Unwilling Addiction as Diminished Control
The modern debate between liberal views of addiction and the medical model reflects a moral debate with a long history. Are “unwilling” addicts to blame for their condition, because they just do not choose to change? Or are they victims because they are not able to give up their addiction?
If Plato’s account is accurate, the “blaming” view goes back at least as far as Socrates:
Socrates: You mean they’ll live like people who are ill, but lack the discipline to give up a way of life that is bad for them.
Adeimantus: That’s it.
Socrates: And what a nice time they have! All their treatments get them nowhere … and they’re constantly expecting every medicine they are recommended to make them better … The thing they can abide least of all is someone telling them the truth—that until they stop getting drunk, stuffing themselves, whoring, and doing no work, no medicine or cautery or surgery, and no spell or amulet or anything like that either, is going to do them the slightest good.1
The “victim” riposte to Socrates is given vividly in Coleridge’s account of his addiction to laudanum:
For my Case is a species of madness, only that it is a derangement, an utter impotence of the Volition, & not of the intellectual Faculties—You bid me rouse myself—go, bid a man paralytic in both arms rub them briskly together, & that will cure him. Alas! (he would reply) that I cannot move my arms is my Complaint & my misery.2
At the core of understanding unwilling addiction is the question of loss of control, of irresistibility. Was Socrates right in implying that of course addicts can give up drunkenness, gluttony, sex, and laziness: they just need to decide to do so? Or was Coleridge right that his addiction involved a paralysis of will, no easier to overcome than paralysis of the limbs?
An “irresistible impulse” may go against what the person strongly wants at nearly all other times—the moment of weakness after two years’ effort to give up smoking. The good question asked by Fitzjames Stephen and Barbara Wootton about how an irresistible impulse differs from one that just wasn’t resisted is hard to answer. Part of the difficulty comes from resistibility being a matter of degree.
Soldiers have been punished, even shot, for falling asleep on sentry duty. A sentry may say that he really tried but could not resist going to sleep. A common response is that he should have tried even harder. Obviously there is no sharp line such as “Everyone can keep awake for five hours but not longer.” Circumstances vary: some sentries are fresh; others have marched for hours. People’s ability varies. But even when the soldier starts fresh, and on earlier spells of duty has kept awake far longer, the boundary is still blurred. Did he fall asleep because he did not care enough or because his tiredness was too great to resist? How do we tell? The blurred boundary is real, but it does not follow that irresistible tiredness is unreal. There is no sharp boundary between sentry duty lasting five minutes and lasting five days. But it is absurd to blame someone who falls asleep after several days awake. Some things really are irresistible.
The case of the sleeping sentry shows how difficult it is to separate defects of character from limited ability. There are two extremes. One soldier has no commitment to sentry duty. As soon as he is alone he makes himself comfortable and goes to sleep. The other has real commitment and stays awake. After very many hours he feels sleepy. He conscientiously struggles against sleep but finally is overcome. If anyone deserves blame, the first sentry does. The second sentry obviously does not. The problems come from the real cases somewhere on the continuum between the two.
It is usually hard to see where on the continuum a particular case falls. Evidence can be about motivation. What did he say to his friends about sentry duty? Or it can relate to ability. How much sleep had he earlier? Had he easily managed sentry duty before? Is there medical evidence? Even detailed answers are often inconclusive. Ability is not all or none but on an ascending scale.
Sometimes unwilling addicts do respond to reasons. They may give up smoking in pregnancy, give up heroin to care better for a child, or just stop buying drugs when they get more expensive. Others do not respond to reasons but a lot of the time wish they did. On the Liberal view, this is just the weakness of will we all know so well, and not because they are powerless. The weakness-of-will model seems right. But how easy it is to overcome weakness of will varies with the strength of the desire to be resisted. Resisting the temptation to spend longer in bed is likely to be incomparably easier than resisting a deep-rooted addiction.
I was—all the empirical evidence suggested—in a pathetic losing battle with the economy of my desires run amok, sometimes fighting off overwhelming craving for my drug, other times knowing, in some sense of “know,” that my relationships with genuinely good people, my work, my life could, indeed would, be lost if I chose to use. And I’d still choose to use. Well, I’d use. That much was clear.
—Owen Flanagan, “What Is It Like to Be an Addict?”
Philosophers from Plato onward have seen in choices like these a paradox needing resolution. People know that marriage, relationships, work, and health matter much more to them than satisfying the craving. They see that they will lose them all if they give way. Socrates (on Plato’s testimony) thought it impossible to make what is seen to be the wrong choice. So he believed people act against what is best only because they do not see what the right choice is. Aristotle saw that some other account is needed, as Socrates’s view “plainly contradicts the observed facts.”3 Lack of self-control does lead people to act against what they think is best.
Denying this comes partly from a seeming paradox: How can someone opt for what is seen to be the less good choice? The paradox comes partly from blurring different things together. There is what I think will be best for me, what I think is morally right, what most of the time I most want, and what at this moment I most want. Dostoyevsky could truthfully say that a decision not to gamble the money would be in his own best interest. He could agree that the decision would be morally right and would fit what most of the time he would want to do. But it can still be true that, in that moment of frenzy, taking the gamble was what he most wanted to do. How can the relative strength at a particular moment of different desires be measured except by seeing which one wins?4
What someone chooses shows what they then most want. But this truth can suggest two pictures, each too simple. One is that, given that the addict chooses what she most wants, the choice reflects a bad desire, not lack of ability. So there is no excuse and she should be held fully responsible for taking the addictive drug. At the other extreme is the view that, because no one chooses what at that moment they do not most want, it was utterly impossible for Dostoyevsky to resist the gamble: he was fated to do what he did and so was not responsible.
These pictures simplify by treating control as being all or none when it is a matter of degree. Yes, the relapsing alcoholic chose what at that moment she most wanted. But that desire went against other things that nearly all the time she cares about much more. She struggled against the desire but was defeated. It is true that Dostoyevsky could not have gone against his strongest desire at the time of acting. But fatalism about his act does not follow. Perhaps he could have thought in advance about approaching his money problems in less risky ways and so have avoided the casino that triggered his frenzy?
In the psychological dimension that runs from being fully in control to total collapse of will, few cases are at the extremes. Most of us, most of the time, are somewhere along the continuum. The blur about drawing a line gives rise to the saying that an alcoholic is someone who drinks more than the doctor.
And abilities are patchy. Ability to resist depends on context. When someone is in the grip of gambling frenzy or of one of the clearly chemical addictions, desire may be too strong to deflect. At that moment the belief that resisting is better may be powerless. But the desire need not be utterly irresistible. Facing a gunman’s threat to shoot if he gambles, the addict may resist. At other times good reasons may still lose out to the brute strength of the desire.
In court cases involving diminished responsibility, the question is sometimes raised: “Would he have done it with a policeman at his elbow?” The answer “no” tends to undermine the defense. But this is too crude. The sentry struggles to keep awake, but after an extremely long time he falls asleep. He should not be blamed. But the answer to the question “Would he have fallen asleep if at that moment his commanding officer had arrived?” might also be no. All the same, without the stimulus or goad of this visitation, sleep may still have been irresistible. Context is crucial.
There was a lot of heroin use among American soldiers in Vietnam, partly because it was easily available. Of the army enlisted men there, 34 percent tried it and 20 percent reported having been addicted to it at some stage. Once back in the United States, 95 percent of those who had been addicted had not relapsed in their first year and 88 percent had not relapsed in their first three years.5 For this large majority, their addiction was reversible. But this does not show that under the stress of war they had the same ability to give it up. The fact that context can increase or limit ability casts doubt on the view that all addictions are either utterly voluntary or utterly inescapable.
Because abilities vary in degree and are patchy, often there is no simple yes or no answer to the question of whether someone can help their gambling or their drug taking. In court cases that hang on issues of responsibility, the law often needs a yes or no answer. Psychiatrists, aware of degrees of capability, can find this difficult. Nigel Walker once said, “The psychiatrist in the witness box is like a wrestler who is compelled to box.”6
Weakness of will is the core of unwilling addiction, but this tells us too little. How much control has an unwilling addict at the time of giving way to a desire? Here another question will be taken first. At an earlier stage, how far could the person have avoided becoming addicted?
And we punish those who are ignorant of anything in the laws that they ought to know and that is not difficult … we assume that it is in their power not to be ignorant, since they have the power of taking care. But perhaps a man is the kind of man not to take care. Still they are themselves by their slack lives responsible for becoming men of that kind, and men make themselves responsible for being unjust or self-indulgent, in the case of one by cheating and in the other by spending time in drinking-bouts and the like; for it is activities exercised on particular objects that make the corresponding character.
—Aristotle, Nichomachean Ethics
Aristotle thought becoming an addict was voluntary: We create our character by what we freely choose to do. Repeating the same actions changes them into habits, which in turn harden into our character. People are responsible for becoming addicts, by choosing lives of drinking or drug taking. What does this picture of self-creation leave out? Not all decisions leading to addiction are equally free. Degrees of constraint vary in two ways of walking into addiction: the primrose path and walking the tightrope. More important, addiction can be an attempt to escape from sometimes daunting problems.
“The typical addict goes down the primrose path believing that there is little danger of losing control.”7 This seems to make such people’s addiction voluntary. But they were mistaken about the risks. Should their ignorance excuse them from responsibility?
Ignorance excuses, unless it is culpable. Was it possible to find out the risks? Should they have taken the trouble to do so? Answers vary in different cases. Distressed parents and friends may say he always brushed aside their many warnings. At the other extreme is a child of 8, with no idea of any risk, liking the smell of glue and becoming addicted. Or someone may not know about her own rare genetic susceptibility to an addiction. Degrees of knowledge and control can vary in ways hard to trace.
The more obviously voluntary route is “walking the tightrope”—seeing the danger but not caring, or even being drawn to the risk. But even here there may be a hint of compulsion. Some people are “sensation seeking,” looking for intense experiences, often through risk in sports, driving, unsafe sex, or drugs. This is correlated with addiction to Internet dependence and with online gaming.8 Evidence suggests that genetic polymorphisms linked to the dopamine system play a role in sensation seeking.9 It is not known how difficult this makes it to resist walking the tightrope. Even this route may be less voluntary than it seems.
These different pathways into addiction are like weather. Larger social and psychiatric problems are climate. Addicts are disproportionately poor people, victims of abuse in childhood, or have other psychiatric problems. In one British study, people diagnosed with personality disorders made up 4.4 percent of the general population.10 A Dutch study found they were 78 percent of drug users and 91 percent of alcoholics.11
“Secondary” addiction comes from these problems and pressures. People choose to take an addictive substance to escape them and become trapped: “Both alcohol and benzos did produce some sort of safe feeling … It was more of an existential anxiety involving not feeling safe in my own skin … I found some substance that alleviated a certain kind of inchoate fear … I used it. Eventually it produced a much worse dreadfulness than the fear it initially provided relief from. But by then I couldn’t find my way to stop.”12
One woman describes some of what she escaped from into alcohol: “A basic fragility; a feeling of hypersensitivity to other people’s reactions, as though some piece of my soul might crumble if you looked at me the wrong way; a sense of being essentially inferior and unproductive and scared. Feelings of fraudulence are familiar to scores of people in and out of the working world—the highly effective, well-defended exterior cloaking the small, insecure person inside—but they’re epidemic among alcoholics. You hide behind the professional persona all day; then you leave the office and hide behind the drink.”13
Many addicts describe trying to escape the pressures of these feelings of fear, inadequacy, or worthlessness.14 They are like Aristotle’s sailor blown off course by a strong wind, except that here the wind is internal. This is where Aristotle’s view conflicts with modern psychiatry.
The thought that addiction is voluntary comes from the way it normally stems from choices made and then repeated. But the thought is too simple. It ignores inner pressures. People’s inner history is usually elusive when someone else wonders if they could help becoming addicts. Even where the history seems fairly clear, there is usually no single question with an all-or-none answer. There are complex questions about how far ignorance was culpable or how far a genetic predisposition could be resisted. And about how strong the pressures were on the small, insecure person inside the well-defended exterior. To most of these questions, the brisk answer is too brisk.
We are not all addicts, but we all know weakness of will. Benefits of a healthy lifestyle are long-term, but at this moment coffee and conversation easily trump a brisk walk. Reluctant addicts are extreme cases of weakness of will. There is the moment of the weak-willed decision to have another drink or to gamble one more time. And there are further motivational problems obstructing attempts to escape addiction. Chemical hijacking may often have a role, but so can other psychological vulnerabilities.
Being in control is being able to take and implement decisions. The processes underlying decision and action are complex, so in unwilling addiction, control can fail in different ways. In current psychology there is an influential two-track model of decision making. One track is planning: consciously investigating and evaluating different possibilities. Planning gives relatively reliable results because its response to new information is flexible. But it is slow. An alternative is to act intuitively. The intuitions may come from stored memory of what has worked before. Intuitive decisions are rapid but their rigidity makes them less reliable.15
This is linked to the contrast between computer and human chess. The “brute force” of computer chess-playing, scanning millions of results, is a vastly accelerated and more thorough version of planning. By contrast, the intuitive human strategies are often rooted in the “feel” memory gives for which moves have promise and which are nonstarters. Often the best strategies combine computer scans with human intuition. Something similar seems to hold for good decision making in general. It calls on both. The skill is seeing when to switch backward and forward between slow, thorough planning and rapid but less reliable intuition.
This two-track model has been used to map how patterns of addiction reflect different vulnerabilities in decision making.16 Intuitions can be fooled by the hijacking of neurotransmitter systems into overvaluing a drug not really liked. Planning is vulnerable to distortions in beliefs about the situation: in slot machine games a gambler may see patterns not really there. Planning is also liable to “judgment shift,” where the pressure of the addictive urge leads the person to downgrade the importance of the values it threatens.17 Or the switching between the two tracks can fail: chemical hijacking can make it hard for the planning system to override a misguided habit.
Efforts to escape addiction are hindered by further problems. Some of these affect willpower and stamina. Others are subtle cognitive distortions affecting the sense of agency.
According to one influential picture of free will, found in Immanuel Kant and many others, desires are the products of causes but the will somehow transcends them. The strength of different desires is caused by levels of sex hormones, or by the person’s degree of hunger, thirst, or tiredness, and so on. But this leaves the person free to choose which desires to act on and which to override. This freedom is seen in terms of the will being outside the causal realm. Philosophers going back at least to Thomas Hobbes have doubted that the will is in this way outside the world of causes. Modern psychology is starting to colonize the will on behalf of the causal realm.
Strength can be exhausted by heavy physical tasks. There is evidence that willpower too can be depleted by repeated demands on it.18 In some experiments people were asked to do stressful things. They had to control their emotions while watching a distressing clip, to list their thoughts while trying not to think of a white bear, or to eat only radishes while next to delicious-smelling freshly baked food. People need willpower for these tasks. Afterward they showed less physical or mental stamina in second tasks. In these they were asked to trace impossible geometrical figures, to solve anagrams, or to keep a painful grip on a handle. They gave up more quickly than control groups.
These unenticing second tasks may not have inspired much commitment. But even when people are committed, stamina seems to fade. In one study people already making a serious effort to diet were less able than nondieters to resist eating ice cream placed temptingly near them.19
Neil Levy has argued that this depletion of willpower helps explain why addictions can be so much easier to resist for a short time than for long periods. People oscillate in what they most want: to escape addiction or to give way to it. However, different strengths of the addictive desire may not be the whole explanation. Varying strengths of the willpower opposing the desire may also be part of the story.20
Perseverance with dreary and frustrating tasks can reduce willpower. But as Janet Treasure has pointed out, “motivational interviews” may increase it. Interviewers show people conflicts between their actions and what they care about, and help give them hope they can change. There is evidence that this procedure helps build stamina in resisting addiction.21 Other evidence suggests that willpower is less depleted when the earlier task is more autonomous. People in one study were asked not to eat something tempting. Those who refrained because they had chosen to diet showed less depletion than those who were simply obeying the instruction.22 In general, there is support for the comparison likening willpower to a muscle. In the short term either physical exercise or exercising willpower can lead to exhaustion. But the habit of such exercise develops strength.23
Fostering the sense of agency is central. As Hannah Pickard and Steve Pearce have argued, if something seems impossible, it is hard to see how a person can form the intention to do it.24 (“Just decide to sprout wings and fly away.”) This is part of something more general. The difficulty of escaping addiction is compounded by the self-fulfilling belief that it is too difficult. And this paralyzing belief is supported by a crude view of decision making, one too readily seen as obviously correct.
Part of building awareness of agency is helping addicts escape from the crude view: from what Jay Wallace has called “the hydraulic model.” This portrays desires as being just like physical forces, with the strongest simply winning.25 As Wallace has pointed out, some decisions are like this, but many others are not so simple.
Some conflicts are settled by brute strength of desire. A runner, thirsty and exhausted after a race, can either collapse into a chair or walk for five minutes to get water. His choice depends only on which he wants more. He is almost passive, letting the desires fight it out. He discovers he wants rest more than water by finding that he slumps into the chair. It wasn’t just collapse, but had an element of decision. Told he would die without water, he would have gone to drink. Such marginal cases of decision fit the hydraulic model.
When pressures are weaker, there is room for active decisions. The strongest desire at the moment of decision does win, but it is possible to influence which desire that is. At one point someone’s strongest desire may be to get rich. By the time of deciding what job to try for, that desire may have been weakened. Active questioning can contribute. Why do I want to be rich? What would I do with the money? How will getting rich change me? And so on. The more active decision goes deeper and expresses more of ourselves.
There are ways of fostering these more active decisions. Hanna Pickard and Steve Pearce, drawing on their work in the Oxford Complex Needs Service, picture a therapeutic community in which people are encouraged both to support each other and to look for deeper understanding of themselves.26 At the core of this is the hope of being able to change. For this, the person needs to see that change may be possible: “We do not help patients by thinking that, at a certain point, they are in a sense beyond help. If we do not explicitly treat them as responsible agents, capable of choosing to make changes for the better in their lives, then it is less likely that they will find a way to treat themselves as such.”27
Active decision making may include thinking about how one choice will affect other choices. This suggests that things you want, like avoiding alcoholism, are to a surprising extent at risk from a single choice.
People discount future benefits and harms compared to present ones. Given this, how do people stop addictive drinking? Liver disease may be years away. A drink now may be tempting, and just one will hardly make a noticeable difference. It can seem surprising that people ever resist.
There are strategies against the weakening effects of this discounting. George Ainslie argues that the calculations should include our own psychology.28 If this time we give in, why suppose we will act differently another time? Each defeat lowers the expectation of future success. And expecting failure makes success even harder. Knowing all this pushes us further into a downward spiral. It turns out that, when deciding about one more drink, the whole fight against ill health is at stake. So we have much more incentive to resist. Resisting this time helps us expect we can do so again and so may start an upward spiral. Because choices influence each other, they should be considered together in bundles. This helps us make and follow supportive rules.
This self-awareness opposes weakness of will. Thoughts about spirals help control the wayward desire. When someone is in the grip of addiction, winning is much harder. Reminders given early of psychological spirals may help more than those given later.
The core of unwilling addiction is weakness of will. Unwilling addicts need to develop willpower to escape. This supports the view of Socrates quoted at the start of this chapter: The thing they can abide least of all is someone telling them the truth—that until they stop getting drunk, stuffing themselves, whoring, and doing no work, no medicine or cautery or surgery, and no spell or amulet or anything like that either, is going to do them the slightest good. The view is often expressed, as in this passage, in terms heavy with blame and disapproval.
But Coleridge’s plea, also quoted above, brings out how unfair the blame may be: You bid me rouse myself—“go, bid a man paralytic in both arms rub them briskly together, & that will cure him.” It may be unfair because, as we have seen, the question of how far a person could have prevented themselves from becoming an addict is often very difficult to answer. It may be unfair because in some cases the escape from addiction can be, as Coleridge suggests, too difficult. Coleridge, like some other addicts, may have been wrong about his own case. But as with the sentry falling asleep after struggling long to keep awake, there are irresistible desires. It is extremely hard to know where the blurred boundary comes between what is resistible and what is irresistible.
It is psychologically difficult to hold simultaneously the two perspectives we need. We should be reluctant to blame, because we are unsure how much freedom of action a particular addict has. On the other hand, the key to helping addicts is fostering their sense that they may be able to resist.
Often a lot of willpower is needed to overcome the intense desires that sometimes are produced by hijacked neurotransmitter systems. Perhaps disconcertingly, willpower itself no longer seems a fully autonomous force. Its strength may vary according to different causal histories. But a causal account of the will does not destroy agency. Causal explanation does not obliterate the distinction between active decisions and those that fit the hydraulic model. Causation is not an argument for fatalism. Agency with a causal story behind it is still agency.
In supporting someone’s escape from addiction, the default assumption should be that resistance may be possible: that willpower, like a muscle, can grow with exercise. Challenging crude models of decision making can be important in fostering the hope of escape. Sometimes that hope can be self-fulfilling.