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Once an addict, always an addict?
ADDICTION:
A Disorder of Choice
By Gene Heyman
216 pp. Harvard University Press $26.95
Reviewed by Ruth Douillette
Addiction both begins and ends with a choice, Gene Heyman argues. Calling addiction “a choice” is bound to stir controversy; most people don’t want to blame a victim, even if he might be a victim of his own choices.
A research psychologist at McLean Hospital in Belmont, Massachusetts, and Lecturer in Psychology at Harvard Medical School, Heyman makes a strong, research-backed case to pull addiction out of the disease category. With compelling logic, bolstered by statistics and anecdotal evidence, he argues that the decision to stop taking drugs is made when the pain of continuing outweighs any positives the drug provides, a point at which addicts choose to get clean.
“It is not possible to understand addiction without understanding how we make choices,” Heyman says. While he focuses primarily on addiction to illicit drugs and alcohol, he makes a case that abstinence involves the same process of choice we use to avoid overeating.
Why does it matter if we call addiction a disease? “If addiction is not properly defined, then efforts [to deal with it] accomplish nothing, or not much.” If it is a disease, is it right, let alone effective, to jail addicts for crimes committed because of their illness, he asks?
It is not fair to punish some and offer cure to others who exhibit the same behaviors. ... If treating addiction is the right approach, then punishing addicts for drug use has to be at least somewhat ineffective, if not counterproductive. Conversely, if punishing drug use is right then treatment programs that do not offer or facilitate differential consequences for abstinence are likely to be less effective than they could be.
Today the majority of researchers and clinicians define addiction as a “chronic illness” or a “chronic, relapsing brain disease,” a sympathetic view that carries with it the assumption of effective treatment programs and a possible scientific discovery leading to a cure, Heyman writes. People assume that if addiction is a matter of choice, one where people harm not only themselves but also others, then the only response is punishment.
Not so, he assures. There are ways to deal effectively with addiction other than medicalizing it or punishing it. Education, for one. Providing incentives for another. One of his suggestions is to train “choice-oriented clinicians” to develop programs that teach addicts to “take advantage of nondrug alternatives.” Such programs, Heyman maintains, are very effective, similar to Alcoholics Anonymous and other twelve-step programs that operate effectively outside the medical or punitive realm.
He’s the first to admit that no one would consciously choose to become addicted; rather it happens as a result of a series of choices to take a drug. And yes, Heyman acknowledges that there are many, who because of various factors—mental health, lack of education, economics, a bad environment—are more likely to make poor choices to start with. The deck is stacked against some.
“Most people who use addictive drugs do not become addicted to them,” he writes, but once addicted, the choice to quit is one that many addicts make, both with and without support, and usually before they turn 30. In one chapter former addicts speak about the turning point that led to their choice to give up the drug.
No one, including Heyman, argues that maintaining the choice to remain drug free is easy. Drugs cause physical changes within the brain that make clear thinking and rational choice difficult. For many, it is a choice made over and over again. Lifestyle changes must be made, and—very important, according to Heyman—the gap formerly filled by drugs must be replaced with something that supersedes the pleasure of a chemical fix. Abstinence must provide greater satisfaction than the chemical high for sobriety to be maintained.
“Quitting can only occur if there is a change in conditions—reducing the value of drug to the alternatives,” Heyman writes. Abstinence will tip the scale toward continuing sobriety when it is perceived as having “more value than the worst drug day.” Making a good choice isn’t easy, but Heyman cites research that shows people can be taught how.
So is this a realistic proposal for the drug addled brain? If you’ve ever tried to make the right choice when out to dinner—no thanks, no rolls for me! Oh, what the heck, and pass the butter, too, please! And may I see a dessert menu?— you certainly understand the difficulty of making and sustaining a good choice even under more benign conditions.
Heyman’s proposal would certainly take time, money, and continuing support, but controlling addiction, or attempting to, already takes time and money—lots, he says. And we are not seeing results; statistics show addiction rates have climbed.
The book requires a careful read if one is to understand Heyman’s premise. His book is not necessarily easy to follow, simply because he weaves many threads together to make his point. But he weaves them on the loom of logic, and the end is a solidly stitched fabric that supports his premise, although not a perfect tapestry.
Those who’ve watched an addict’s “good choices” fail repeatedly have reason to be skeptical that the fix is quite as simple and logical as Heyman proposes. You can lead a horse to water, but what do we do while waiting for him to want to drink? What if he never does?
Those who want to argue the disease model would do well to read the Heyman’s counterpoint first. It may or may not persuade them, but it will make the argument more cogent. And I for one would enjoy the debate.
Ruth Douillette retired after 35 years as a middle school teacher, and now freelances as a writer and photographer.
Her essays have been published in the Christian Science Monitor, Cup of Comfort, Chicken Soup for the Soul, and
Under Our Skin, an anthology about breast cancer. Her photography has been featured in flashquake's gallery of art.
Ruth is a member of the National Book Critics Circle. For a sample of her writing
and photography, visit Upstream and Down~.
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