Choice isn’t simple

Some people say that addiction is not a choice, it’s a disease. As you know, I’m not one of them. But even those of us who believe in choice ask how much volition (intention or will) is involved in the choice to use or not. I think that choice is a lot more complicated than most people think. For now, I’ll skip the philosophical objections to the idea of “free choice.” Sticking to brass tacks, I think that volition interacts with many other factors when we make choices — especially choices about addiction.

rejectedgirlChoices are based on appraisals (interpretations) of situations. People with addictions choose whether to get high or abstain based on appraisals of the quality of the high, the consequences of indulging, the proximity of other people who might approve or disapprove, and so forth. Since our appraisals are determined by factors outside our volition or awareness, especially in a complex situation changing moment by moment, the choice we make in that situation is less determined by our volition and more determined by luck and circumstance.

guyonsofaAppraisals are also strongly affected by internal variables: mood states, present emotions, beliefs, (biased) recollections of previous events. But this list doesn’t yet scratch the surface. There is my sense of emptiness and dislocation at this moment, compared with how I think I’ll feel after getting high, compared with how much drug I possess or can afford, in the context of building excitement and/or building anxiety and shame. These “internal state variables,” as psychologists call them, are highly complex and they change from moment to moment. Since that mix of factors will certainly affect one’s choice (e.g., to use or abstain), I can’t see how the choice can be entirely voluntary, entirely an expression of “free will.”

Over the time scale of development, habits evolve and consolidate, creating a spiral of increasingly strong predispositions to seek addictive rewards while alternative rewards become less meaningful. Is there any voluntary choice left after those habits congeal? Yes, I believe there is. Which is how people can slow down or quit. Recovery involves choice, and choice whitewalkercannot suddenly be imported into a system that has none. Changes in appraisal, emotion, and social factors strongly influence volition, which influences actions, all of which alters one’s belief in oneself — one’s self-efficacy. That’s why self-talk and help from other people socialfactors(friends, partners, books, stories, podcasts) can be so important. Once addicts tune into the possibility of volitional choices, the mechanism underlying volition itself grows in strength and availability.

In my book and elsewhere, I emphasize how synaptic networks can compete with each other, but when any of these networks is activated repeatedly, it becomes stronger, more likely to win the competition. This is the case when addiction arises in development, but also when it declines, replaced by the desire for and belief in alternative outcomes. I also think that addicts temporarily lose the capacity — or at least belief in the capacity — to make reflective judgments, and that loss is underpinned by a loss of connectivity between the prefrontal cortex (“the bridge of the ship”) and the striatum (“the engine of desire”). Then this connectivity can return, gradually, as people recover. Now newly forged connections between these neural systems allow desire and decision-making to work together in the service of future-oriented goals. To put it simply, I see this as the resurgence of volition in a system overwhelmed by habit.

There are many other goads, nudges, constraints, and impacts on volition — the voluntary component of choice. Most important are the psychological mechanisms of “now appeal” and ego fatigue. The passage of time also has enormous impact on volitional choice. Also critical are the roles of impulsive and compulsive action tendencies. How much volition manindenis available during the impulsive phase of addiction, as one’s imagined future slides down a sort of chute into the “now”? Some, I think, but not much. Once the compulsive stage of addiction is reached, how much volition is present? Now action is put in motion before one is even aware of making a choice. Still, compulsion is not abnormal or pathological. When we examine more mundane decisions, like whether to check that the stove is turned off, it’s clear that volition and compulsion mix together, competing and cooperating, as we make choices. It’s not mandatory to recheck the stove.

According to a developmental-learning model (like mine, or that of Maia Szalavitz), interpersonal, social, emotional, and personality factors all contribute to a developmental trajectory that continues to adjust itself, to consolidate itself. So we don’t have to waste another moment conceiving of addiction as a disease. Using personal reports, psychological research, and neurobiological findings as our sources, we can achieve a far more detailed understanding of choice in the context of development, with its phases of relative stuckness and relative flexibility. We can also study the links between brain changes and environmental forces, to increase our knowledge of how addiction develops and how it can be overcome.

31 thoughts on “Choice isn’t simple

  1. Jasmine March 6, 2017 at 5:21 am #

    As always Marc, thank you for another thoughtful posts. I too have been thinking about different theories of addiction, dependency, etc.

    Most of us involved in academia, peripherally or otherwise, have been trained to find a theoretical box as a point of reference. Getting published and recognized most often means a theory in which to frame our “data” will support or challenge this or that theory. Sometimes, this data may lend itself to another theory, like those in the postmodern tradition seem to get lost in the trees without an understanding of an overall forest. In short, I think focusing on this or that theory loses much in translation.

    A quote from Ram Dass that I find instructive: “Across the planes of consciousness, we have to live with the paradox that opposite things can simultaneously be true.”

    That’s not to say overall tendencies can’t be discerned, nor that “data” can’t fit within different, perhaps even opposing theories. But, it seems (to me) that much can get lost when we try to pin down experiences and narratives to fit within this or that paradigm, to categorize our “work” for scholarly debate and discussion.

    I’m not suggesting a few malard ducks can substantiate whatever (eugenic) theory, but rather to maybe focus less on what fits in whatever rigid theoretical packaging so that we lose less in the process of translation.

    • Cheryl March 6, 2017 at 9:38 am #

      I myself have experienced different situations above mentioned when “choice” fluctuates according to the situation, mood etc. The longer I stay away from Method( my doc now) the easier it becomes to make the choice to stay abstinent. But, if an old using friend starts messaging me the choice becomes weaker. Also, where I’m living has been an issue. “Like being at a Carnival and can’t eat the cotton candy.” I am not able to move right now due to.Financial resources are

    • Terry March 6, 2017 at 4:47 pm #

      anybody who has undergone the agony of addiction especially to something like alcohol or heavy drugs knows that such an assertion that choice is involved goes against the seemingly impossible craving which occurs and which so often results in destructive use. this is the conundrum with trying to theoretically explain addiction and arguments against disease. like you Mark I do not believe the disease notion however I have known craving and that led me to drink perfume and other less socially acceptable beverages and at those times there was in my mind, body and soul, seemingly no choice and the only way I could deny those cravings at that time was to hospitalise myself. from the miles away I am now my theoretical mind says choice is evident however I recall vividly the powerlessness against that craving. it is the fear of going back to that which ahs me now chose not to drink alcohol and I now have that ability to choose, but I didn’t think (or feel) I did then.

      • Carlton March 7, 2017 at 10:48 am #

        To Terry’s point, a “choice” was never out of sight while addicted, but it was like the choice of having going out in a blizzard in regular cloths. and “choosing” not wear severe winter cloths.

        There was a “Logic” that people just did not understand how essential the addiction was to ones life.

        An addiction can become to SEEM as essential to life as air, food and water is, and choosing not to eat, breath to drink for the remainder of ones life can seem to an impossible, and even fatal choice.

        • Terry March 7, 2017 at 5:17 pm #

          when I gave up smoking nicotine a few years back my thoughts after were – why did I not do that sooner ?? – as Carlton says the choices then seemed so different now to what they seemed then when the only choices were not whether to smoke or drink but what others things to sacrifice in order to do the addictive thing. addiction is very different after the event and can be thought of in more rational terms yet when engaged in it there seems no choice, yet a some point I chose to go to a detox, or to ring and ask for help – choice arrived eventually amidst the fog of confusion created by compulsion and craving, a choice to live or die presented itself and demanded an answer, procrastination no longer an option as the reality of just how serious the situation had become became clear.

  2. matt March 6, 2017 at 6:22 am #

    Change in the volitional and compulsive use of substances involves developing a new flexibility in perspective, unlike the friable, unidirectional inflexibility involved in our development of compulsive use. Our perspective had become a narrowly focused beam on one reward to soothe and solve everything. A solution it seemed we could trust, until it stopped working. Trust is not just the expectation that people will do well by us, but also denial of the reality that they may do wrong. When distrust is turned inward it creates a shit storm of cognitive dissonance. The difficulty in addiction stems from losing the ability to trust ourselves not to inflict self-harm. When we can’t trust ourselves, who or what can we trust?

    When we open our perspective with acceptance and flexibility to new possibilities, we regain the ability to trust ourselves to do the right thing. Recovery is uncovering potential; addiction becomes brittle inflexibility. When we become honest and can trust others, we can become honest and trust in ourselves— a notion that may seem backwards, but the mechanism in successful recovery, nonetheless.

    • Dr. Ron March 6, 2017 at 5:54 pm #

      Interesting elaboration on the elements of trust,cognitive dissonance and their influence in further corrupting agency in effective decision making..It actually mirrors my experience, especially when adding the element of drug induced paranoia to the mix .

      • matt March 7, 2017 at 8:14 am #

        Thanks, Dr. Ron!

        …and what do we need to stop it? Honesty…intention (internal motivation)…and agency?

        • Dr. Ron March 7, 2017 at 11:21 am #

          Choice is ultimately paramount but in what direction?
          Volition is only useful if applied prudently, in the environment of cognitive dissonance, and the dissolution of moral ethical and criminal boundaries, the absence of self trust or even the notion of self leaves one with only the choice to use, however seemingly involuntary.
          I recall early in recovery for lack of a better term how confusing life had all become and more so, who, if not me, could I trust to guide me in healthy choices to restore a semblance of order to life which I initially found in an environment of other recovering addicts.
          This also brings up the considerations of MISPLACED trust, betrayal, both internal and external; perceived victimization and helplessness opposed to agency and accountability and of course the 800 lb gorilla, FEAR,and their effects on a fragile psyche and decision making capabilities.

          • matt March 11, 2017 at 5:33 am #

            I think this is why the agency and accountability involved in helping others can be powerful in rebuilding positive self-concept and move us forward in changing our life for the better. If I “hate” myself and my life but am able to help another in a similar situation to find a better way, I am sending a powerful message to my self-destructive brain that I too may be worthy of the same redemption.

  3. Mark March 6, 2017 at 6:48 am #

    If we can use technology to “enhance morality” (http://journal.frontiersin.org/article/10.3389/fnhum.2017.00077/full?utm) doesn’t it stand to reason that the environment can work to impair “morality” and all the choices that seemingly go along with it?

  4. Nicolas Ruf March 6, 2017 at 8:35 am #

    The blind don’t need light; they need eyes.

    Buddhist saying

  5. William Abbott March 6, 2017 at 11:18 am #

    You have hit at the crux of the problem – the disease model totally misses the point and the choice model is incomplete. Yes it seems to the heavily addicted they dont have a choice any more-and hence the AA idea of higher power– let G do it.
    But as I am beginning to understand it is for most a re awakening of the continued existence of choice and then beginning to use it , is the key to recovery in many. And therein lies the power of mutual support groups .. ” I felt the same way , but I got it back—and so can you ”

    This works.

  6. Coffeeshoptea March 7, 2017 at 1:51 am #

    Hi, I went to a pub to watch football on Sunday.I haven’t had a drink for many yrs and I only go to pubs to either watch fooball or for live music. I went outside at half time and saw someone I hadn’t seen since my drinking days
    We had a chat and I went back inside for second half. Immediately I noticed the guy next to me’s drink and having a big gulp of that beverage felt like it would go down reall nicely. It felt like it would be refreshing and hit a spot that my tea wasn’t. It was almost like a “craving” maybe 6.5/10. I’ve not felt that for yrs,luckily I’ve studied conditioning reflexes and I realised that this guy could have triggered this. Considering I only ever seen this guy in a late night bar and I was alway pretty drunk, and up for more and some,there must have been a strong association still present, even after 15 yrs of abstinence. This puts the question of choice into the spotlight. A. I was able to choose not to drink because I had self efficacy and no recent alcohol consumption or ambivalence about cost benefits of drinking and B
    to attribute this seemingly puzzling desire to drink alcohol to what I had learned regarding conditioned responses albeit later than I had the desire,probably about 5 mins.This has reinforced the multitude of factors surrounding choice regarding substance use and I am fortunate enough to have an.awareness of these but must still be vigilant. I think the principles of conditioned responses should be taught to people struggling with substance use to help give them some kind of rational in order for them to make more informed choices. Thanks for your article

    • Marc March 20, 2017 at 7:27 am #

      I agree that conditioning plays an enormous role in this kind of choice. But that just puts a name to some of the complexity. We are always choosing among “known” pathways, even if “known” by association, by proxy, by analogy, etc. That means that some conditioning has gone into the framing of each potential pathway. So we are comparing what we presently think and feel about pathways that were established in the past. That means: not only what and how we learned about that pathway is important, but so is how we feel about it given everything that’s happened (or not happened) since then.

      So, sure, let’s teach conditioning in high school. But let’s begin to recognize its complexity. Pavlov’s S-R mechanisms and Skinners reinforcement mechanisms are like letters in an alphabet. Now let’s put them together to make words.

  7. Richard Henry March 8, 2017 at 12:16 pm #

    Hi Marc… A pleasure as always.
    Choice for me and what I told myself when I was using cocaine was the next morning. You could say a consequence of use or side effect…
    If I didn’t feel so good the next day I wouldn’t do it.
    I believe their is an underlying issue for every use a “Reward” in my case I believed I suffer from “Reward Deficiency Syndrome” as I shared in my book Life in the Game of addictions.
    Fighting for years to finding the answer to my Substance use disorder or in my case Amphetamine Use Disorder has I think finally been recognized and a Off label medication called Vyvanse was study to have positive results.
    I just started it 1 week ago and my choice to use or not has become so much easier.
    It seems to address that desire to use (Crave) I no longer fight the urges, it seems to satisfy that need.
    Like suboxone or Methadone for Opiate Use disorder I believe this is a breakthrough in finally coming out with something to address Amphetamine Addiction.
    As always I respect your input and feedback.
    Thanks and respect Richard henry

  8. Joanna Free March 8, 2017 at 4:56 pm #

    We so love a box, a label for things… so tidy.
    But life isn’t tidy. And we don’t fit into boxes
    (at least not when we’re alive!).

    Today, I’m in 12 Step fellowship again.
    I love it.

    I missed it, having left because I no longer could say, “I have a disease, and flaws of character, and the need to take a moral inventory, etc…”

    Then I remembered: Take what you can use and leave the rest.

    The need for fellowship is undeniable for me. My big family is all over the map. I live in a small, conservative town. I work to develop community, but it isn’t enough and it isn’t deep enough.

    If I lived in a large city, or in a place where more choices were available, I might choose a different community. Maybe. Maybe not, now.

    From where I stand today, I am profoundly grateful to have found my way back to a community that is ever-evolving, engaged in self-examination, taking daily actions in the direction of the lives we desire (thereby changing neurophysiology and patterns) and supporting one another in doing the same.

    This is how we were meant to be: talking, listening deeply to each other and to the deeper sense of who we are and how we want to show up in the world. Words of encouragement. The sharing of experience, strength and hope. Laughing at ourselves and our falling down, cheering our collective getting back up again.

    Some think they must say, “I have a disease” in order to belong in these fellowships.

    Not true.

    The only requirement for membership is a desire to effect change in the way that is the focus of that particular fellowship.

    When I remembered that, and was ready to make changes that only fellowship can do for me, I was able to remember this essential point.

    And, on an outreach call, when someone asks me, “Is it OK to do this a different way?” I get to be one of the people who says, “Yes. yes it is… use your creative mind, it’s OK! Try something new, and maybe you’ll figure out a way none of us have thought of before and blaze a whole new trail to follow. And if you do, let us know!”

    So thankful for voices like yours, Marc, reminding us to think outside the little boxes of this versus that.

    These aren’t sports teams were rooting for here… as in, my Choice Team is better than your Disease Model Team…
    these are our creative, expansive, amazing human lives.

    Thank you.

    • matt March 11, 2017 at 6:10 am #

      Thank you…and thanks for the reminder that there are as many ways to “recover” as there are to become “addicted”. We can’t do this alone, but you also can’t be assigned a community. We choose our community from an array of options as vast as our human spirit…

    • Carlton March 11, 2017 at 3:27 pm #

      That description also fits the AA home-group I attended in the 1990’s too, despite the fact it was on Perry street in Greenwich Village… here in the heart of a big city, (NYC), and I believe is still there!

      I think when Addiction is finally understood in the near future, recovery programs will not be radically changed, because the essence and value of the humility and humanity that is present is so helpful to people.

      The different TYPES of beliefs, help different TYPES of people, no matter what addiction is.

      • Joanna Free March 13, 2017 at 1:50 pm #

        Yes, and yes, matt and Carlton – I know groups like that, have had the great fortune of being a part of them.

        We had a group in Portland, Maine in the early ’90’s in which we kept changing the language of the readings to make the group ever more inclusive… we wanted EVERYONE seeking what we had (smo-briety:) to be able to find and connect with us. The group grew and grew. We eventually had to change the group’s name because we were no longer abiding by the traditions… but we had a full room and so much laughter, compassion, listening… and recovery and discovery there.

        Yes – humility and humanity.

        Someday, I’d like to (will) start another group like that (have done so in the past, with a lot of shared success).

        There ARE so many ways to grow and become more fully, richly our individual (and collective) selves.

        • Carlton March 13, 2017 at 2:52 pm #

          Joanna,
          I should add that just as in a prisoner-of-war camp the humble and humane realizations and bonds people make are real, but the ultimate thing is not to be there.

          This is true is for ANY recovery program, even physical recovery programs.

          For a large percentage of people, the underlaying belief that one is defective and has an incurable disease it not helpful, nor evident.

          And to have the “official” definition that addiction is a disease is something that many of us are trying to correct, because of this.

          But saying it is NOT a disease can be just as unhelpful , because it undermines the VALUE that the BELIEF offers to a large percentage of people.

          I think the eventual understanding of Addiction and will accommodate ALL the beliefs, and defined from a humanistic, not a medical or biological definition.

          • Joanna Free March 13, 2017 at 7:55 pm #

            Point taken, Carlton… though for me, when I can find the kind of warm, honest, irreverent and reverent depth of community in the world around me that I can so readily find in those rooms, then (maybe) I’ll find other ways to serve and grow in community. From where I stand, the fellowship I belong to is a fit and a a gift.

            Especially when I remember: I get to do it (life) my way.

            No POWs here – just glad to be connected and evolving with others who are glad to be connected and evolving with me.

            • Carlton March 15, 2017 at 8:09 am #

              Yes, your warm and apt words describe what most people probably feel in Recovery Support groups and fellowships.

              Although my description is not often heard, It may be a common experience by people that no longer feel addicted.

              The most important thing though, is that these two differing experiences beg the question of what addiction (and recovery) is.

              To subject and treat all people as if addiction is a disease is
              not sound.

              A person cannot be honest with oneself if they do not find or feel that the addiction was a disease, although it is currently and officially defined as such.

              This Blog is one place that is open to this discussion.

  9. Mark March 12, 2017 at 8:38 am #

    Marc, what do you think of this recent research?

    http://newsroom.ucla.edu/releases/ucla-research-upend-long-held-belief-about-how-neurons-communicate

    With the cerebellum so dendrite-rich, might we simply dance our way to recovery?

    ~ Mark

    • Joanna Free March 13, 2017 at 1:38 pm #

      Mark – and Marc – I feel like dancing just thinking about this!

    • Marc March 20, 2017 at 8:19 am #

      Thanks for the link. I’ve read it but I don’t think I understand it. Better go to Science next.

    • Carlton March 18, 2017 at 12:05 am #

      In hindsight, what was apparent at all the recovery groups I was in, from AA, St. Jude, Cornerstone, and finally SMART, was how varied the peoples origin and background was.

      Not or question the correlation, but to point out the correlations are
      probably many, including being born with a silver spoon in your mouth.

  10. Clifford Edwards March 18, 2017 at 6:56 am #

    The disease model is an idea, nothing else. Personalities are needed to turn ideas into ideologies and that’s probably what most 12 step groups, and by extension, treatment centres, do. It can however create an unhealthy dependency.The turning point for me was a simple hyphen: dis-ease. I realized that whenever if felt it, I’d melt it. With drugs or drink. Then in recovery with food or money or whatever. Each person has to find a way to live with their dis-ease. No-one gets immunity from it! Find a way to make it less personal: there are many roads home.

    • Marc March 20, 2017 at 8:23 am #

      I like the way you frame it: Find a way to make it less personal… Good idea!

  11. Mark March 23, 2017 at 7:23 am #

    As if things weren’t hard enough already …

    The Pleasure Center in the Fear Circuitry

    http://news.mit.edu/2017/brain-circuit-pleasure-inducing-behavior-0322

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