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Addiction: A Disorder of Choice Hardcover – 2 Jun 2009
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"This is a rich book that reverberates far beyond the field of addiction studies."
-- Financial Times, 13 June 2009
About the Author
Gene M. Heyman is a research psychologist at McLean Hospital and a Lecturer in Psychology at Harvard Medical School.
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The author is not saying that people choose to become addicts. Day by day they choose the easier route of continuing their self-destructive behavior, rather than taking a long term view. He stresses that the evidence is that, when the price of addiction becomes too high (risking the loss of family work or social position) the vast majority choose to give up their addictive behavior. This explains why the almost all of those taking heroin or cocaine in their teens and 20s give it up in their 30s. If not, the world would now be full of addicts in their 60s and 70s. He asserts that the apparent inconsistency with popular perception, given the known high failure rate of treatment for addiction, reflects that those who seek medical help are those who have already failed to beat their addiction on their own, and so are not typical drug users.
The principles of addiction he describes here also apply more widely. Anyone who has tried to get fit or to lose weight will recognize the challenge of changing the habits of a lifetime. If you only consider the short term, the easiest route is to give in to the temptation of the status quo, and it is only by taking a longer term view that we can achieve genuine change, but it is possible.
For the specialist, the complexities of drug addiction may well be familiar but, overall, this book is much more interesting to the general reader than its title and topic would suggest.
The book starts out as clear as a whistle, as if to emphasise the title with the opening statement: "This is a book about addiction. It is also a book about what we choose to do... that is, it is also a book about voluntary behaviour." That this is significant, Heyman goes on to say, is not only because addiction helps us to understand voluntary behaviour; "it shines a light on its dark sides". What Heyman proposes is a theory of choice so universal that it also, controversially, includes addictive behaviour.
The argument he wishes to settle once and for all goes against the orthodox view of addiction. Writing from an American perspective, he targets the assertion made by the National Institute on Drug Abuse (NIDA) that addiction is a "chronic, relapsing brain disease". In the UK, it is more difficult to find such a body which nails its colours to the mast so firmly. The National Treatment Agency website is mostly concerned with "problematic drug users" and what to do with them, without mentioning a theory of addiction. Nevertheless the disease model influences `rehab', `detox' and treatment centres, and Alcoholics Anonymous and Narcotics Anonymous fellowships, up and down the country.
Heyman, as one would expect from a research psychologist and a lecturer in psychology at Harvard Medical School, presents with academic rigour and clarity an analysis of research findings. Significantly, he points out, those supporting the disease model have studiously ignored "the four largest, most methodologically rigorous studies of psychiatric disorders" in analysing the nature of addiction. These, which included large samples of addicts who had never sought treatment as well as the more familiar samples taken from those engaged in drug treatment, enable a far more accurate picture of addiction to emerge. Instead of the high remission rates shown by in-treatment samples, once we take good account of the fact that most addicts do not seek treatment, we can see that tens of thousands of addicts will, without help, be ex-addicts by the time they are 30 years old.
The notion that "addiction is not a chronic disorder, but a limited and after some years, perhaps, a self-correcting disorder", as Heyman puts it, is not borne out in studies carried out on those engaged in treatment, however. Here we do find a picture which makes addiction look more like a chronic and relapsing disease. Having established that people in treatment are much more likely to suffer from additional psychiatric disorders and medical ones, Heyman suggests that such barriers "make it less likely for drug users to become involved in viable alternatives to drug use". He still recognises the importance of drug treatments to give additional support to co-morbid individuals, but wants treatments to be effective and based upon the right model.
The `solution-focused' approach, often described in biographies written by addicts about how they resolved their problems without seeking treatment, points towards the tendency for financial and family concerns to supplant drug use - and is compatible with the findings from the study that followed soldiers' attempts to recover from opium addiction (with, and largely more successfully without, seeking treatment) when returning to the US from the Vietnam War. The book cites not only this study but further work by the researcher who carried it out, along with work by others providing evidence "that social conditions play an important role in the etiology of addiction". For therapists encouraging people to get their needs met as a replacement for addiction, these studies provide ample grist to the mill.
But then Heyman shifts from his masterfully incisive analysis of highly pertinent research and we get to the part of the book that covers the `choice' element promised in the title. He bases the discussion upon "three self-evident principles that pertain to all voluntary activities and their logical implications" and painstakingly seeks to establish two concepts of choice, which may not be quite as complicated as the process he takes us through. I am attempting to distill all the graphs, examples and theories into a nutshell when I say that local choice seems to involve choices made on the basis of immediate considerations, whilst global choices are about decisions based on what is best over a series of events, or that take a strategic view. It seems that Heyman is trying to establish a `proof' for short-term and long-term decision making.
Heyman contends that over-consumption, including addiction, can be encompassed within his theory, and he tackles how behaviour can be both voluntary and self-destructive. By mapping the over-consumption of addictive drugs, he makes sense of people choosing to use drugs, rather than choosing addiction itself. He also covers some of the finer points of addiction, helping to explain the excuses that may accompany relapse, the association between addiction and spontaneous recovery, and ambivalence in choices.
For those trying to beat addiction, Heyman puts it quite aptly: "Quitting requires a steadfast commitment to the global approach to choice and a plan of action that erases reminders of the day-to-day pleasures of drug use" This seems to equate with the human givens understanding of the addiction `circuit', and the need for therapy to target the false expectations of addiction trance states. Heyman also holds that "capacity to reflect upon the options is one of the factors that distinguishes global choice from local choice" - which seems to fall within the scope of `the observing-self'. Furthermore, it seems reasonable to suggest that global choices are most likely the domain of the prefrontal cortex. Local choices are perhaps dictated by the all too frequently unhelpful pattern matches and the partial truths - for example, of "euphoric recall" - presented by the alliance between amygdala and hippocampus. Heyman adds, in an incisive and highly challenging observation for addiction treatments, that, "Intoxication and withdrawal interfere with the current value of everything but drug use". Whilst this is a major problem for resisting drug use, the tools of human givens therapy for breaking trance states and recalibrating faulty unconscious pattern-matches, along with focusing a life towards getting needs met, and away from a drug using life-style, seem to provide a fighting chance.
Alas, having shone in his ability to reach a wide audience for most of the book, Heyman runs the risk of losing all but those schooled in behavioural economics by the end. It is not clear if he even recognises addictive non-drug activities, such as eating, exercise and sex (he does mention gambling), let alone successfully incorporate them into his theory. Smoking is given special attention, as a kind of exception that proves the rule, because tobacco is not an intoxicating drug, but his argument includes a consideration that cigarettes are not really addictive (akin to a frantic goal-line scramble!) to make his theory work. Having triumphed till half time, in my football analogy, the second half is about grimly hanging on, only to succumb to a scrambled, messy, last-minute goal, but possibly an own goal at that.
As someone who works in the field of addiction, I found the first half of this book well worth reading. As for the second, perhaps Heyman has not captured a piece of truth of sufficient magnitude to simplify reality but, rather, has complexified it.
I'd call this book a must-read, not just for addiction issues but for anyone on any kind of self improvement path.
I particularly loved the parts about Global vs Local decision making - that alone has changed my life and allowed me to implement healthy habits in a number of different areas.
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