by Gene M. Heyman
Harvard University Press, 2009
Review by Christian Perring on Jun 24th 2009
Gene Heyman's Addiction: A Disorder of Choice explores similar themes as Jeffrey Schaler's more didactic Addiction is a Choice (Open Court, 2000), and Herbert Fingarette's more philosophical Heavy Drinking: The Myth of Alcoholism as a Disease (University of California Press, 1988). Yet Heyman refers to neither of these books, making his own independent argument instead. Heyman's position is relatively nuanced, and is not an indictment of all current approaches to understanding addiction and its treatment. In an atmosphere where the main view of addiction is that it is very much a disease (see for example, the HBO Addiction series with many figures from government health agencies giving their opinions), his somewhat skeptical view which emphasizes how much it is a matter of individual lack of self-control and failure to take the long view of one's personal interests is likely to both cause controversy and be condemned by many in positions of authority in the mental health field. Indeed, various blogs are already buzzing with counterarguments and dismissals from those in the biological tradition, and a recent article in the Toronto Star quotes several highly placed psychologists and psychiatrists saying that Heyman has misunderstood the literature.
Heyman proceeds with his arguments methodically, covering the history of the understanding and treatment of addiction and the transformation of both health and social policy in treating addiction as a disease, some of the social factors relevant to the prevalence of addiction, explaining the variety of first person descriptions of addiction, the rates of relapse after recovery and remission, the problems with standard disease models of addiction, and then two chapters on addiction as a bad choice due to being short-sighted in evaluating the outcomes of one's actions.
It is important to be clear on Heyman's main claims. While he is critical of disease models that say that addicts have no choice and that addictions never end, he is not saying that it is always easy or even possible for addicts to stop their self-defeating behavior. He emphasizes that there is good evidence that what addicts say about their experience is often true -- viz., that it is extremely difficult for them to stop their addictive behavior. Furthermore, and this is crucial, he is not saying that there should be no entry for substance in the diagnostic manuals. He thinks that there should be ways for addicts to get helpful treatment, and never proposes that treatment should not be available to addicts. He does point to problems with treatment, showing that the remission rate for people who get go through standard treatments is worse than that for people who get no treatment. He explains that it is not clear why this should be, but suggests that it may be because people in treatment have a higher rate of comorbidity with other psychiatric disorders than those not in treatment. He argues that most addicts make the effort to end their addictions around the age of 30, because it becomes so transparent to them that their addiction is bad for them, and because of external pressures such as having no more money to pay for their drugs. Heyman's main target is the conception of addiction as a form of compulsion which leaves people with no choice: he points out that people not only have a choice, but that they regularly exercise that choice in response to their circumstances. He spends a good deal of time explaining how it is possible that people can make bad self-destructive choices voluntarily.
Heyman does not address the social and legal implications of his view, but there is no reason to conclude from his book that he is advocating an unsympathetic attitude toward addicts. He does not suggest that we should blame addicts for their addictions or refuse to help them. Given that he acknowledges how difficult it can be for people to make the right choice, his view leaves open the possibility of being fully empathetic toward addicts as we would with many people who had a hard time making good decisions. It also leaves open the different possibility that we should hold addicts accountable for the emotional damage and financial problems they cause for others. Heyman is not attempting to supplement his assessment of the evidence regarding autonomy and choice with a moral theory or moral perspective about the blameworthiness of addicts.
The scientific, social and historical literature on addiction is now massive, so it would be impossible for Heyman to do an exhaustive survey, especially in a 200 page book. His coverage is done well, and includes a good deal of interesting material. Of course, those with expertise in the areas Heyman discusses will notice gaps and may find the brief discussions of insufficient depth. However, to complain about this is to want the book to be a different kind of investigation. Heyman has one main goal: to make a case for showing that choice is involved in addiction. He shows how the trend to addiction as a disease has its roots in seventeenth century thought, and he outlines some of the trends in its categorization since then.
The main argument of the book has two sides. First, Heyman shows the weaknesses in the disease models of addiction. Second, he spells out what is involved in seeing addiction as involving choice. Along the way, he makes many important subsidiary claims. Chapter 4 looks at whether addiction is a chronic disorder, as has been claimed by many proponents of the disease model. He examines two major surveys: the Epidemiologic Catchment Area Survey (1980-1984) and the National Comorbidity Survey, 1990-92. They both show remission rates for substance abuse and dependence disorders far higher than for all other major mental disorders. He argues that this shows that the conception of addiction as a chronic mental illness is mistaken, and that the low remission rate among patients in treatment for addiction is due to the fact that those in treatment are much more likely to have other concurrent mental disorders and are more likely to relapse. Despite the fact that often patients in treatment have a high relapse rate, Heyman argues that treatment can be useful, and shows that a program for drug-using physicians and airline pilots who could lose their jobs if they relapsed, the abstinence rates were high, often more than 80%. Thus, Heyman argues, the right treatment can be highly successful with sufficient motivation. He also highlights the fact that most people who qualify for a diagnosis of substance dependence never get treatment and end their additions on their own.
Heyman moves on to showing that the arguments for the disease model of alcoholism, according to which addictive behavior is involuntary, are flawed. He concedes that people can have a genetic disposition to addiction, and explains that this does not show that addiction is involuntary, because people can be genetically predisposed to voluntary behavior. He gives the example of religious belief, showing that identical twins are more likely to have similar religious beliefs than fraternal twins.
He proceeds to discuss the evidence from neuroscience. It is often claimed that the study of the changes in the brains of addicts prove that addiction is involuntary, and Heyman shows the flaws in these arguments. He does this with the surprising example of OCD, a condition that most people are willing to grant is a disorder and whose associated behavior is normally seen as involuntary. He discusses work with OCD patients that shows them how to overcome their obsessions and ritualized behavior by learning to ignore their obsessive thoughts. This treatment was successful and resulted in their brains returning to normal. Pharmacological treatments had similar effects. This shows the plasticity of the brain, and shows that OCD is not permanent, and can be overcome. Heyman draws a parallel with addiction, and spells this out by referring to patients who overcame cocaine addiction by learning to ignore their cravings.
With both arguments here, concerning religious belief and OCD, it is not entirely clear that the arguments make the point that Heyman wants to make. One could reverse the interpretation of the study of the genetics of religious belief by arguing that it shows that genetics, being an influence on one's belief. The argument concerning OCD is even more problematic, since the fact that we can overcome changes in the brain and overcome the disorder does not in itself show that the behavior associated with OCD is voluntary. This highlights one of the persistent problems facing not only Heyman but anyone else working in this field: what counts as voluntary action, and what we might mean by involuntary action. Nevertheless, it takes little thought to realize that Heyman's main claims here are correct. There is no reason why there should not be genetic influences on one's preferences and one's voluntary behavior, no matter how one wants to define voluntary. Similarly, the fact that there are changes in one's brain does not in itself show that the associated behavior is involuntary. In order for this argument based on brain changes to work, it has to be based on particular facts about how the parts of the brain that control voluntary action have been bypassed, or possibly, as some occasionally claim, "hijacked." However, the deliberate and complex behavior of addicts who show considerable ingenuity in finding ways to get their drugs and hide them from others make it puzzling how we could possibly understand their behavior as involuntary. It is certainly very different from the tics associated with Huntington's disease or the rituals associated with OCD. In order to make the argument successfully, one has to have a sophisticated account of what counts as involuntary. This is a central area of the debate, yet neither proponents nor opponents of the brain disease model really grapple with the meaning of involuntary action. It is no surprise that Robert West has recently written, "It is unlikely that a consensus will emerge because there is no objective way of deciding the issue" (in Addiction Treatment: Science and Policy for the Twenty-first Century [Johns Hopkins, 2007], edited by J.E. Henningfield et al.)
What both these previously mentioned arguments do show is that the fact that a condition has genetic elements or is associated with brain changes does not imply that it is permanent. Heyman gives stronger arguments concerning the voluntary aspect of addiction with his examination of successful treatments that encourage addicts to stop their drug use by giving them incentives. He gives the example of treatments in which addicts earn vouchers when they pass tests that show that they have not used recently. This treatment is successful and shows that addicts respond to incentives in ways that people with other mental disorders do not, strongly suggesting that addictive behavior is more voluntary then that associated with other mental disorders.
In Chapter 6, Heyman brings in rational choice theory and the work of behavioral economist and psychologist Richard Herrnstein to make the distinction between taking a local and a global perspective. This explains how if one is taking a short term perspective, it can be better for an addict to continue taking drugs in order to avoid withdrawal symptoms. One needs to shift to a longer term, global perspective in order for it to be rational to make the effort to quit drugs. On this view, one of the causes of addiction is that addicts do not take a long term perspective in their decisions, but only think of the immediate future. Heyman points out that this approach can equally explain all forms of excessive behavior, including modern acquisitiveness. This analysis suggests that if we can get people to take a longer perspective about their long term welfare, then their own concern for themselves will make them end their addictions. So this is a view that there's a fundamentally cognitive aspect to the problem of addiction. Heyman regards the principles of rational choice theory as self-evident, and so he does not try to empirically justify their applicability to addiction or other real world situations. There's no doubt that it is a helpful perspective in some ways, but we need more evidence that it is really illuminating. If addiction treatment were just a matter of correcting a cognitive error, it would be much easier, and addiction would be short lived, since from early on, addicts know that their addictive behavior is not in their long-term interests. Clearly there are many factors that mean that simply providing addicts with information about rationality does not help them change. So rational choice theory seems of limited use here: it shows one aspect of the problem, but it is a long way from being anything like a full explanation of addiction. Indeed, in a recent overview of work on addiction, focusing on the more sophisticated theories of behavioral economists Gary Becker and George Ainslee, philosopher Gideon Yaffe explains how both their approaches are flawed in giving an account of addicts responsibility for their behavior. ("Recent Work on Addiction and Responsible Agency," Philosophy and Phenomenological Research, 2002, Vol. 30, No. 2, pages 178-221.)
The final chapter goes some way to integrating a variety of factors into a view of addiction as voluntary behavior. Heyman discusses neuroscientific work on addiction regarding the role of dopamine. He does not doubt that dopamine plays a role, but he points out that it cannot be the whole explanation of addiction. He points to several other factors that may explain why some people become addicts while others do not, and why some people get more addicted than others. These include different biological and cognitive reactions to drugs, different social circumstances and being single or married in particular, and educational level of achievement. Heyman also briefly surveys how different treatments, from methadone replacement for heroin to Alcoholics Anonymous, can be helpful in getting people to end their addictions. He explains how all these factors are compatible with a voluntary model of addiction. He ends with a brief assessment of the benefits of his view, such as that it is more optimistic about the possibility for change than the standard disease model. At the same time he points out that it is part of human nature as set out in the rational choice theory he has set out for people to engage in behavior that is not good for them in the long run, and that can lead to serious self-harm.
So where does Heyman's Addiction stand in relation to the rest of the literature? Despite the controversy and condemnation it is drawing from the defenders of the brain disease medical model, the position of the book is quite moderate. Unlike some others who have rejected the disease model, Heyman is content for substance abuse disorders to remain in the diagnostic manuals of mental disorders since it enables addicts to get treatment. He agrees that often the plight of people with addictions is very difficult, and the road to recovery is a real struggle. He provides strong arguments for his claims that the behavior of addicts is voluntary, using it to explain the way that addicts are able to control their actions when their circumstances change. It is possible that the behavior changes are involuntary responses to changes in circumstances, but it is notable that the behavior of addicts changes far more than that of other people with mental disorders when there are reasons for motivations to change, and so there's strong reason to think that addiction is fundamentally different from disorders such as schizophrenia or Alzheimer's in the person's control over his or her actions.
Those who are fervent defenders of the disease model are unlikely to change their views in the face of Heyman's arguments, but it will be interesting to see how they respond to his arguments. So far their main line of attack has been in their insistence on the neuroscientific evidence. It is true that Heyman does not spend much time addressing the neuroscience, and a full defense of his view needs to address that literature in relentless detail. However, the place for such work is not in a book, but rather in scholarly journal articles, since the task will be technical. Furthermore, in order to accomplish it, it will require careful debate over what counts as voluntary action, and this will require both philosophical and neuroscientific expertise. One of the potential problems of Heyman's book as it stands is that it gives a minimal discussion of the nature of voluntary action. But this may be wise, since the philosophical debate on what counts as voluntary action has reached no consensus and it is itself highly technical (see for example George Wilson's discussion of the philosophy of action in the Stanford Encyclopedia of Philosophy). If Heyman had included it in his book, he would have lost many readers. Instead, he sticks to an intuitively appealing notion of voluntary action and makes his argument using empirical evidence concerning voluntary action rather than doing tricky conceptual investigation of abstract contested concepts. While this approach may leave philosophers unsatisfied, it is likely to be more convincing to most other readers.
In addition to its helpful but brief survey of the history, experience, and science of addiction and its treatment, the main value of Heyman's book lies in its setting out of evidence for his view using relapse rates from large scientific surveys include those who are not in treatment. The book will be of interest to most researchers in addiction, those who work in mental health treatment and policy, people with addictions and their families and friends.
© 2009 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.