Tuesday, December 15, 2015

Addiction: Brain Disease or Moral Failing

In the past we had our suspicions. Now neuroscience has demonstrated that many mental illnesses, especially addictions, are brain diseases. By this theory, the human mind is powerless to change brain chemistry.

The theory appeals because it is completely non-judgmental. It provides a foolproof pseudo-scientific absolution.  It tells the patient that there is nothing he can do on his own to change his addictive behavior. What better for an alcoholic than the message that his brain chemistry is making him do it.

Such is the way people today have learned to think about addictions. Such is the way that Michael Botticelli, the Director of the Office of National Drug Control Policy explained it on 60 Minutes the other day.

In a Forbes article Dr. Sally Satel takes Botticelli to task for his conceptual errors.

She begins by summarizing his opinion:

 “We’ve learned addiction is a brain disease,” he said, echoing an increasingly prevalent view. But especially coming from such a visible spokesperson, that theory does harm to addicts, their families and policymakers. “You know the hallmark of addiction is that it changes your brain chemistry. It actually affects that part of your brain that’s responsible for judgment,” he goes on. “We don’t expect people with cancer to stop having cancer.”

True enough, Satel writes, addiction does change brain chemistry. But the analogy is simplistic and misleading:

Comparing drug addiction to cancer is misguided in profound ways. Of course drugs change the brain, but the neural changes that occur in the brains of addicts do not necessarily disable their capacity to reason and to respond to rewards. Indeed, a vast literature shows that addiction is an activity whose course can be altered by its foreseeable consequences. By contrast, no amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing a patient with breast cancer to keep her tumor from spreading, or threatening to impose a penalty on her if it did. It won’t work.

The important treatment point is that addicts respond to rewards and punishments. When the moral cost of their addiction becomes too high they can exercise judgment and stop. They also respond to moments of self-awareness. When they see the horrors they are visiting on themselves and others, they can choose, voluntarily, to change their behaviors. Brain chemistry notwithstanding, they retain free will and can use it to direct their behavior.

It isn’t always about rewards and punishments:

Many autobiographical accounts by former addicts reveal that they were startled into quitting by a spasm of self-reproach. In The Night of the Gun, the late New York Times columnist David Carr movingly recounts how he decided to kick his habit after he realized how profoundly irresponsible he’d been when he locked his twin baby girls in his car while he met with his dealer to score crack.

The same paradigm, Satel remarks tellingly, does not apply to cancer. The analogy is specious. You cannot talk a patient out of cancer. Bribes and punishments have no appreciable effect on the growth of a tumor. Self-awareness has no impact on the progress of the disease.

It is vitally important that we understand the distinction Satel is making. Mainly, because making addiction purely a brain disease deprives us of one of the most important treatment factors: the patient’s free will and his ability to choose to act differently.

Satel offers an example:

A classic example comes from heroin-soaked Southeast Asia in 1971. When President Nixon decided to drug test Vietnam veterans as a condition of returning stateside, the vast majority of those using heroin on a regular basis managed to stop (detox was offered to them as well). An important goal – coming home – was at stake, and most men controlled their behavior accordingly. Notably, within the three years after they returned, only 14 percent of men who were addicted in Vietnam resumed regular use in the U.S.

If 86% of a sampling of heroin addicts were able to overcome their addictions within three years of returning to the United States, surely that argues against the notion that they are victims of their brain chemistry and that they cannot, of their own volition, pursue effective treatment.

The moral of the story is that neuroscience has its limits, even when dealing with conditions that do have a physiological component. If we take addiction to be a brain disease we deprive the addict of moral agency and absolve him of responsibility for treating his addiction.

This ends up sounding judgmental, but we do best to respect addicts enough to have confidence that they can undertake actions that will help them to overcome addiction. By trying to pretend that they are not responsible we are counseling inaction, and even suggesting that they cannot possibly resist temptation.

And yet, each moment when addicts choose to shoot up or to take another drink they could have done otherwise. Surely we will never say the same about people who suffer from cancer.

Keep in mind that 12 Step programs only work for those who participate in them actively. The same applies to many other mental health treatments.

1 comment:

Ares Olympus said...

To be fair we can consider cancer is in part a behavior-related disease as well, and cancer treatments may include changes to improve diet or exercise or sleep or mental destressing or whatever, and a patient is resisting a lifetime of bad habits to change.

So whether you blame brain chemistry or bad habits, the problem is the same, its easier to keep doing what's worked in the past, even when you have clear evidence its going to kill you in the long run.

Stuart: The theory appeals because it is completely non-judgmental. It provides a foolproof pseudo-scientific absolution. It tells the patient that there is nothing he can do on his own to change his addictive behavior. What better for an alcoholic than the message that his brain chemistry is making him do it.

I think this is a strawman reduction. There's a difference between saying you are powerless and something is difficult. The purpose of acknowledging something is difficult is help you take it seriously, and see you may need some help to change your behavior. In contrast, it's easy to judge someone else's failure to change as being weak-willed because it's not a problem you have, and on the outside it seems obvious, you just rationally determine what's best and do it, and you can't see why there's any problem at all, looking from the outside at something obvious.

And actually 12-step programs start with the assumption of powerlessness, not neuroscience "We admitted we were powerless over our addiction - that our lives had become unmanageable."

Back to the virtue or vice of being "completely non-judgmental", I try to see both sides. The difference to me comes down to punishment vs consequences. That is, if you're being judgmental, you may decide to punish someone for giving into their addiction, and we can question whether punishing someone is going to help change their behavior, and the answer is probably largely no. But to the degree addictions make a person undependable, or threaten the safety of others (like drunk driving), then you need consequences, like getting fired from a job, or taking their driver's license, and ideally in all cases, the addiction will accept there's a problem and that the consequences were necessary, rather than punitive.

And that goes to the problem of denial and I don't have enough experience to see all the patterns of denial, but if you have someone in your life in clear denial, again you have to judge what you need to do to defend yourself from their destructiveness, and then sometimes all you can do is collective evidence of things that are not working well, and point those out, and I'd hope most addicts would SOMETIMES see past their denial and accept responsibility for negative consequences.

And does it help to label someone as having "bad character" or whatever if they just refuse to see? I don't think it'll help the addict, but it probably helps a co-dependent set boundaries and be prepared to follow through with consequences.

And it still goes back to how to best understand how hard change is. If you're challenging an addict, you need to set goals and limits that are most likely to succeed, and ones that the addict himself is willing to agree to.

The key reason I see being judgmental as counter-productive is when the addict himself seems to want to be judged, especially things like "loser" or "screw up" or whatever name-calling, is because those labels are applied to him as a person, rather than his behavior. And so that becomes his identity, and he'll gladly live down to those standards, and may even do it just to hurt you for judging him.

Once you're interacting with someone who is willing to die, its not a fair fight, and they'll take you down too if you let him. At best maybe you can remind them that what they do matters, and try to find examples. But maybe playing a Christmas Carol works too - showing him the world will go on when he leaves it.