Addiction: a Disorder of Choice.
Article Type: Book review
Subject: Books (Book reviews)
Author: Westlake, Gregory M.
Pub Date: 01/01/2010
Publication: Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616
Issue: Date: Jan, 2010 Source Volume: 21 Source Issue: 1
Topic: NamedWork: Addiction: A Disorder of Choice (Nonfiction work)
Persons: Reviewee: Heyman, Gene M.
Accession Number: 288874137
Full Text: Addiction: a Disorder of Choice Gene M. Heyman. (2009) Harvard:Harvard University Press.

'Addiction: a Disorder of Choice' is a very different book, that is highly scholarly in its style, grounded in clear research and has a fascinating attention to detail. More psychological in his approach, Heyman offers us insight into the mindset of 'addiction' , and therefore some kind of strategy for a solution is possible. His scope is wide and historically fascinating. At 173 pages of text, in seven chapters, the book is succinct, but with several pages of notes, and a respectable reference list of 17 pages.

Starting with a critical view of the 1914 Harrison Narcotics Tax Act and past responses to addiction, the book traces features of illicit drug use prior to the first legal prohibitions. It is essential to do this to come to a better understanding of addiction as addictive drugs promote chaotic and unhappy social relations, and medical problems, which have led to social policies more notable for their costs rather than their effectiveness. It was over a century ago, in the 19th and early 20th centuries, that Americans tended to medicate themselves rather than seek out professional help. Such medicines included alcohol, opiates, and cocaine, all used as self treatments. Such potions were unregulated and commonly thought to be the best option. It was during this period that America was described as 'a dope fiend's paradise' , (Brecher, 1972). Interestingly, the differences in self administration techniques were accompanied by important demographic differences. For instance, the opium drinkers and eaters in the public's eye were refined, simply taking a sophisticated indulgence. Laudanum drinking was an aristocratic vice more common among the educated and wealthy. However, opium smokers were considered social outsiders, and not mainstream Americans, usually Chinese immigrants who were labourers. They came to be known as 'yellow peril' , far from being fallen aristocrats, they would have been depicted as being evil. Finally, the heroin sniffers were usually underemployed young men who would quit school early, had a history of delinquency and liked to go to vaudeville shows. So therefore, physicians attended opium eaters; law enforcement officials dealt with opium smokers and heroin sniffers. These distinctions were institutionalised in the 1914 Harrison Act. The focus then shifts to the toll on contemporary American society, with various modes of data outlining the fact that between 2001 and 2002 almost 14% of all Americans who were 18 years old and older had a history of addiction. We then learn that addiction is framed as a chronic, relapsing, brain disease that is a chronic illness that should be classified with diseases like asthma and diabetes, according to The National Institute on Drug Abuse, (N.I.D.A.). However, the fact that treatment often teaches, offers advice, arranges contingencies, and conveys techniques for improving social relations and generally taking advantage of non-drug alternatives fits neither a medical model nor a penal model of rehabilitation. Such dynamics are simply the most logical treatment approach if addiction is not a compulsive disorder but one in which voluntary behaviour is self-destructive.

Substance dependence as opposed to addiction is then explored. It is said of substance dependence that it is a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues the use of a certain substances, while encountering problems, resulting in tolerance and compulsive drug-taking behaviour. Addiction is also defined in the Oxford English Dictionary as being compulsive, so we can be sure that researchers are speaking of the same phenomenon in both instances. Having ascertained this, the author includes some very useful graphs used to illustrate various fascinating statistics. For example, to illustrate the chances of being diagnosed with a psychiatric disorder, or perhaps the influence of neighbourhood on drug use itself, and even drug use, and drug disorders as a function of income.

Moving on, we can read of the subjective experience of drug-taking, as Heyman includes several first person accounts of positive initial drug experiences,

These vignettes continue, covering negative drug experiences, reflections on addiction, withdrawal, quitting and not quitting. They convey the spectrum of drug experiences to the reader, which is useful for anchoring the text to a sense of everyday reality.

The prognosis for addicts is then questioned, although initially the picture looks bleak with addiction researchers claiming, 'that "cure" is an unrealistic hope, and that addictive treatments should be considered in the category with other disorders that require long-term or lifelong treatment', (p.65). This gloomy vision has empirical support, with, 'the claim that addiction is a chronic relapsing disorder can be backed up by more than a hundred years of research', (p.66).

However, the author then proceeds to examine the various surveys concerning psychiatric health and treatment. Firstly, there is the Epidemiologic Catchment Area study, which started in 1980 and took four years to complete, with 19,000 subjects participating. The data showed that at approximately age 24, more than half of the former 'addicts' , no longer reported one symptom. By the age of 37, 75% who were once drug dependant no longer reported one symptom.

The next surveys are 'The National Co-morbidity Survey', (N.C.S.), 1990-92 and replication 2001-02, with about 8,100 and 9,300 subjects. This study also confirmed that most lifetime addicts were in fact in remission. Although, addicts in treatment were more likely to relapse, indicating that clinic addicts could be using more addictive drugs. A more likely explanation though, is that addicts in treatment are much more likely to suffer from additional psychiatric disorders than those not in treatment. So, the author emphasises that in fact clincs can help, and that recovery, not relapse was the norm, hovering at around 80 to 90% for certain middle class professionals.

Genetics are then focused upon, with the author explaining that most of the research has focused on alcoholics, as it is easier to conduct multigenerational research on legal drugs than illegal ones. Dr. Robert Cloninger's work in Sweden is reviewed, showing that the biological father's drinking pattern was normally a good predictor of alcohol abuse in their sons, even if they were adopted. Supporting this argument, a US government public health bulletin reported in June 2008, 'Drug addiction is a brain disease because the abuse of drugs leads to changes in the structure and function of the brain' , (p.95). A historical overview of 17th-century understandings of addiction is then given, which also relates to this argument. The focus then reverts to the present day, looking out drug users who were doctors or aeroplane pilots. If they tested positive for drugs they would lose their jobs, and professional careers, so there were serious consequences. This theme of using incentives, even modest ones could persuade addicts to quit using drugs, and has been used in the form of vouchers and prosocial lifestyles. It was found that just as heavy drug use initiates a downward spiral of increasingly negative consequences and decreasing options, healthy alternative activities can set in motion an upward spiral of increasingly positive consequences and increasing options.

The psychology of 'choice' is then viewed, looking at the concept of 'local choices' and 'global choices'. Local, meaning choosing the option that has currently the higher short-term value. In global choice, however, the best choice is the total collection or sequence of items that would have the higher value. The conclusion being, that addicts normally choose local choices, and not global ones. As the author phrases it, a person who framed his or her choices globally, would never use drugs, as it would affect the quality of their overall lifestyle. A heavy drug user who would switch to a global choice perspective will stop using drugs; however, it would be difficult to maintain this new perspective, as the rewards associated with this perspective accrue rather slowly. At the beginning of abstinence the value of the non-drug day is less than the value of the most recent drug days, from a local perspective. So the value of lifestyle, and a nondrug alternative, is of key importance.

'Just say dopamine', was a title for an article in Science News during the height of the recent war on drugs. However, Heyman correctly comments though that aversive events increase dopamine levels too. He states that with rats, 'a tale pinch illicits avoidance, and the release of dopamine in the nucleus accumbens' , (p.143). Marriage is relevant though; as is the case with schizophrenia, there are relatively few current addicts who marry according to the data on marital status. Cultural traditions and social institutions offer a wealth of information and proscriptions to set limits on behaviour, through social teachings. Social roles, lifestyles, and even religious values set limits on appetites and the maintenance of prudential rules. Such prudential rules are reinforced by the benefits that come with global equilibrium, and are reinforced on a moment to moment level by their social implications. So, lost time in the late teens and early twenties due to a regular regime of intoxication, can be unrecoverable warns Heyman. Research on drug use implies that these individuals repeatedly make choices that are not in their long term interest, thus this suboptimal thinking is considered by the author to be a 'disorder of choice'.

Although not as radical as Schaler's work, this book clearly achieves its goal of delivering a psychological theory with which to combat addiction. I consider this book to be well researched, and written in a highbrow scholarly, refined, academic style. I would recommend this book to academics, as well others with an interest in psychology. For existential practitioners, despite seemingly orthodox, this book would definitely be of use, as it provides an eloquent discourse challenging the chronic, disease model of addiction, and offering a functional psychological explanation that would be applicable in certain cases, informing their practice for the better. In presenting a theory based on the concept of choice, Heyman is contributing to the existential psychotherapeutic literature on addiction, for those therapists on the quest for a solution.

References

Brecher, E.M. (1972). Licit and illicit drugs: The Consumers Union report on narcotics, stimulants, depressants, inhalants, hallucinogens, and marijuana--including caffeine, nicotine, and alcohol. (1st ed.). Boston : Little, Brown.

Walters, G.D.(1999). The Addiction Concept: Working Hypothosis or Self-Fulfilling Prophesy. Boston: Allyn & Bacon.

Warner,J. (1994). Resolv'd to Drink No More': Addiction as a Preindustrial Construct. Journal of Studies on Alcohol. Vol.55. pp.685-691.
... I found complete satisfaction.... at first I felt
   exhilarated...

   (p.46).

   '....and then came a surge of astonishing pleasure, in which I
   could think of nothing but how oddly benign the drug felt.....'

   (p.47).

   ... from the very first hit some drugs makes some people feel
   fantastic... when it happens to you, you don't forget it. And you
   want more. Once is never enough

   (p.47).
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