Is Addiction a Choice??

I read with much interest Tom Matlack’s article ‘Addicts are Superhuman‘ and reflected on my own work with those who suffer from substance addictions.

When I tell people I work with addicts, the reactions I get are surprisingly similar. They say that it must be hard working with people so down and out, that it must be so difficult. My response is always the same — that it isn’t as hard for me as it is for them. You see, one of the big assumptions that people make is that people who are addicted to drugs or alcohol live on the street or in share houses, or have just been released from prison. These people are dirty, they drink from paper bags, they have destroyed their families and they don’t contribute to society because of a choice that they made in deciding that they would abuse drugs or alcohol. But this is not the case, not for the people that I work with.

The people I work with are parents holding down a job and caring for their children, or professionals who work at their career day in-day out and get the job done well. These people function in some aspects of their lives, but in others they struggle and they use drugs and alcohol to cope with feelings and physiological urges which can’t be quelled in any other way. They are in a constant existential struggle between their need to keep their feelings at bay and their desire to quit altogether, this time for good. I want to ensure that my clients and colleagues have an understanding of what addiction is, and what it is not. In some ways, I suppose I see myself as somewhat of an addiction treatment apologist.

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Addiction is an illness so stigmatised that opinions are hard to change even for those closest to the person suffering. Although it’s an illness, the response is often “Well, why don’t they just stop?” or “They are just doing it to themselves,” as though this is a choice that people make to destroy themselves and their bodies in order to chase a high in order to escape any psychological demons they have or to just simply ‘have fun’. The shift away from the disease model of addiction seems to focus on the idea that we want people to choose to use drugs, because this would explain their behaviour in a parsimonious manner and abrogate anyone else of responsibility or a duty of care. If someone chooses to use alcohol and drugs to deal with their demons, well then, that is their coping mechanism and we can’t take it away from them.

In the case of men, we are very good at becoming confederates in each other’s drinking behavior by creating reasons to drink with friends for sports, meetings, academic achievements or just a way to get away from daily stresses. The reality is that there are a lot of people out there who drink more than others, who must be the last person standing or the one who always initiates drinking the drinking or drugging. But how do most men approach those behaviors in other men? I have seen this approached in a few ways. First is the ‘blowing it off’ approach. This is the approach that says, “He will work through it” or “He will grow out of it soon enough.” Second is the ignorance approach —  that there isn’t a problem at all.  Third is the recognition there is a problem but that this problem can be easily explained by the fact that, “He is an adult, and has made a choice.” The fourth  and most helpful approach is the hardest approach, that of recognising that there is a problem and having the difficult conversation with our friends to tell them that maybe they are drinking or using too much. With this comes a personal responsibility though, which means that we must either disengage from our friend with an addiction, or change our drinking behavior when he is around. My feeling is that a friend who recognizes the problem in a friend but keeps partying with him is part of the way addiction is perpetuated. The individual with the problem gets some kind of passive positive feedback from being ‘allowed’ to drink around friends and as a result the perception of the problem is minimised. What occurs is a perpetual Catch-22esque loop: If friends and acquaintances think that the problem will just go away, or avoid talking about the problem, the individual with the problem will start to believe that there isn’t a problem and continue drinking.

This article is not about justifying the “I have an illness” stance (or more correctly “I have a dysfunction in my brain in the reward circuitry”) and allowing the sufferer to ‘get away’ from their responsibility of their drug use. It is also not about blaming friends and family, and telling them they need to change first. The reality is that for a person suffering from an addiction there are several issues occurring all at once on the psychological, biological and social spectrums and these act together in a manner which makes the decision to stop very unappealing. In some cases, the executive function of the brain is impaired to the extent that the concept of change doesn’t even enter the equation. As a psychologist working with these issues I have seen friends and families of addicts whose ignorance of what addiction is actually helps creates an environment where the addict uses more because they feel cut off and isolated. But the important thing to remember is that for the person who is truly addicted, the concept of choice is a distant one.

There is a strange irony in the belief that addicts have a choice and yet the option that we justify, — the option of drinking and using — is a choice which impairs the ability to rationally think about consequences and outcomes.

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