances.

choosingThe second reason to maintain a choice model of addiction is that the process of overcoming addiction through a sense of agency, empowerment, and personal growth and self-understanding — a process that Lewis describes in The Biology of Desire with great care and acuity — itself presupposes that addicts have choice and a degree of control. Agency needs to exist to be mobilized: you can only decide to quit and do what it takes to stop using and change how you live and the kind of person you are if you have some choice and control over your use and your identity.

Recall that the moral model of addiction has two features. It views drug use as a choice. And it adopts a critical moral stance against this choice. Because of the evidence [just reviewed], I believe we must accept the first feature. But that does not mean we must also accept the second. Just as addicts have choices with respect to drug use, we have choices with respect to how we respond to people who use drugs.

Marc Lewis has diagnosed a genuine dilemma: the disease model is neither credible in the face of the evidence nor helpful in so far as it disempowers addicts; but…a choice model invites blame and stigma by attributing agency and responsibility to addicts. In response, he has opted to distance himself from both. But that is an unstable position… We must accept a choice model of addiction – although [we also] need to contextualise choices and understand the variety of ways control, agency, and so too responsibility, may be reduced in addiction.

However, accepting a choice model of addiction incurs a moral burden… Choice models of addiction ought…to be paired with a practice of [questioning] our own attitudes towards addiction alongside a commitment to working for social justice. [It is possible to distinguish] our concept of responsibility from our concept of blame.

Suppose we begin by asking a direct question to challenge the moral model: What precisely is supposed to be wrong with using drugs? Throughout human history, drugs have been used as means to achieve a host of valuable ends, including (1) improved social interaction; (2) facilitated mating and sex; (3) heightened cognitive performance; (4) facilitated recovery and coping with stress; (5) self-medication for negative emotions, psychological distress and other mental health problems and symptoms; (6) rat park funsensory curiosity – expanded experiential horizon; and, finally, (7) euphoria and hedonia – in other words, pleasure. Drugs make us feel good, provide relief from suffering, and help us do various things we want to do better. [It] is difficult to see what could possibly be wrong with using drugs in and of itself. Suppose now we ask a further direct question: When use escalates to the point of addiction, who is to be held responsible for the ensuing negative consequences? According to the moral model, it is addicts themselves, who are not only responsible but [blameworthy], as they are considered to be fundamentally people of bad character with antisocial values… As an advocate of a choice model of addiction, I do not of course deny that some responsibility — but, crucially, responsibility as distinct from blame — lies with addicts themselves… The point I wish to emphasise however is that, in placing blame squarely on addicts or their disease, both models are united in enabling us to keep the focus of our attention away from ourselves and our society, avoiding the question of whether we, as a society, also collectively bear some responsibility for drug use and addiction and their consequent harms.

Do we collectively bear such responsibility? …A disproportionate number of addicts come from underprivileged socioeconomic backgrounds, have suffered from childhood abuse and adversity, disadvantaged youthstruggle with mental health problems, and are members of minority ethnic groups or other groups subjected to prejudice and discrimination. They may experience extreme psychological distress alongside a host of mental health problems apart from their addiction, feel a lack of psychosocial integration, and are at a socioeconomic disadvantage such that they have severely limited jobless.homelessopportunities. These circumstances are central to understanding addiction in many contexts. Put crudely, the reason is simply that drugs offer a way of coping with stress, pain, and some of the worst of life’s miseries, when there is little possibility for genuine hope or improvement… In such circumstances, whatever harms accrue from using drugs must be weighed against whatever harms accrue from not using them. For this reason, the explanation of addiction and its associated negative consequences must lie in no small part with the psycho-socio-economic circumstances that cause such suffering and limit opportunities. And the existence of these circumstances is a feature of our society for which we must all collectively take some responsibility.

Both the moral and the disease model of addiction can therefore be seen to function as a psychological defense — protecting us from focussing our attention on the existence of these circumstances and their role in explaining drug use and addiction, thereby keeping consciousness of our own collective responsibility for these facts at bay. Perhaps one reason, then, why we blame and stigmatise addicts for their choices is that it is more comfortable than facing up to aspects of our society which make drugs — whatever their costs — such a good option for many of our already vulnerable and disadvantaged members.

 

33 thoughts on “Addiction as choice — responsibility without blame

  1. Annette Allen May 28, 2017 at 4:38 am #

    Thanks Hanna – and Marc. Very powerful and insightful observations. When there’s no way out, we have to find ways to self-medicate, recognising the extreme forces keeping us where we are. Junk food, gambling, drugs, porn etc. All cries for help and connecting with something.

    We CAN make change happen, in small ways. Portugal is showing the way forward, for sure. Here in the UK, our drug laws are punitive, as there’s such political and societal unwillingness to tackle the way we view each other.

    We are all worthy – that’s the truth. My younger (drug addicted) brother taught me not to fear addiction. He was often very lonely, and felt stigmatised. This taught me compassion.

    • Terry May 28, 2017 at 10:17 pm #

      a general reply – no necessarily to what you have said Annette – Drug use does not of itself equal addiction. Most drug users, most doers of any “addictive” behaviour are not addicted – there are too many assumptions and the main one is that all drug use is negative and all drug users are addicts. this is a moral judgement those who are tasked to serve those who have problems with substances continue without challenge. someone has to stand up for drugs and the good they do, just like the good alcohol does for most – how many lives has drug use saved ? ask a doctor and they will tell you, why then do we treat those society calls illicit drug users differently to those who seek relief of stress created by all manner of medical or psychological ills by conventional means and try to attribute theories on why they make a choice those in power in a society do not agree with

      • Annette Allen May 29, 2017 at 3:31 am #

        Terry, agreed. I learnt a lot about long term drug use from my brother. He was a registered heroin addict, and did fine when he was on methadone AND in a caring relationship. (First when our mother was alive, and next with a great friend.) He relapsed, badly, when both died. Sadly, after his friend died, he took his life, 4 months later.

        Societies always look for scapegoats. Addiction is a biggie – I wish it wasn’t so, but we seem incapable of looking deeply at OUR OWN behaviour….

        • Terry May 29, 2017 at 6:01 pm #

          drug users for some reason are scapegoats Annette and too often misunderstood – and your point about how a person can mange when the supply is stable and other factors improve like a relationship is very important. so much “addictive” use results when a person life is full of stress, and it waxes and wanes through their drug sue lives yet we focus on the worst of it and see that as the persons life. I too lost a brother recently who spent his life managing as best he could low level drug dependency. he died of lung cancer from nicotine. the cannabis he was also addicted to saved his mind but the tobacco he mixed it with killed him. Irony or an indictment on a society of such hypocrisy when it comes to medicines. Thanks Annette, you brought me down to earth again. too often we end up in the clouds thinking theory when reality is, well, real.

          • Marc May 29, 2017 at 6:15 pm #

            These themes continue to resurface in the comments on this blog, and in contemporary works such as Hare’s book, Chasing the Scream….. I truly believe that more people are listening than ever before.

  2. Peter Sheath May 28, 2017 at 5:05 am #

    Thanks Hanna for such a great piece and thanks Marc for sharing. This argument choice v disease has been raging for, what seems like, ages. It’s strange that the disease model seems to have been pretty much accepted within most areas of medical treatment and policy making yet the choice/learning model has had lots of legal precedents, tried and tested within the criminal justice system which almost always rejects defences based on addiction powerlessness (Poland, addiction and responsibility). I guess it’s a highly politicised and cultural thing in that could you get public funding for something that people can choose to do? Or can we accept a legal defence of “it was the desire to smoke some crack that made me do it?” I’m currently working fairly exclusively with men who have sex with other men and use chemicals to enhance the experience. The drugs they use are addictive, mainly methamphet, GHB and mephedrone but I’ve not yet met anyone who would fit the diagnostic criteria. They all have loads of social capital and in the main manage to negotiate and maintain boundaries around their drug use and sexual practice. Choice continues to be really important to them, they choose to use social network apps to hook up and negotiate everything from sexual preference to chem use, prior to meeting up. Where I come in is that there isn’t a long term drug use wisdom in this community, more often than not they are injecting (slamming as they call it) which has become an intrinsic part of their sexual practice. Hardly anyone knows how to inject safely and the risks from both the drugs and the sex are enormous. I try to help them find safer ways of doing it and offer a way out if that’s what they’re looking for. All choices they make more often than not.
    An area I’m having increasing difficulties with is language and, in particular, the reductive vernacular we’ve developed in a very clumsy effort to describe people’s subjective experiences. Addiction has become a very loaded, diagnostic word that we have lazily used to describe a very complex human subjective experience. You hear it all the time, from the disease model, “my name is Peter and I’m an addict,” to the medic diagnosing someone as, “suffering from addiction.” The trouble with this is that when applied to quite vulnerable and suggestive people this term begins to take on a life of its own and becomes a self fulfilling prophecy. “I’ve been told by my doctor/sponsor/etc. that I suffer from a chronic relapsing condition, so that’s who I am.” Personally I think we should campaign to do away with all reductive attempts to describe human subjective experience in a label. It probably causes more harm than good and always means that choice has been removed.

    • Marc June 15, 2017 at 10:59 am #

      Peter, what great points! I like your example of a group who apply choice consistently but don’t have the knowledge or wisdom to maximize the benefits.

      And what you say about the laziness and destructiveness of labeling is important: “The trouble with this is that when applied to quite vulnerable and suggestive people this term begins to take on a life of its own and becomes a self fulfilling prophecy.” This is a specific example of how one’s identify becomes the leading edge of one’s personality development, a process that you also see clearly in normal adolescence. As I am called, so shall I be.

  3. matt May 28, 2017 at 7:24 am #

    There is always a context for “addiction”. It does not happen in a vacuum. It is also driven by human nature and by that I mean the continual striving to want what we don’t have…in other words, motivation. There is a violence to motivational forces and change that can be softened by recontexualizing or decontextualizing what we really want as humans, which is ultimately the safety and comfort to survive in peace. As social beings what that ultimately amounts to is connection. And as many folks currently propounding on the nature of addiction have observed, the opposite of addiction is connection. In a consumer society, connection is a very different thing than consumption, and many of us get lost in the shuffle.

    • Marc May 28, 2017 at 9:10 am #

      Lovely, Matt.

      You’re saying the “motivation” is always there, right, and the goals are what shift according to circumstance and context…right? And then our interpretation, our understanding of the motivation, needs to change….to support rather scorn when mistakes are made.

      I love this line: “There is a violence to motivational forces and change that can be softened by recontexualizing or decontextualizing what we really want as humans, which is ultimately the safety and comfort to survive in peace.”….e.g, connection, safe connection.

      I have recently considered comparing “recovery” to tobogganing. You can’t usually just stop….rather, you learn to modify your use, to gradually acquire control.

      How?

      Learning a lot of small skills, like leaning, and like pushing your fist into the snow just so, without overturning the whole thing and crashing. Note that the main challenge facing tobogganers is the steepness of the hill, gravity, in a word. And in addiction the analogy is with habit strength, or, in a word, developmental inertia. You can’t get rid of gravity — or habit strength — but you can learn to work with it, to modify your response to it. And here’s the clincher. The way to maximize your odds is to have a few other souls on the same toboggan, leaning and nudging, in order to modify the direction forward, but you have to be in sync with each other. Yes, connection: but that connection has to be helpful, empathic, and congruent. The loving parent who says: “One more time and you’re out of the house” isn’t helping a whole lot despite the presence of loving connection.

      • matt May 28, 2017 at 8:58 pm #

        I agree, except for what you’re describing as a “loving connection.” Addiction is a sort of connection too. The connection I was characterizing as its opposite is imbued with helpfulness, empathy and congruence. When a parent says: “One more time and you’re out of the house” they may be loving, but that’s not the connection I’m referring to.

  4. Nicolas Ruf May 28, 2017 at 8:58 am #

    I like to think that I keep an open mind about the nature of addiction, but I probably like to think a number of other things about myself that may not be true. I’ve been thinking about the fact that animals forcibly administered drugs do not get “addicted” although they show reinforcement effects like conditioned place preference, ICSS, and they become physically dependent. But if you change their circumstances, their diet, their social lives, their environment, they change their patterns of use. They have choice in other words. Animals, however, that freely choose to administer drugs, when they get ADDICTED, do not alter their pattern, in any meaningful or consistent ways, with differing external circumstances. That initial free choice implies a vulnerable or anticipatory state that then is rewarded by the drug at the cost of choice. This becomes the kindled and dissociated ADDICTION.
    What is needed then is not choice but epiphany. I’ll just share one story, versions of which will be familiar to anyone familiar with ADDICTION. D was sitting at his kitchen table with a bottle of whiskey which he knocked off onto the floor. Reaching for it he fell off his chair and was lying there thinking that if he had a straw he could get the spilled whiskey from between the floorboards. Looking up he saw his dog looking at him with love and worry and pity, and he said, “I’d better go to the hospital”. He detoxed there and hasn’t had a drink in nine years. Is that choice, or is it, as Leonard Cohen says, “There’s a crack in everything; that’s how the light gets in”? This kind of ADDICTION is a dissociated state.

    • Marc May 28, 2017 at 9:26 am #

      Nick, I’ve got to hand it to you. Although you and I have taken opposite sides in this argument so many times….so often….that my first response on seeing your name on a comment is generally “oh-oh”. But sometimes, like this time, you do it so eloquently and persuasively that I can’t get a toe-hold to begin my rebuttal.

      Which is a long way of saying: I agree with you about this.Once addiction acquires automaticity, that kind of self-perpetualing inertia that hives it off from all other influences, especially social ones, then…you’re right. It’s intrinsically “dissociated”…. At which point “choice” becomes a bit of an abstraction, if not a full-out logical flaw.

      I’d like to see how Hanna responds to your point, if she does. That point being, in a nutshell, if I get you right, that choice is present during one phase of the slide into addiction…and then it isn’t.

      There’s still the problem of heavily addicted people who suddenly quit….cold turkey or not. That’s hard to square with your choiceless algorithm here. But I admit that’s a relatively rare event. And the most parsimonious explanation is probably yours: that choice blinks out after a while.

      So, maybe I’m getting too soft, but on this occasion I’m going to, um, call off the dogs.

      My best to both of you. I was with my daughter the last two weeks…she came to visit. And we reminisced about your beautiful company and beautiful cuisine.

      • Nicolas Ruf May 29, 2017 at 10:35 am #

        You guys are welcome any time. Doesn’t epiphany solve the problem of the heavily addicted suddenly quitting? As the Buddhists say, “the blind don’t need light; they need eyes.”

        • Marc June 15, 2017 at 11:01 am #

          Gotta get a new slogan, Nick. This one is starting to look worn out.

  5. Hanna Pickard May 28, 2017 at 10:10 am #

    Marc: I don’t think I quite responded to Nick’s point at least if it’s as you describe it, so let me try to here. I hope everyone will forgive me doing a little bit of philosophy to reply!

    I take choice to involve something quite minimal: you have choice if there are at least two options open to you, to act in a certain way or to refrain, and you have the capacity to go either way – a capacity which of course you may or may not choose to exercise. With animals, at least animals like rats where there is plenty of evidence of sociability and emotion but to my knowledge no evidence of self-conciousness or foresight, they cannot “think” about whether or not to refrain. So we operationalise this idea just by seeing what they do if we intervene and change their options. If in response they change the behaviour, we interpret that as evidence of choice. My paper co-authored with Serge describes the history of those interventions. With people like us, who are self-conscious and have foresight, how you know if someone has choice is very different and much more complicated. My sense is that the evidence points to that capacity being intact but not often exercised, even with heavily addicted people, but I am open to hearing reasons why I have not interpreted that evidence right!

    I think the reasons why people don’t exercise that capacity as they become more and more heavily addicted are multiple and inevitably specific to the individual. But they range from things like cravings and habit and at least in some cases dope-sickness or withdrawal, to the relief and pleasure in use, to self-hatred and lack of hope, to — as I said in my reply to Peter — not knowing who you would be if you weren’t an addict. There’s a huge amount of variability and complexity.

    So I guess I see the transition to heavy addiction as involving an increasing number of these reasons, which are not only independent but often causally connected, feeding into each other. This reduces any reason to exercise the capacity for choice — and also probably diminishes self-belief that if they tried to quit or do anything different, they really could. (And of course, this is also re-inforced by external stigma and quite often lack of real alternatives in people’s socio-economic circumstances.)

    • Nicolas Ruf May 29, 2017 at 9:51 am #

      All well and good, but what if the solution (choice) is the problem?

  6. Hanna Pickard May 28, 2017 at 12:31 pm #

    Hi everyone,

    I’ve been struggling to get comments posted and I don’t understand why. So I’m trying once more — this time without any links to other sites in case that’s been the problem. Below is the first comment I posted in reply to everyone which I had thought was up before my second comment replying to Marc. I’m sorry that it’s appearing so late and out of order:

    Thanks Annette, Peter, Matt and Nicolas, for reading the blog and sharing your thoughts. It’s not often that I find people who approach these issues with a similar outlook so I’m really glad to have the chance to be part of this conversation. Thanks too to Marc for the opportunity to be part of his blog!

    Annette: I couldn’t agree more about Portugal. The criminal justice system is unjust in so very many ways, but in the US and UK this is one of the worst. Drugs that are chemically pretty identical to those licensed for medical use are illegal on the street, where stop and search policing and harsh sentencing are then used disproportionately in ethnic minority communities. And more theoretically, I just can’t see how any good theory of the justification for criminalising forms of conduct could ever include drugs. It’s a public health problem. Not a crime.

    Peter: What you say about the role of education and choice in your work with men who use drugs to enhance sexual experiences really strikes a chord with me. One of the things I’ve always been amazed by in clinical work is how when we re-frame behaviour which society and which a person him or herself initially calls “compulsive” as a choice there is often a huge sense of relief — relief at the experience being recognised for what it is and also for the sense of control and possibility that choice opens up. In my experience, the language of choice can help people feel less overwhelmed and out of control, and more ready to think reflectively and creatively about ways they can take better care of themselves and other people, and find ways to live that have more meaning and value for them.

    What you say about the language of “addiction” itself also strikes a chord. In ways it’s resonant for me both with some of the insights of self-labelling theory that sociologists like Harold Becker wrote about decades ago and also some more recent work in cognitive science aiming to understand things like the importance of self-efficacy and stereotype threat – basically, seeing yourself an an “addict” comes with a kind of script that means you and others have a set of expectations that become, as you say, a kind of self-fulfilling prophecy. It keeps people stuck. On the other hand it can be so much a part of someone’s identity that it can be hard for them to know who they are, if they are not an addict? I think this is one of the things that can be a really impediment to people making changes — a sense of loss of a known and familiar self, together with a sense of the utter unknown of the self you would then have to create and become. I’ve just started to work on some of these questions and I haven’t made much progress yet! But if you’re interested there’s a short interview and public lecture I gave about some of these issues — which I can send you links for if you’d like.

    Matt: Yes! Belongingness seems so rare an experience for so many of us these days and it is so important. (Bruce Alexander is my hero 🙂

    Nicolas: I am lucky enough to have as one of my collaborators the neurobiologist Serge Ahmed who works on animal models of addiction and has done a series of really fantastic experiments about rats and the circumstances in which they will or will not choose non-drug versus drug rewards. We wrote a paper together that has a section summarising the history of these experiments and which connects to the points you are making. It’s available on my website and is called “How do you know you have drug problem? The role of knowledge of negative consequences in explaining drug choice in humans and rats” and the relevant bit is Section 3. The upshot is that I think there’s a solid explanation for why addicted rats sometimes fail to choose alternative rewards which is in keeping with a choice model. From Rat Park onwards there has been so much to learn about drugs from animals and on the whole the lessons have not been recognised!

    • Nicolas Ruf May 29, 2017 at 11:02 am #

      Hi Hanna, I read your and Serge’s article and am thinking. I’ve got it In iBooks now so that it can torment me. I’m not clear on the conditions of cocaine administration; when you say in the absense of other reinforcers, is that voluntary choice? And when you talk about the time between offering the sweet v the cocaine being sufficient to cancel the anorexic effects of the drug, do they go back to the drug once they’ve satisfied the munchies? I’m not sure about ignorance of adverse consequences, but denial is a dissociated state.

      I hope that you find a different hero. Rat Park is fraught with problems, from replication to amount of sweetener in the different solutions to whether the rats were forcibly administered the morphine. Maybe the morphine rats, when they tried morphine in RP, were transported back to the cages. Similar to heroin-addicted VietNam vets doing heroin back in the States being transported back to Nam: state-dependent learning and dissociation. Looking from the inside out is different from looking from the outside in.

      Come on up to Maine when you get to Princeton and we’ll hash it out. And maybe Louise will cook for us!

      • Hanna Pickard May 29, 2017 at 11:53 am #

        Hi Nicolas, Thanks so much for reading it. Let me try to respond but get back to me if what I say doesn’t hit the mark.

        ‘In the absence of other reinforcers’ means there is no alternative reward available that will compete in value with cocaine at the time of choice. So there will be food and water in the cage but not e.g. sugar or saccharin or another rat to snuggle up with. Typically when rats are in a cage with unlimited access to cocaine and no alternative valuable rewards they escalate use and stop eating and drinking — and sometimes they die, presumably through starvation and dehydration. These experiments are often taken to show that use is involuntary. The reasoning is that only that could explain why the survival instinct does not kick in. But I think the experiments do not show establish whether use is voluntary or involuntary. Why? In a nutshell, there is no good alternative for the rat. So … if I imagine being alone for weeks on end in a cage with nothing but cocaine …. I imagine I might take a lot of cocaine and not care very much about food and water or indeed my own death …. And also of course we know from the other set of experiments we discuss in our article that if given a forced choice between drugs and an alternative reward they value, addicted rats will very often choose the reward (my all time favourite experiments are with same-sex snuggling — it’s such a lovely result that addicted rats will forego drugs to get that!)

        With respect to your question about time, the experimental paradigm is forced choice, so the rats have to choose between cocaine or another reward — and the key finding is that they choose cocaine only when they are under the influence and so their appetite is suppressed. That’s part of what explains why the rats who are alone in a cage with only cocaine keep using until death — cocaine is an appetite suppressant. Interestingly, you don’t get the same pattern with heroin, which is not an appetite suppressant. Rats who are alone in a cage with nothing but heroin, food, and water, will sample all three reliably and stay alive. And I believe I’m right in saying that if you give rats free access to cocaine and other really strong rewards like sugar and the company of other rats, they will sample all of them, going back and forth between them. But I’m not 100% confident about that — happy to check with Serge if you’d like!

        I think of Rat Park as the origins of a new kind of experiment with rats, which after some decades has now conclusively shown, I think, that (1) enriched environments protect against relapse and (2) if given a forced choice between drugs and other genuine goods, addicted rats usually if not always choose those other goods. But Bruce is a hero of mine as much for his work on belongingness and the perils of globalisation and for championing harm minimisation and safe injecting sites in Vancouver as for Rat Park. But I hadn’t thought about the learned association between morphine and cages — that’s really interesting!

        Can I ask, what did you mean by your comment ‘what if the solution (choice) is the problem?’ I didn’t understand?

        I’d love to visit Maine! That’s really kind. Thank you. (Who’s Louise?)

        • Nicolas Ruf May 29, 2017 at 4:01 pm #

          Hi Hanna, Thanks for the clarifications. What I mean by the solution being the problem of course applies to addiction, but is probably best illustrated by OCD. Let’s say hand washing. I wash my hands because they’re dirty. But I don’t think they’re completely clean. I’m worried about my hands being dirty. I can’t get it out of my mind. I can feel the bugs crawling around. I’ll use a stronger soap and scrub them longer. That’s fix it.
          Louise is my wife and a fabulous cook (as Marc can confirm).
          N

        • Marc June 15, 2017 at 11:11 am #

          Hanna, I haven’t pitched in much in this comment section, but I don’t have to. Your explication of the issues, your clarification of the confusing bits, and just your general knowledge and generosity in sharing it are wonderful contributions to this blog, in general, and this discussion in particular. I just want to thank you. This has been an excellent dialogue.

          • Hanna June 15, 2017 at 4:16 pm #

            Thank you for your kind words Marc and even more for inviting me in the first place. It has been a pleasure to be part of the conversation. What a reflective and nice community!

  7. Karen T May 28, 2017 at 5:07 pm #

    The beauty of Marc’s work is, he has shown how the choice model and the disease model overlap; the brain forms pathways of habit, which make the option of getting high progressively easier to choose. In this article, Hanna points out the social influences that make getting high the easier choice. The choice and the disease model overlap a great deal if you consider that the brain develops in a social context from day one. The psychologist Sue Gerhardt’s work suggests that actually, the brain is primarily an organ of sociality. She wrote Why Love Matters: How affection shapes a baby’s brain, and The Selfish Society: How we all forgot to love one another and made money instead. The Selfish Society is about how capitalism encourages us to value material “success” over human connection, and how the childcare practices that stem from these values literally warp babies’ brains. I think this society we are creating might be a big factor in much addiction, to both legal and illegal substances and behaviours.

    • Annette Allen May 29, 2017 at 3:26 am #

      Thanks, Karen. I’ve noticed this a great deal since 2000, and particularly with the advent of smartphones when many people ‘swish’ away their longings for connection and ways to ease their boredom. I left full-time employment to enjoy contract work, because it offered me many more chances to travel and connect with different people. Spontaneity and laughter keep us fresh and alive – and it’s rare to see that in modern society. Love does, indeed, matter….

    • Hanna Pickard May 29, 2017 at 12:07 pm #

      Hi Karen, I really like Gerhardt’s work and that strand of Marc’s work too — and what you say seems very true to me. Rather than just blame drugs, we have to look at ourselves and our society and try to change what’s wrong with that. Choice models used to be paired with judgmentalism and moralism but I want to try to use the model to shine the light on us and our society rather than only on what’s going in with addicts (and their brains). We have to ask, what’s going on with US, that so many people in our society are making choices that are ultimately self-destructive? People make choices relative to a context. So what can we do to make that context different and better, so they might want and feel able to make other choices, not necessarily not using drugs, but not doing so so self-destructively? Or that’s my hope, anyhow!

  8. Conor May 29, 2017 at 11:18 am #

    I am reminded of the problematic assumptions that underpin rational choice models in economics and sociology when I think about unbound choice or pure voluntarism in addiction, as well as the interminable agency/structure debates. Choices are constrained and shaped, rationality is bound and limited. Great discussion.

  9. matt June 1, 2017 at 6:29 am #

    This may seem trivial and obvious, but I feel it’s worth noting here. Whenever we make the decision to use– no matter how wild, or constrained, or shaped or rational or irrational– we are making a choice. This is the most viscerally empowering realization I see in the people I work with. When it is couched in morals, values, judgments, disease and biological imperatives which ALL treatment approaches practice at some level no matter how veiled or explicit, it is obscuring the freedom of choice of an individual to make the best decision for themselves and consequently everyone else around them. We are social beings and need one another. The decision to use or not is one of existential humanism, not disease.

  10. Carlton June 2, 2017 at 8:28 am #

    The “Difficulty of Choice”, that Marc mentions, also applies to the Dilection Model of Addiction.

    ( Dilection n.1. Love; choice.)

    For instance, a person can choose to move from place to place.

    However, if a a relationship develops with a local person, that “choice “ to move can be then become very difficult.

  11. Carlton June 2, 2017 at 9:26 pm #

    By replacing the word “Addiction” with the word “Love” in the title of this Post, another perspective is offered;

    “Love as choice — responsibility without blame”

    It is generally held that love is not something thought or learned initially, but felt,
    like the beginnings of an addiction.

    “Choice” is a cognitive activity and so the words, “Love as choice” seems an odd way of putting it, and perhaps throws some light onto understanding addiction?

    Humans naturally empathize with the plight that other humans may experience when Love is the main factor.

    Non-sensical and extreme behavior often occurs, but is somewhat familiar and not readily condemned, due to the inevitable, natural and universal experiences of love.

    A person can make seemingly Non-sensical choices while in love, and while addicted.

    Staying in love for life is not uncommon, but falling out of love is quite common too.

    And in the same way, staying addicted for life is not uncommon, but no longer craving or desiring an addiction is quite common too, but not readily researched or studied yet.

  12. Carlton June 5, 2017 at 8:56 am #

    The Irresponsible behavior and a sense of entitlement (especially for drinking) attached to addiction has a history, and “set the tone” of the general publics understanding of addiction.

    For instance, woman were barred from the 1886 opening of the statue of Liberty.

    The reason being that the police could not guarantee the safety of woman due the drunken behaviors expected by the large crowds of celebrating, (and thus drinking) males.

    But the accessibility and availability of various drugs (especially pharmaceutical
    drugs) has become pretty universal.

    Although well described in Hanna’s post here, there seems to be a general change of direction of the publics take on addiction, in that addiction is less seen as a self-indulgent thing, and more a problem the anyone can experience, as depicted in various current ads and public notifications.

  13. Carlton June 9, 2017 at 10:23 pm #

    Hanna,
    Yes this is true, you wrote;

    “In contemporary Western culture, we typically hold people responsible for actions if they have a choice and so could do otherwise, and we excuse people from responsibility if they don’t. ”

    However, society understands and empathizes with a persons choices, (for better or for worse) when Love is the main factor.

    In fact, Illogical, extreme, dangerous behavior is always occurring, but when love is recognized as player in the scenario, people don’t generally condemn or say the person “made a choice” to be in love. and then condemn or treat the person harshly.

    The Dilection Model sees the impetus of addiction as uncannily similar to Love.

    This model is not formulated from professional research and but is derived from hindsight and talking from others that were also addicts at one time in their lives.

    I think if professional studies or research is done along these lines, there will be new understanding of addiction, and recovery too.

    Carlton

  14. Hanna June 15, 2017 at 4:12 pm #

    Hi Carlton

    Thanks for these thoughts.

    I haven’t thought seriously about the connection between love and addiction although the analogy is suggestive and interesting. One difference is that normally we think of love as positive and good and enriching, and although drugs can be those things in some contexts, however you draw the line between drug use and addiction it seems like it will involve crossing over to the negative to some extent or in some sense. Unless you were thinking of love in relationships that are abusive and self-destructive — where maybe the analogy with addiction is really very strong indeed. Anyhow thanks for making me think about this!

    Hanna

    • Carlton June 23, 2017 at 12:28 pm #

      Hanna, Yes, it may seem counter-intuitive to those who are daily involved with addiction in some way, but this fact became clear in-hindsight once the actual feelings changed during my own recovery process.

      An Interestingly, when a person no longer feels compelled, attracted or drawn to a person or thing, associated habits, thoughts and behaviors, usually change and dissolve because a person is no longer “in Love” anymore.

      Falling “out of love” is a familiar as staying in Love for life, is.

      I think this is what happens to the large percentage of people that leave recovery programs and/or no longer pursue something that they were once considered addicted too.

      Seeing addiction and recovery in this way was the reason for presenting this new model, and I think the over-arching nature of it, will account for all the other models in some way.

      They will no longer be in positions of confrontation with each-other, and will all still be intact and referred too by different types of people.

      A “common denominator” can be considered with this model.

      Carlton

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