Do addicts have self-control?

This book review about "addiction and freedom" is worth reading, and it's a good companion to the book review about medicating children that I blogged recently. The book is Addiction: A Disorder of Choice by Gene M. Heyman, a Harvard psychologist. The reviewer is a psychiatrist, Sally Satel.

Both this review and the one about children illuminate the same fallacy, which I'd paraphrase like this:

1. A certain behavioral/mental problem -- call it "X" -- is associated with brain activity in ways that can be observed and predicted.  

2. Therefore, the solution to "X" must take the form of psychiatric/medical assistance; the solution cannot be individual free choice. (Indeed, even invoking that concept may be detrimental.)

There's a lot that could be said about why this is a fallacy and why it's so common. The question of free will lurks under the surface of the discussion, though Satel understandably sticks to talking about science, policy, and history, and hardly touches the philosophical problem. Here's what she says about the fallacy:

[M]uch of the public, and a dismaying number of psychiatrists, psychologists, and neuroscientists, mistakenly believe that if a behavior is influenced by genes or mediated by the brain then the actor cannot choose his actions. While every behavior has a biological correlate (and a genetic contribution) and every experience that changes behavior does so by changing the brain, the critical question, Heyman wisely says, is not whether brain changes occur (they do) but whether these changes block the influence of the factors that support self-control. . . .

Heyman uses the phenomenon of addiction to make a profound point about neuroscientific progress in general. "The implication is that as we learn more about a disorder," he writes, "the more likely it is to be thought of as a disease" -- and, consequently, as a condition whose course cannot be modified by its foreseeable consequences. Indeed, reconciling advances in brain science with their meaning for personal, legal, and civic notions of agency and responsibility will be one of our next major cultural projects.

Progress in brain science will also force a confrontation with the fact that the common interpretation of pathological behavior is often informed by a primitive form of dualism. If biological roots can be found, then we reflexively think “disease”—as in the obliteration of choice-making ability. The mechanical “brain disease” rhetoric is a symptom of the growing tendency to privilege neuroscientific explanations as the most authentic way of understanding human behavior.

In addition to logically explaining why that's a fallacy, Satel also says that the people who came up with the idea that addiction is a disease and is incompatible with self-control were motivated by political and financial concerns (and probably emotional impulses):

In fairness, the scientists who forged the brain disease concept had good intentions. By placing addiction on equal footing with more conventional medical disorders, they sought to create an image of the addict as a hapless victim of his own wayward neurochemistry. They hoped this would inspire companies and politicians to allocate more funding for treatment. Also, by emphasizing dramatic scientific advances, such as brain imaging techniques, and applying them to addiction, they hoped researchers might reap more financial support for their work. Finally, promoting the idea of addiction as a brain disease would rehabilitate the addict’s public image from that of a criminal who deserves punishment into a sympathetic figure who deserves treatment.

Those concerns may be admirable. But having good intentions behind your account of reality hardly ensures that your account will be accurate.

Finally, I had never heard of this incident (which begins the review), and I'm surprised it isn't better-known:

In 1970, high-grade heroin and opium flooded Southeast Asia. Military physicians in Vietnam estimated that between 10 percent and 25 percent of enlisted Army men were addicted to narcotics. Deaths from overdosing soared. In May 1971, the crisis exploded on the front page of The New York Times: “G.I. Heroin Addiction Epidemic in Vietnam.” Spurred by fears that newly discharged veterans would ignite an outbreak of heroin use in American cities, President Richard Nixon commanded the military to begin drug testing. In June, the White House announced that no soldier would be allowed to board the plane home unless he passed a urine test. Those who failed could go to an Army-sponsored detoxification program before they were re-tested.

The plan worked. Most GIs stopped using narcotics as word of the new directive spread and the vast minority who were detained produced clean samples when given a second chance. More startlingly, only 12 percent of soldiers who were dependent on opiate narcotics in Vietnam became re-addicted to heroin at some point in the three years after their return to the states. “This surprising rate of recovery even when re-exposed to narcotic drugs,” said the epidemiologist who collected the data, “ran counter to the conventional wisdom that heroin is a drug which causes addicts to suffer intolerable craving that rapidly leads to re-addiction if re-exposed to the drug.”

Satel says our ignorance of this real-life experiment represents a case of "generational amnesia." It's easy to keep believing in a dogma if you don't look at any of the evidence that goes against it.

(Photo by Daniel Modell, a.k.a. dM.nyc.)