Tipping The Sacred Cows Of Addiction

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I have nothing against Alcoholic Anonymous per se. I know that it’s been helpful for thousands, perhaps millions of people since 1935. There are currently estimated to be just under 2 million members in a little more than 114,000 groups around the world, with the majority being in the U.S. and Canada.

I grew up with an alcoholic stepfather who was also psychotic and prone to violence, and many, if not most, of his circle of friends were similarly afflicted. When I was in my early 20s, I even went to a couple of meetings for “Adult Children of Alcoholics,” though I don’t recall if they were affiliated with Al-Anon or Adult Children of Alcoholics (a.k.a. Adult Children Anonymous). Not to disparage those groups, but it wasn’t for me. I was an unfocused, troubled youth, trying to find my way in the world alone. But it didn’t take me long to figure out that I wasn’t that untypical or that it had as much to do with losing my mother to breast cancer at 21 than anything else, not to mention my own personality quirks.

But I’ve never been comfortable with their tacit suggestion that it’s the only way. For A.A. to work, one has to admit being “powerless” when in fact many people are powerful enough to overcome their addiction. I remember seeing a documentary several years ago that contrasted AA with a philosophy common in Japan for working with people with addictive behaviors. To the Japanese way of thinking, a person wasn’t “cured” until they could enjoy the occasional drink without lapsing back into their over-indulging ways. That always seemed more correct to me. The AA way of simply avoiding alcohol never seemed like a cure but a way of circumventing the problem without actually addressing it or the underlying causes.

On their website, under the heading “is AA for you?,” it states. “We who are in A.A. came because we finally gave up trying to control our drinking. We still hated to admit that we could never drink safely” and the general pamphlet about A.A. goes on to say that members “cannot control alcohol. [They] have learned that [they] must live without it if [they] are to avoid disaster for [them]selves and those close to [them].” Their stated purpose “is to stay sober and help other alcoholics to achieve sobriety.” But, of course,” staying sober for many is a lifelong struggle. For many they believe it’s the only way they can function. But what if it wasn’t the only way, as so many A.A. members insist? Wouldn’t that be something they would embrace? Well, no, apparently not. It appears that the only way being powerless works is to believe it, then the rest can fall into place. So it’s my experience that challenges to the A.A. ethos are fierce and vigorous, because they believe it will undo the base upon which its foundation stands. If they’re not powerless, then it becomes a house of cards.

So with that in mind, the Toronto Star published an article last week entitled Addiction: Could It Be a Big Lie? The article is examining a new book by Harvard professor Gene M. Heyman, a psychologist. His new book carries the incendiary title Addiction: A Disorder of Choice and “argues that addiction isn’t really an illness, infuriating the medical establishment.”

According to the article, it’s not the first to do so, but is one of several published in the first decade of the 21st century to challenge the conventional wisdom, which the article calls an “overwhelming scientific consensus that addiction is an involuntary disease.” The Star goes on to give voice to people who disagree, who use the opportunity to insult both the author and Harvard itself for even allowing a dissenting opinion into the world.

Heyman’s goal is nothing short of persuading “us that we have been persistently deceived by so-called addiction experts who do not understand addiction.” The book is complex and the publisher describes it like this:

In a book sure to inspire controversy, Gene Heyman argues that conventional wisdom about addiction—that it is a disease, a compulsion beyond conscious control—is wrong.

Drawing on psychiatric epidemiology, addicts’ autobiographies, treatment studies, and advances in behavioral economics, Heyman makes a powerful case that addiction is voluntary. He shows that drug use, like all choices, is influenced by preferences and goals. But just as there are successful dieters, there are successful ex-addicts. In fact, addiction is the psychiatric disorder with the highest rate of recovery. But what ends an addiction?

At the heart of Heyman’s analysis is a startling view of choice and motivation that applies to all choices, not just the choice to use drugs. The conditions that promote quitting a drug addiction include new information, cultural values, and, of course, the costs and benefits of further drug use. Most of us avoid becoming drug dependent, not because we are especially rational, but because we loathe the idea of being an addict.

Heyman’s analysis of well-established but frequently ignored research leads to unexpected insights into how we make choices—from obesity to McMansionization—all rooted in our deep-seated tendency to consume too much of whatever we like best. As wealth increases and technology advances, the dilemma posed by addictive drugs spreads to new products. However, this remarkable and radical book points to a solution. If drug addicts typically beat addiction, then non-addicts can learn to control their natural tendency to take too much.

But as the Toronto Star points out, it’s “fundamentally based, however, on that last, simple point: Addicts quit. Clinical experts believe addiction cannot be permanently conquered, Heyman writes, because they tend to study only addicts who have entered treatment programs. People who never enter treatment – more than three-quarters of all addicts, according to most estimates – relapse far less frequently than those who do, since people in treatment more frequently have additional medical and psychiatric problems.”

Star reporter Daniel Dale continues:

People who have stronger incentives to remain clean, such as a good job, are more likely to make better lifestyle choices, Heyman writes. This is not contentious. But he also argues that the inability to resist potentially harmful situations is a product of others’ opinions, fear of punishment, and “values”; it is a product of a cost-benefit analysis.

He does not dispute that drug use alters the brain. He does not dispute that some people have genes that make them more susceptible to addiction. He disputes that the person who is predisposed to addiction and the person whose brain has been altered are not able to ponder the consequences of their actions. In other words, he disputes that biological factors make addicts’ decisions compulsive.

I find such discussions fascinating because of my own experiences along with what I’ve seen and read about addiction. In my stepfather’s case, his family enabled him by pretending his aberrant behavior didn’t exist and dismissed or excused his violence as something my mother and I either deserved or exaggerated. My mother was also a party to the dysfunction and was clearly co-dependent, but that’s a story for another day. The point is, you’d be hard-pressed to find a more dysfunctional individual who seemingly could not control himself. And yet every summer we’d take a one-week car vacation and over the course of my childhood we drove (from Pennsylvania) as far north as Canada, as far south as the Florida Keys, and as far West as Indiana. A few weeks before we’d load up the car, my stepfather would inexplicably just stop drinking and work harder than I’d ever seen him (for most of the time, he was a mechanic, and owned his own repair shop) to save up money for our vacation. There was no fanfare, no detox time, he’d simply be drunk one day and decide the next it was time to earn the vacation money. It was usually two weeks and sometimes longer if my folks had planned a more extensive trip. So every year, for between two and four weeks, my stepfather seemingly just flipped a switch inside himself and became sober. There were no side-effects I ever saw, no temptations I ever witnessed, it just seemed as natural as the sun coming up each morning. This odd, almost contradictory behavior, I realized (unfortunately, not until I was older), seemed to seriously fly in the face of what conventional wisdom had to say about alcoholism, that my stepfather had no control over himself or his actions. And his example wasn’t the only one I saw, just the one I knew best.

But when Join Together posted this story, most of the comments were predictably dismissive and downright abusive or insulting. Some took a “how dare he” position as if a contrary opinion constituted a personal attack. They seem to think his opinion was just shot from the hip or has no foundation whatsoever and therefore he had no right to state it, even when none had actually read it. I haven’t read it either, of course, but I’m willing to give it a chance whereas the addiction crowd doesn’t seem capable of that, and I suspect it’s that house of cards idea that it could all come crashing down. But that’s what happens when you build with straw or sticks, an idea comes along and huffs and puffs.

The history of science is filled with examples of individuals who theorized beyond the scope of the conventional wisdom of the day and were insulted, disgraced, ruined or worse before later being vindicated. Obviously, I can’t say with any certainty that Heyman’s ideas will stand up to further scrutiny and testing, but history suggests we should at least listen to him and explore his ideas further, and not so quickly dismiss them out of hand, as appears to be what’s happening. The only news organizations to even cover the book’s publication are from Canada. A Google News search came up with not one American article, which in and of itself I think is telling.

The other Canadian piece is an interview in Maclean’s, essentially Canada’s weekly Time magazine and Newsweek rolled into one. It’s a very interesting and enlightening read. Heyman, I’m not surprised to learn, comes across as very even-handed and practical, even saying kind things about A.A.’s effectiveness, despite the addiction crowd’s apparent attack on him.

To the question about how on earth “the idea that addiction is a disease governed by uncontrollable compulsion [took] root?” Heyman replies.

The first people to call addiction a disease were members of the 17th-century clergy. They were looking at alcoholism and they didn’t describe it as sin or as crime. I have a theory as to why they thought this—and why we think it even today. It’s this problem we have with the idea that individuals can voluntarily do themselves harm. It just doesn’t make sense to us. Why wouldn’t you stop? In the medical world, in economics, in psychology and in the clergy, they really have no category for this, no way of explaining behaviour that is self-destructive and also voluntary. The two categories available to them are “sick” or “bad.”

And that does seem to conform to how I see addiction and alcoholism portrayed, yet I have witnessed so many people who have been able to simply quit of their own volition that on reflection it seems almost obvious that it can’t be a disease. It would be like deciding to cure your cancer and then just doing so by simply making such a decision. It would be like saying “that cancer was ruining my life so I just decided to quit having it.” If one person did that, it would be a miracle. But if thousands, perhaps millions of people can effectively just quit doing something considered to be a disease, wouldn’t you have to reevaluate or reconsider that very notion?

And on the other side of the coin, I see lots of people who get drunk and use being drunk as an excuse to do things and get away with doing things that wouldn’t be tolerated from a sober person. To me, that’s the really bad side of viewing alcoholism as a disease. It allows people to not be responsible for their actions when they can persuade others that it was the alcohol that “made them act that way.” Sure it was. I’ve known — and still know — plenty of bad drunks who still play that game. Many people let them get away with it, and I contend it’s because they accept the idea that they can’t help themselves when they’re drunk, that they’re somehow not responsible for their actions. Bullshit, I say. People should be held accountable for their actions, whether sober, falling down drunk or somewhere in between. So I imagine a lot of people who’ve been getting away with acting badly and blaming alcohol will be quite unhappy with Heyman’s assertions, after all it undermines their ability to be jerks and get away with it. But I also believe such people are ruining it for the rest of us, who don’t turn into assholes when we drink too much. I get more talkative and eventually more sleepy. I get friendlier and am probably better company as I’m less reserved in person than usual. But that’s about it, I retain my ability to judge right from wrong, to know what’s acceptable behavior and what’s not. I don’t harass people or get in their face. I’m usually acutely aware of my own level of intoxication. Most importantly, I don’t think I’m unique in that. The majority of people I drink with regularly are similarly self-aware and don’t become a drunken Mr. Hyde to their sober Dr. Jekyll.

So who’s right? Obviously, it’s a complicated question and one not easily decided. But like most things, it’s worth at least discussing the possibility that alcoholism is not a disease, even if it makes some people uncomfortable and may undermine conventional wisdom. We can only evolve in our intellectual understanding of the world if we remain open to new ideas. Some of us can discuss such ideas over a beer, others not so much, at least as long as we cling to the idea they just can’t help themselves.

Comments

  1. Matt says

    As per usual, Mr. Brooks, very insightful and well-written. I’m glad to see this topic coming up for discussion, as it’s something I’ve always taken issue with. Until about a year ago, my brother-in-law (who had been and on-and-off alcoholic for a good two-thirds of his life) was living with my wife and me. I hadn’t had an experience like this before, so I was shocked when his misbehavior (like going through a good third of my beer cellar) was rationalized by his extended family as a product of his “disease.” Then my father died of heart disease. It frustrates me that people, especially the loved ones of alcoholics, will equate alcoholism and other diseases. My brother-in-law had to choose to put the bottle to his mouth; my father couldn’t choose to have his valve fail. Something is very wrong with that.

    Forgive the rant, this is just a subject that has been very prevalent in my life recently.

  2. says

    Great read. I’m generally fascinated by things pertaining to drugs, alcohol and the usage thereof. Plenty often I find myself at odds with how alcohol consumption is dealt with by the mainstream, even the so-called “experts.”

    Yours is a well-reasoned, fair introduction to what I believe could be a very valuable dialog should we ever become mature enough to have it.

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