Addiction: A Disorder of Choice

Lots of good sense but too narrow a base leads to author's success and failure, says Bruce Alexander

November 19, 2009

Gene M. Heyman's book is interesting and controversial, but not controversial in exactly the way its title would suggest. It does not argue that people choose addiction of their own free will rather than being "hooked" against their will. Its agenda is quite different.

Heyman first attacks the myth that drug addiction is an incurable disease. Fifty years ago, proponents of this myth said "once an addict, always an addict"; today they say that "addiction is a chronic, relapsing disease". A sidebar to this myth is that only medical treatment can help addicted people.

Heyman shows that even for heroin - surely the gold standard of addictiveness - most addicted people grow out of their addiction by age 30, quite often without treatment.

The most important evidence comes from clinical interviews and large-scale epidemiological studies. Heyman also points out that countless Alcoholics Anonymous and Narcotics Anonymous members have successfully helped each other give up their alcohol or drug use, which is the symptom of their supposed disease.

The symptoms of real chronic diseases, such as diabetes, asthma or Alzheimer's, cannot be eliminated by group meetings.

Heyman's arguments on this topic are masterful and conclusive. He may have finally driven a wooden stake through the heart of a myth that many researchers have striven to slay for decades. Is drug addiction a "chronic disorder"? No, Heyman shows, it is a "limited, and after some years, perhaps, a self-correcting disorder".

Having dispatched a major myth, Heyman turns to explaining the real mysteries of addiction, including why most addicts are able to quit before too much harm is done. Heyman's theoretical explanations are all ultimately based on Skinnerian behaviourism.

Drug addiction, within this theoretical framework, is controlled by the same principles as any other behaviour. Addiction occurs partly for genetic reasons, but primarily because of antecedent events, ie, "reinforcements" of drug-using behaviours and strategies in the past, according to the laws of a hedonic calculus, which derives primarily from Richard Herrnstein's "matching law" and from behavioural economics. The arguments at this stage of the book become complex, especially for readers who are not schooled in behaviourism.

Apparently disregarding his book's title, Heyman asserts that addiction cannot be explained by free will. He argues throughout the book that addiction is a voluntary behaviour, but maintains that "voluntary behaviour is not the same as free will". "Choice" in his language is no more than a situation in which more than one voluntary behaviour may occur. Choices are embedded within strategies, which he calls the "local view" and the "global view", but these strategies are not a matter of free will; they have antecedents too. Ultimately, addiction or abstinence is determined by environmental contingencies and heredity.

The book's title seems problematic, because readers unfamiliar with the specialised language of behaviourism can reasonably assume that it attributes addiction to free will.

There is lots of good sense about drug addiction in Heyman's book, and it can be read with profit by general readers and specialists.

In my view, however, his behavioural analysis of addiction is too narrow to provide a full understanding. Why does he work within the narrow confines of Skinnerian behavioural theory, the key elements of which are based on the responses of isolated pigeons and rats? How could such a theory possibly be encompassing enough to explain the social and soulful complexities of human addiction? And why create a theory of addiction based on the properties of "addictive" drugs, when most addictions today do not involve drugs, but a far broader range of habits including gambling, love, internet games, shopping, eating/dieting, and on and on? (Heyman does mention gambling addiction, in passing.)

I believe that Heyman sets an impossible goal by trying, at great length, to explain why people only get addicted to drugs. He explains this untrue "fact" by positing four properties of drugs that make them uniquely addicting.

But tobacco does not have two of the four properties, so he has to find a special explanation for tobacco addiction. At this point, the argument becomes overstretched - tobacco is addicting, he says, because you can smoke along with virtually any other activity. Since tobacco is the only universally compatible behaviour, it is uniquely addicting, since no other behaviour can take its place. However, there are many other behaviours that can be performed with virtually any other activity, such as chewing gum, talking and whistling a happy tune. Why aren't they as addictive as smoking?

Heyman takes on two major tasks in his book: first, negating the myth of addiction as a "chronic, relapsing disease", and, second, showing that behaviourism can provide a fruitful explanation of the mysteries of addiction.

I believe that he succeeds brilliantly at the first but fails - perhaps also brilliantly - at the second.

Addiction: A Disorder of Choice

By Gene M. Heyman

Harvard University Press

216pp, £19.95

ISBN 9780674032989

Published 25 June 2009

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