All About Addiction aims to be a place where an open conversation about issues relevant to addiction can be discussed. To that end, the following is a piece from Christopher Russell that challenges the notion that people in some way lose control over their behavior suggesting instead that their seemingly compulsive behavior is actually volitional. Look for an upcoming post featuring Dr. Jaffe’s views on some of the points made by Christopher.
The Myth of “Loss of Control” – By Christopher Russell
Popular wisdom among addiction neuroscientists states that while initial drug use is voluntary, with repeated drug consumption the consumer moves closer to a critical, tipping point separating non-addicted from addicted drug use (e.g. Leshner, 1997). At the passing of this critical point, believed to reside in drug-induced changes to one or more brain sites and gene expression, the individual is argued to lose his ability to control (experience loss of control) is use of drugs thereafter. Beyond this point, drug use is now something which happens to the individual, compelled by pharmacological causes, not something the individual does for phenomenological reasons.
This notion of a physical “loss of control” as an explanation for why some people continue to use drugs has prevailed as the core hypothesis of the view of addiction as a progressive disease for the past 200 years (Levine, 1978) and today remains largely accepted by the general public as a taken-for-granted, scientifically-proven truth of addiction. Furthermore, the primary use of the word addiction has come to describe a particular set of behaviours which have a causal basis operating irrespective of the will of the individual (Davies, 1996), with “addicts” used as the term to distinguish those who are no longer able to control their drug use from those who are still able to control their drug use.
But why has this belief become so ubiquitous among the general public when the neuroscience community has produced no evidence which is sufficient to warrant the conclusion that certain individuals are physically unable to stop using their drug? Additionally, no evidence has been provided which warrants the conclusion that a critical, tipping point exists in the brain at which a person shifts from non-addicted to addicted drug use, the point at which the “loss of control” is assumed to occur. Both beliefs remain hypotheses for which there is as yet no evidence, however, the public understanding tends to be that these arguments have been long since proven as basic truths of addiction. What we do know and can show today is that some people find quitting a drug to be easy, a bit hard, quite hard, or extremely difficult. But evidence of the difficulty to exercise control should not be confused with an inability to exercise control, no matter how much the evaluation “I can’t stop” feels like a literal truth about our capabilities. This 3-part blog describes what we can and cannot show about the nature of drug use today and why the “loss of control” myth has prevailed as a “fact” of addiction for many people.
What we can and cannot show about addiction today
What we can and cannot show about the nature of addiction today is summed up by Akers (1991), a sociologist:
“The problem is that there is no independent way to confirm that the “addict” cannot help himself and therefore the label is often used as a tautological explanation of the addiction. The habit is called an addiction because it is not under control but there is no way to distinguish a habit that is uncontrollable from one which is simply not controlled”.
In other words, we have only shown that some people do not stop using drugs, not that they cannot stop using drugs (which would show true loss of control). The belief that some people cannot control their drug use will soon be shown to be a scientific fact, which comes from the moral judgment that people who do not stop when they say they really want to stop and who continue to use even to the detriment of other important things in life like work and relationships must be doing so not of their own will, but rather, their behaviour must be being compelled by a force outside of their will. In other words, the value-laden judgment is that no person in their right mind would voluntarily pursue this life; therefore, it fits with our view of a moral society to think that a drug “addict” is not a morally reprehensible person, but rather, must be using drugs against his will. But we must remember that to say “for why else would this poor person continue to use drugs?” is a value-laden statement about how we believe morally decent humans should behave. We should not infer that people cannot stop using drugs simply because we observe them not stopping. This may be useful information in itself, but is not evidence of a loss of control.
What medications do and do not do
Of course I do not deny that the use of medications like naltrexone, acamprosate and buprenorphine make it easier to forego certain drug use by blocking parts of the brain which motivate drug use. I would encourage people to use these medications if they find it helps them to not use other drugs. However, reducing the difficulty of quitting should not be confused with restoring the individual’s ability to quit as if this ability was at any point lost. Medications can help people quit using drugs and great strides are being made to manufacture medications which make the process of quitting easier to do and tolerate. However, these medications are not necessary for controlling drug use in the way heart medicines, radiation therapy, and insulin is necessary to stave off the mortal threats of heart conditions, cancers, and diabetes respectively. These groups of people do not have agency over their conditions in the way drug users have over their behaviour.
No medication has yet been shown to restore a drug user’s free will to reject drugs. Additionally, manufacturing medications has long been considered by addiction researchers such as Bruce Alexander, Stanton Peele, and John Davies to be focusing on the thin edge of the wedge; too much focus on the uses of medication, they would argue, restricts the need for drug users and treatment providers to consider a broad social analysis of why drug use is so prevalent in our societies.
The paradox of “behaving responsibly” after loss of control
The paradox inherent to the belief that some drugs erode free will and others can restore free will is that a drug user is expected to exercise his control and his will to sign up for and attend treatment and take medication like a “responsible” person should do precisely when we believe he has been robbed of his control and will to make choices about drugs. This paradox is also seen in the myth that an “addict can only quit after he hits rock bottom” which is promulgated by the 12-step movement; we expect people to show free will to quit precisely when they are thought to be least free to make choices about drugs. In other words, we expect so much self-control from those we believe are no longer capable of self-control!
The defence of this paradox has tended to be along the line of “he has not lost his free will to control all parts of his life, only the parts which involve drugs”. In one of his early speeches in San Diego, June 6th, 1989, William Bennett, former National Drug Policy Director and drugs czar appointed by President George H. W. Bush, defined an “addict as a man or a woman whose power to exercise rational volition has been seriously eroded by drugs, and whose life is organised largely – even exclusively – around the pursuit and satisfaction of his addiction”. Bennett’s statement reflects a common logical contradiction. Organisation of one’s life around anything is a rational skill, a wilful act, often requiring complex cognitive operations to be performed such as planning for an event which is two and three moves ahead. As Schaler (1991: 237) notes, “If an addict’s power to exercise rational volition is seriously eroded, on what basis does the addict organise life?” Interestingly another curious medical-moral contradiction by Bennett was noted by Massing in his book The Fix. Massing said “Addicts were in his (Bennett’s) view irresponsible individuals lacking basic levels of self-control” (p195). If these people do lack the capacity for self-control, how can they be responsible for not showing self-control? If they were irresponsible, it is their irresponsibility which causes drug taking; self-control is irrelevant. Bennett appears to be of the view that addiction is a moral failing which the addict is helpless to prevent, which is logically impossible.
Instead, what we do observe is that drug users are actually very good at putting in place the conditions by which drugs can be obtained, and that many people who are diagnosed as drug addicts do show a great capacity for self-control of behaviours except for those involving drugs. So addiction neuroscience is not pursuing a neurobiological basis of free will, per se, just the basis of our free will to control drug use, which is an even harder premise to swallow.
Stay tuned for Dr Jaffe’s reponse and part 2 coming soon.
References:
Akers, R. L. (1991). Addiction; the troublesome concept. The Journal of Drug Issues, 21(4). 777-793. (only available in print form at present).
Davies, J. B. (1996). Reasons and causes: Understanding substance users’ explanations for their behaviour. Human Psychopharmacology, 11, 39-48.
Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278,45−47.
Levine, H. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 39, 143−174.
Massing, M. (1998). The Fix. University of California Press Ltd; London England.
Schaler, J. A. (1991). Drugs and free will. Society, 28(6), 235-248.
12 responses to “The Myth Of “Loss of Control” As A Scientific Truth Of Addiction”
The idea of claiming something doesn’t exist – simply because it isn’t (currently) measurable smacks of a philosophy of science called reductionism – or nothing-but-ism.
Also, just because other aspects of an addict’s (or alcoholic’s) life is apparently under rational control doesn’t logically force the conclusion that continued use is really volitional.
Before A.A. and in its early years that was one of the big stumbling blocks to finding recovery. The moralistic approach of those who could “drink like gentlemen” yielded no approaches that produced recovery.
Thanks is due to Dr. William Silkworth who realized that the drinking stories of problem drinkers, especially the inability to stop after the first drink, were not mere excuses, but were actual phenomena, i.e., real events/processes.
A pertinent change of subject: The claim that unmeasurable means non-existant makes me wonder if love, or other positive human sentiments, are unmeasurable – and therefore non-existant….
If I have missed something important – which is a possibility – do please let me know! I am studying in the AODA counseling field and seek better understanding all the time!
All the best,
Larry
Thanks for commenting Larry and I agree with nearly everything you say, which is why I plan on writing a response to Christopher’s piece. However, surely you agree that this view is not new and I believe that while its supporters believe they are less stigmatizing than those who believe in addiction having a neurological aspect, I think quite the opposite is true and that their view supports the notion that if addicts just wanted to stop badly enough, it would be no problem.
This is a very thorny, tricky subject… I think many ppl who have not experienced what it’s like to be addicted to drugs, or a substance try to inject their personal moral feelings about it.. and try to make it the truth. The fact is we don’t know what it’s like to be addicted until we experience it.
Thanks for commenting Larry. My point is not that “loss of control” doesnt exist because we havent found it. My point is the opposite; people are saying “loss of control” does exist when they cant show scientifically that it does exist. “Loss of control” may exist – but as yet no one has provided sufficient evidence that it does exist. And as I said in my piece, the feeling of loss of control is not evidence of an actual loss of control, but this seems to be the evidence we all fall back on. If someone can procide evidence that free will does reside in a brain site(s)and that drugs act to erode this site I will be happy to consider it.
Regarding Dr Silkworth finding that an “inability” to stop was a real phenomenon, I will be happy to consider this evidence if you can provide me with more information om what he found and how this shows that the drinker’s ability to control had been lost.
Thanks also to Henway for your comment.
Actually Henway, you raise an interesting paradox. You seem to be saying we cant know what addiction is like till we’re in it, but people in addiction tend to inject their moral feelings about it and so are hindered in assessing their situation scientifically (i.e. free of moral feelings). Interesting.
Why haven’t you cited any references that aren’t 15-20+ years old? Especially in a field that has changed so much in the last two decades?
Brian
This certainly wasnt intentional, I could just as well cite more recent work which make the same points. You’ll notice that most of my points are about our (lack of) philosophy of science rather than our practice of science. My argument essentially mirrors Descartes’ dualist philosophy; the idea that the mind transcends the brain and so regardless of the extent to which drugs cause damage to the physical, drugs cannot compel further drug-taking because drugs, a physical property, cannot erode the will, a non-physical property. The mind thinks and is non-physical whereas the brain is physical but does not think.
To modernise Descartes’ point then, people can do all the science in the world, but they will not be able to say that drug-induced brain damage is the cause of future drug-taking. The cause of drug-taking (the mind) and the effects of drug-taking (the brain and body) are two completely different sets of phenomena which require different levels of explanation. Minds do not exist in the observable universe, and scanning all the ‘addicted’ brains in the world wont change that.
I realise that citing Descartes takes me further from the current science of addiction; but part of the reason why I think the ‘loss of control’ notion has become popular is because people are happy to charge ahead with science without a grounding in a philosophy of science.
The only problem with rooting an argument in such a philosophy is that, as you pointed out, no argument will persuade you that another viewpoint is wrong since “people can do all the science in the world, but they will not be able to say that drug-induced brain damage is the cause of future drug-taking.”
I personally believe that holding such a viewpoint is counterproductive for any purpose other than philosophical musing. If we are to learn, we have to be open to the fact that our viewpoint is wrong and starting out believing that no evidence can alter our “truth” leaves us dogmatic at best and blind at worse. As you know through numerous discussions we’ve had Chris, your arguments ignore scientific findings and when those are presented you simply claim that they don’t show something that can not be shown (your good old “show me a study where brain changes cause a man to leave his house, get his car keys, drive his car, buy a six pack, and drink it” argument). To that I say this: Show me direct evidence that the mind transcends the brain. Unless you can, I think this argument is at a standstill.
Please read carefully Dr Jaffe, Ive seen you get angry when people misquote your work. I am only responding because you have mischaracterised my position to your readers here and do not appreciate it. First, the “people can do…” quote is a quote which describes Descartes’ dualist philosophy and how it applies to drug-taking” – it is not my philosophy, it is a description of A philosophy, one which you do not seem to believe, which is fine, or respect, which is not fine. I am of course open to evidence that my beliefs about the volitional nature of drug use are misguided, unlike you are in this instance by attacking a longstanding, historically debated philosophical tradition as “counterproductive for any other purpose than a philosophical musing”. You say that “no argument will persuade you that another viewpoint is wrong” – this is untrue. If I am shown evidence that which proves ‘loss of control’, evidence which cannot be refuted by me or others no matter how hard we try, then I will acknowledge it as the best available ‘truth’. I have yet to read such evidence, though you will surely tell me that I need to read more widely!
“We have to be open to the fact that our viewpoint is wrong” – yes we do Dr Jaffe.
Are you suggesting there is no need for philosophy now that we have science? I was under the impression that we do science because of philosophy, not in place of philosophy. And just as I cannot show you evidence that the mind transcends the brain (as I clearly stated in the previous post, “does not exist in the observable universe”) no more than you can show me that the will is a material phenomenon locatable in the brain. Neither of us can prove our points in a scientific way (which is precisely my point), yet Im sure you will claim that science will some day locate the will and show how drugs destory this. I also cannot show you that love transcends the brain, or that the soul transcends the brain. Again, Descartes’ point is that the mind is nonphysical and the brain is physical and thus, never the twain shall meet. Can you show me that the will is a physical mechanism? No, no more that I can prove that the will transcends the brain. It is better to be accurate than pragmatic with false sense of reality (which Im not suggesting you have, this is just a general point).
My mind is entirely open; yours I suggest, has been closed for some time to a conception of addiction which is neither neuroscientific nor pragmatic. If this debate is to be continued, perhaps it could be continued in a more respectful manner when discussing two sides to a question which is far from answered. Nothing I have written is original thought; my writing mirrors the reasoning argued by others, including Descartes. At the end of the day, we see addiction differently, as Im sure many of your readers do. My views about drug use as volitional may not be pragmatic for investigators who seek definitive knowledge about reliably identified causes and effects, but I would rather solve a problem with due diligence rather than running with a theory because it is the most likely to be proven one day.
Chris,
I was quoting your comment and saying that starting at that point leaves us unable to reach any alternate conclusion. The assertion that you, rather than Descarte, hold that view is your conclusion from my comment (and you did also say”My argument essentially mirrors Descartes’ dualist philosophy”). I was merely suggesting that doing so is counterproductive. If the recognition that neither points can be proven is indeed there, why don’t you place it in a more prominent place in your argument? Why don’t you say “addiction might be a biological issue or it might be one of choice?” The argument I keep hearing, and please correct me if I’m wrong is that “Addiction is not biological in its nature but rather a matter of choice.” That does not sound like an open minded viewpoint to me, but rather one that is rooted in one side of the argument.
Regarding my own viewpoint, yes I have a biological bias, although if you read my response to your post, my argument centers around that fact that while you’re trying to place “will” in the brain, I am talking about “capacity,” which is an altogether different concept. If you can agree that regardless of where “will” resides it is dependent on the body and the physical to carry out its purpose and intention, then “capacity” is where the will meets the physical. Just like the HD, or Parkinson’s patients, who can will to move all they want but are unable to because of brain abnormalities that reduce their capacity to do so, so the addict’s will is only a part of the relevant equation.
Put all of this within the context of environmental influences, learning, and motivation (or what you call “will”) and we have something close to a complete argument. I fully accept that “will” plays a part, but I’m far from agreeing that biology doesn’t.
Dr Jaffe
I have said so many times to you now in personal correspondence that if I were to sum up my position in a sentence (which I dont like to do because the arguments are far more nuanced) then that sentence would be “drug use is primarily a matter of choice influenced peripherally by drug-related pharmacology”. Here I am clearly acknowledging the role of both choice and biology, and I appreciate that you would probably swap the words ‘primarily’ and ‘peripherally’ in my sentence. Ive never said addiction is 100% one thing, 0% another thing. And as to the recognition that neither point can/has been proven, the title of the original piece was “the myth of ‘loss of control’”, not “the evidence that addiction is a choice”. I have argued only that one point (loss of control) hasnt been proven, not that the counter-point has.
Your research on ‘capacity’ is much more along the lines of what is needed to prove ‘loss of control’ is indeed a fact of addiction. However, you are equating flailing limbs with very controlled, deliberate strings of drug-seeking behaviour. These are two very different actions; one is reflexive, the other is reasoned, mediated for whatever the reason may be. I have said many times that drug-induced brain changes can make it extremely difficult to forego drugs and very appealling to continue using drugs, but these changes in themselves have not been proven to cause drug use irrespective of the individual’s will. So I would ask, being the less educated of the two of us on this matter: do some people buy liquor, open the bottle, and drink it down because they are physically incapable of not doing these things? Or, at the point of putting the bottle to mouth to drink, is the person doing this of his own will or is something else controlling his body at that moment?. I am genuinely interested in the answers because these answers will shape how I and others will think about whether certain behaviours originate in the mind as distinct from the brain or in the brain which houses the mind.
HD actions are by no means reflexive. Reflexes are specifically motor responses that are involuntary and in response to an outside stimulus. That is absolutely NOT the case with HD. HD movements are specifically the inability of the brain to gate, or control, its own self-generated movement sequences. No outside stimulus means no reflex. In Parkinson’s, entire movement sequences are prevented by another brain dysfunction. Between HD, Parkinson’s, and the reversal learning evidence I’d presented you have what I consider irrefutable evidence that brain function can absolutely trump motivation when it comes to producing behavior. That is unless the claim is that Parkinson’s patients just don’t “want” to move enough…
The question of whether biology is primary or peripheral in this equation is moot to me – It is significantly involved in every aspect of perception (which also affect will by the way) and action, as are a host of additional factors. This isn’t a “which side is bigger on the pie of behavior” argument to me. Everything is inextricably linked and impossible to disentangle. Biology, capacity, choice, will – They are all crucial parts of the overall equation of behavior. When you put them together, you get actual output, without any part, you have little more than either philosophy, or an incomprehensible mess.