More on choice and addiction

why oh why by larryosan
why oh why by larryosan

From Kevin McCauley:

The argument against calling addiction a disease centers on the nature of free will. This argument, which I will refer to as the Choice Argument, considers addiction to be a choice: the addict had the choice to start using drugs. Real diseases, on the other hand, are not choices: the diabetic did not have the choice to get diabetes. The Choice Argument posits that the addict can stop using drugs at any time if properly coerced.

As evidence, the Choice Argument offers this scenario: a syringe of drugs is placed in front of an intravenous drug addict and the offer is made to “Spike up!” When the addict picks up the needle and bares his arm, a gun is placed to his temple and the qualifier is added that if the addict injects the drug his brains will be blown out. Most addicts given this choice can summon the free will to choose not to use drugs. The Choice Argument claims this proves that addiction is not a disease. But in real diseases – diabetes, for instance- a gun to the head will not help because free will plays no part in the disease process. So the Choice Argument draws a distinction between behaviors – which are always choices – and diseases.

This is a powerful argument. It is also wrong.

While it is true that a gun to the head can get the addict to chose not to use drugs, the addict is still craving. The addict does not have the choice not to crave. If all you do is measure addiction by the behavior of the addict – using, not using – you miss the most important part of addiction: the patient’s suffering. The Choice Argument falls into the trap of Behavioral Solipsism.

Just as a defect in the bone can be a fracture and a defect in the pancreas can lead to diabetes, a defect in the brain leads to changes in behavior. In attempting to separate behaviors (which are always choices) from symptoms (the result of a disease process), the Choice Argument ignores almost all of the findings of neurology. Defects in the brain can cause brain processes to falter. Free will is not an all or nothing thing. It fluctuates under survival stress.

Hat tip: Matt Statman


Am I enabling?


Loved ones often struggle with the question of whether they are enabling. offers a good post on the subject.

By way of quick review, “enabling” actually means doing positive things that will end up supporting continued negative behavior, such as providing your child with money so they won’t “go hungry” during the day, knowing they use it to buy pot. Another example is going to talk to your child’s teacher to make sure she doesn’t get a bad grade, even though her bad test score was due to drinking. Or calling your husband’s work to explain he’s sick today, when he’s actually hung over.

These are examples of doing something “nice” for your loved one that actually (from a behavioral reinforcement standpoint) might increase the frequency of the negative behavior, not decrease it. The logic: if they act badly and nothing happens, or something good happens, this behavior is encouraged, even if what you are doing is “nice”. This IS enabling, and this is not helpful in changing behavior in a positive direction.

But everything nice is not enabling! And that’s the quicksand we have developed in our culture. Staying connected, rewarding positive behaviors with positivity, being caring and loving; these things are critical to positive change.

So what’s the difference? Positive reinforcement is doing “nice” things in response to positive behavior. Simple as that. When your loved one wakes up on time in the morning, when he takes his sister to school, when she texts you tell you she’ll be late, when he doesn’t smoke pot on Friday night, when he helps you make dinner instead of going for a quick drink with the boys on the way home. These are positive actions, and acknowledging them, rewarding them, being happy about them, is a GOOD thing, not enabling.

Identity and recovery

By Matthew Burpee via flickr

Healthland has a post on the relationship between identity and health:

When is a label a badge of honor, and when is it a harmful stigma of sickness or deviance? This question is of critical importance to public health…

But what does any of this have to do with health care? One of the best ways to change health behavior, it turns out, is to change a person’s self-identity. When a smoker begins to view herself as a nonsmoker or a teen sees binge-drinking as something “people like me” don’t do, behavior change is typically more lasting than if the person’s sense of identity is not invoked.

Research on everything from exercise, eating behavior and sexuality to political action and drug use suggests that having one’s identity wrapped up in a particular behavior is a crucial motivating factor to sustaining it. Once you see yourself as a runner, not running becomes far harder to do, for example.

There are also overwhelmingly negative issues associated with identity and labeling, however. The most obvious example would be a person whose identity and sense of self are tied directly to unhealthy behaviors — for example, viewing oneself as a “dope fiend” whose life purpose is to seek heroin or other drugs. If you believed that this identity was immutable or desirable — for example, if you use drugs as a way to rebel against conventional life — the possibility of change may be precluded before it is even truly considered.

She discusses the double-edged nature of identity a little further:

Once people see themselves as sick, they often limit themselves based on their view of what illness means.

In some cases, though, a “sick” identity can be liberating. For example, if a child learns that she has Asperger’s, which helps explains why social interaction is so difficult for her, she might stop blaming herself for being “weird” or “antisocial” and discover a whole community of similar folks. Similarly, people who suffer from depression, who find out that their miserable sense that everyone hates them or that nothing is any good is a treatable chemical state, can be empowered to seek positive change.

Whether a sick identity is a motivating power for change or a limiting stigma often depends on individual perception. Some people would rather be “sick” than “bad,” for example, and having a disease that explains otherwise undesirable behavior without placing blame will often allow the person to absolve his “weakness” and ask for help. In contrast, others view the idea of sickness as a cop out that denies a person agency and, therefore, dignity.

I’m convinced that identity is a critical element in making maintaining changes over the long term. I’m also convinced that whether the identity is helpful or harmful depends on what the identity offers. Does it offer hope? Community? Recovery? Or, does it offer despair and isolation?

The post is in response to TEDMED 2012. It will be very interesting to see videos of the talks as they are released.