If it wasn’t rational, cont’d

PET brain scans show chemical differences in t...
PET brain scans show chemical differences in the brain between addicts and non-addicts. The normal images in the bottom row come from non-addicts; the abnormal images in the top row come from patients with addiction disorders. These PET brain scans show that that addicts have fewer than average dopamine receptors in their brains, so that weaker dopamine signals are sent between cells. (Photo credit: Wikipedia)

Sam Wilkinson responds to the the coverage of Hart’s research (That crack and meth addicts in a lab will decline drugs for money.) and agrees that addiction is rational.

Hart has found the same thing. It isn’t the addicts are powerless; it’s that nothing on the other side of the scale weighs as much as does the benefit of the whatever-is-being-sought. Back on that Sunday in September 2006, nothing on that scale weighed as much as getting blind drunk. My perceived options in that moment were narrow. By artificially increasing the number of options, Hart shows that even the farthest gone can still make what we might be more willing to describe as the rational decision. Where we stumble is in misunderstanding that the desire the use is rational too.

He goes on to give a really wonderful description of addiction.

Addiction is so harrowing a foe because it literally becomes the solution for everything. The mind’s calculator shows the same answer no matter what the problem is. How do I solve an emotionally devastating day? Beer. How do I celebrate a beautiful day? Beer. How do I unwind after a long day? Beer. How do I endure an uncomfortable situation? Beer. How do I…? Beer. The answer is beer. It does not matter what comes after the ellipses. I wrote this several months ago after giving alcohol as a gift. I am more than six years sober and if I don’t pause long enough to think about the answer my brain is giving me, drinking suddenly starts to make an incredible amount of sense. But if I did stop short of that longer consideration, my conclusion wouldn’t be irrational, especially if I’d only thought to consider all of the good things there are about drinking. And there are good things.

I have a few thoughts.

First, I’m not sure Wilkinson and I are so far apart. During educational talks, I sometimes say, “If drugs did for you what they did for me, you’d be an addict too!” So, if he’s saying that a fundamental characteristic of addiction is that there’s something different about the way addicts/alcoholics experience drugs and that this dramatically changes the decisional balance about using, then I’d agree. I’m not sure I’d strenuously argue that this is rational. Sure, there’s an internal logic to it, but that’s only because the equation is rigged by brain dysfunction.

Second, I’m also not sure that I’d argue this means addicts have control. Hart’s experiments demonstrate that addicts have influence over their use, not that they have control–that they can delay their use, not that they can stop because of incentives. Does anyone really question what the addict is going to do with that $20 after the study is over? I mean, if I’m really hungry and you offer me $20 to skip a meal, I might take you up on that. But, eventually, no amount of money is going to be enough to get me to skip a meal. Sure, some people are super-human and have the force of will to starve themselves in the name of a cause, but that seems like a case where the exception proves the rule.

Third, Wilkinson uses his own experience to understand the matter. He’s 31, which means he was in his mid-twenties when he quit. We know that large numbers of people in their late teens and early 20s meet diagnostic criteria for alcohol dependence and that something like 60% of them will “mature out” and moderate or quit without any professional help or involvement in a mutual aid group. I believe strongly that those who mature out and those who have chronic problems have categorically different problems and we need to be very careful using the experience of one group to understand the other. I don’t know the writer and I don’t know which category he falls into, but he certainly fits the maturing out pattern.

Fourth, the degree to which we insist on free will and rationality is striking. Think for a moment about the argument that it’s rational for people to destroy their lives using drugs. We’re willing to twist ourselves in meaningless mental knots, ignore the obvious (like the fact that Hart’s subjects are very likely to use the money they get in these studies on drugs), and ignore the common sense ethical problems (experiments that put addicts up for a week, provide them with drugs and release them with a pocket full of money). All to make it fit into our monoculture.

If it wasn’t rational, cont’d

English: Cocaine user "tweaking" or ...
English: Cocaine user “tweaking” or withdrawing from cocaine searches ground for small bits of lost or overlooked crack cocaine, while standing beneath an anti-cocaine graffitum. (Photo credit: Wikipedia)

Yesterday I posted about a recent NY Times column arguing for a rational model of addictive drug use:

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

I was thinking about it a little more and several people have spoken with me about it.

I have two thoughts that I’d add to yesterday’s post.

First, it might be rational if the person’s life is hopeless. This premise worth thinking deeply about.

nihilism by Brett Jordan
nihilism by Brett Jordan

Second, several people have commented on the ethics of his studies:

Dr. Hart recruited addicts by advertising in The Village Voice, offering them a chance to make $950 while smoking crack made from pharmaceutical-grade cocaine.

Um, yeah.  There is that. It never ceases to amaze me that a human subjects review board would approve this kind of study.

If it wasn’t rational, they wouldn’t be doing it

mencken-complex-problem

Ugh.

The NY Times has another column promoting a rational addiction model.

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

Here we go again. Their drug use by addicts is rational. A rational choice. If you had their lives, you’d be an addict too.

I’m not even clear that there’s a causal relationship from poverty to addiction. If so, how strong is that relationship?

In an article titled, “Taking Absurd Theories Seriously“, Ole Rogeberg walks through an extensive takedown of rational addiction theories. This video is great.

Why do people insist on framing addiction as rational?

For others, it’s assimilation into the monoculture:

To begin with, in the economic story, you are an individual.

The economic story also says that as a human being, you’re rational. In economic thought, being rational doesn’t mean that you’re sensible or that you’re a clear thinker. Being rational means that when you’re faced with a decision, you move through a three-stage process to decide what to do. Assuming you know what your goals are, you first lay out all the ways you could reach each goal and identify the costs and benefits of each possibility. Next, you analyze which option is most efficient — the one that most directly lets you get the most of what you want while costing you the least of your resources. Finally, you choose that most efficient option, because in the economic story, your best choice is always the most efficient choice.

In the economic story, you’re someone who is self-interested, in the most positive sense possible.

Being cast as someone who is rational and self-interested might sound relatively harmless, but that way of thinking has implications because it’s based on the assumptions that you know what condition you’re in, you know what your options are, and you know what you want, but those assumptions don’t necessarily hold. … The story says that you act as you do because you’re trying to get what you want, and the rest of us can tell what you want by watching how you act.

For others it’s philosophical:

Although addiction may be defined and operationalized in a number of different ways, the heart and core of the concept lies in its implication of the loss of the ability to choose – that is, the loss of free will.  Hence, and logically, the concept of addiction also implies the actual existence of free will.  And there lies the rub.

The addiction concept repackages one of the Big Questions – free will and determinism – into a new and seemingly more manageable form.   But should we be entirely comfortable with the tacit implication that ordinary, non-addictive conduct is freely willed?

Of course, this assumption underlies much of our day-to-day lives.  We show up at work late and we are responsible for the choices we made that caused our lateness.  Our legal system relies on the same assumption as well.  It assumes people freely do what they do and must take responsibility for their actions.

This came up again recently when Sally Satel published a book questioning neuroscience and addiction:

“Brainwashed” is nervously libertarian; Satel is a scholar at the American Enterprise Institute, and she and Lilienfeld are worried that neuroscience will shift wrongdoing from the responsible individual to his irresponsible brain, allowing crooks to cite neuroscience in order to get away with crimes.

Once it’s defined as a choice, and the rational choice theory isn’t satisfactory, we’ve got economists coming up with their own answers to the age old question of, why do they do it? [emphasis mine]

First-hand accounts of poverty generally recognize that heavy users of drugs and alcohol pay a high material cost.  Yet they rarely reach my verdict: that other factors – like low IQ, low conscientiousness, low patience, or plain irrationality – must be driving both poverty and substance abuse.  Instead, observers usually say that the poor consume drugs and alcohol to “dull the pain.”  Some even argue that the poor are being entirely rational: If your life is a living hell, narcoticizing yourself is the simplest solution.

There’s just one problem with this explanation: By almost all accounts, substance abuse eventually makes your life worse.  The long-term addict’s life is utterly wretched – even if you average in his periodic drug-induced euphorias.  Someone who has yet to start using drugs and alcohol doesn’t face a choice between “full pain” and “dulled pain.”  Instead, he chooses between two paths of pain:

Path #1: Full pain in the short-run, followed by gradual life progress.

Path #2: Dulled pain in the short-run, followed by a gradual downward spiral into abject misery.

Suppose you’re poor.  Your life is unusually painful, so the immediate effect of drugs and alcohol is especially attractive.  The long-run prognosis for a poor substance abuser, however, is especially repellent.  You hit “rock bottom” sooner because you don’t have far to fall.  And your version of “rock bottom” is extra bleak because you lack the financial resources and social connections to cushion the blow and get back on your feet.

The lesson: On net, poverty isn’t a believable root cause of substance abuse, because being poor doesn’t make substance abuse a better overall deal.  Why then would poor people be more inclined to narcoticize themselves?  Once again, we should look for root causes of poverty and pathology.  Low patience is the most obvious suspect.  If you loathe to defer gratification, you’ll tend to have low income, and eagerly use drugs and alcohol today despite their awful cost down the line.

While I detest the blogger’s character-based explanation. He closes with a very salient question and observation:

Closing questions: If you were poor, would you turn to drugs and alcohol?  If you were a social worker, would you advise the poor to turn to drugs and alcohol?  I doubt it.  The reason, of course, is that on some level you already know what I’m telling you: Poverty is no excuse for substance abuse because substance abuse is an absurd response to poverty.

UPDATE: I’ve had several posts over the years about free will and addiction. One important thing to keep in mind is that when we say it’s a brain disease, it doesn’t mean the person always has zero control over their behavior.

Here are some excerpts that offer different ways to think about it.

On co-existing deterministic factors and free will:

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

On deterministic factors as a continuum:

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic’s throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

On will power as psychological energy:

…within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

…Acknowledging these considerations does disavow the role of choice. Even on the end of the continuum where a person’s biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

On ditching the all or nothing mentality:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes).