I am on a study break from exams and do not have much time but I did want to answer one part explicitly: it’s rare but one can die from opiate withdrawal (http://www.nida.nih.gov/infofacts/heroin.html).

I don’t think, however, that should take away from your main points. I too agree that there are often more moral implications to drug use than medical disease. I stiffened up when I was told in my pharm class that alcoholism is a disease and not a moral issue. It surely has effects on health but does that make it mutually exclusive from moral matters? Are STDs totally divorced from morality?

Hi HB: I’ve responded to this thoughtful post at my own blog. But since it’s not really a traffic generator, I’ll go ahead and reproduce it here.

He or she didn’t mean it that way, but it sure did make those million World of Warcraft players he described sound like complete failures in the real world and their online comforts but frail distractions from their quiet desperation.

This is pretty much what I was trying to say, with the exception of replacing the world “frail” with “powerful.”

You worry about denying these people human agency, but I don’t know how to maneuver around the fact that when two people both pursue a single unshareable thing, only one of them will walk away affirming the reality of human agency. Talent is not equally distributed, and I think ultimately there is some form of a zero-sum game going on. There are going to be winners and losers in a competitive environment. Some people will go close to undefeated, which means there are some people who will be close to perpetual failure. That means that there are going to be some people who walk around with very limited control over their lives, and so the world is a scary place. We can encourage them to try, but doing so, I think, demonstrates a lack of proper respect to their experience.

When we encourage people “to make better homes, to produce good food, to manufacture good products” - we’re assuming the problem is a person who doesn’t realize how much control over their lives they have. But most people run thousands of mini-experiments a day to test their control over their lives, and to wave our hands and say, “Try more,” fails to see that. Besides, what are “better homes,” “good food,” “good products”? “Good” is a relative word, and their homes, food, and products are only “good” if they’re better than someone else’s. Which is exactly the point! We’re talking about people who persistently lose, whose yield from effort is reliably less than other people’s.

These people are losers, regardless of whether or not we use a word to identify that phenomenon. “Winners,” “losers,” “addicts,” were around before people knew to call them winners, losers, and addicts. I think this is hard for generally capable people to understand - they are familiar with their own powers of self-determiniation and self-definition. But losers do not have the ability to define their person in defiance of the definition being constantly projected onto them - this is central to their identity as a loser.

Something I’ve come across in my studies, which your last paragraph brought to mind, bcg, is what psychologists call a “locus on control.” The basic idea is that people have a locus of control which informs them where efficacy and influence come from. Someone with an internal locus is going to believe that they is in charge of their own destiny, captains of their fates, masters of their souls. They make decisions, and those decisions have an impact on their lives. Others, with external locii, however, feel that they do not have control over their own lives. Their decisions don’t matter, outside forces make choices or act upon them, and their own wants and desires are irrelevant.

It is probably easy to slip into one frame of mind or another, but much harder to try to change that frame once you are within it. Someone who doesn’t believe they have the power to change their lives is probably going to make bad decisions and choices, because they believe that regardless of their choices, things will be bad for them.

I don’t have really anything more to add, but there it is. There might be some internal psychology which also affects “winners” and “losers” beyond mere concious self-perception.

Hi Neil - The point I’m making is that there are reasons that some people have external loci of control - because when these people were operating under the assumption of an internal locus, they were confronted with failure, invalidating the assumption.

It’s quite a pleasure to wake up to such substantial and personally interesting writing on my own blog. Thanks, HB, and thanks bcg; I’m enjoying your comments here tremendously.

One thing I should note is that HB frequently refers to views expressed in David Simon and Edward Burns’s The Corner: A Year in the Life of an Inner-City Neighborhood. (They’re the guys who brought us The Wire.) He gave me the book as a gift, and it’s become easily the most influential thing I’ve read in at least a year or two on my thoughts and understanding of the world. I highly, highly recommend it. (And it’s only $11.53!)

Comments so far have brought a number of things to mind, things I’m not sure I can string together as of yet.

In talking about why humans do the things we do, there are two things I’ve read that have struck immediately and powerfully home in describing at least my experience of decision-making.

The first is Socrates’s argument that all human beings desire the Good in the Meno (do a command/control + f for “desire the good”). It was an important revelation to eighteen-year-old me that the dichotomy of virtue vs. villainy as white-hats vs. black-hats was wrong, even as a way of understanding myself internally. (If I smoke a cigarette when I “want” to quit, it is because I have been convinced by my passions that smoking is really good, regardless of what I believed five minutes ago, not because my ‘bad impulses’ have won out against my ‘good impulses’.)

The second is the article “First Person Plural” by Paul Bloom in the most recent Atlantic. To prove its relevance to the current discussion, I’d quote this segment:

But what’s more exciting, I think, is the emergence of a different perspective on happiness itself. We used to think that the hard part of the question “How can I be happy?” had to do with nailing down the definition of happy. But it may have more to do with the definition of I. Many researchers now believe, to varying degrees, that each of us is a community of competing selves, with the happiness of one often causing the misery of another. This theory might explain certain puzzles of everyday life, such as why addictions and compulsions are so hard to shake off, and why we insist on spending so much of our lives in worlds­—like TV shows and novels and virtual-reality experiences—that don’t actually exist. And it provides a useful framework for thinking about the increasingly popular position that people would be better off if governments and businesses helped them inhibit certain gut feelings and emotional reactions.

And, later on in the article:

The population of a single head is not fixed; we can add more selves. In fact, the capacity to spawn multiple selves is central to pleasure. After all, the most common leisure activity is not sex, eating, drinking, drug use, socializing, sports, or being with the ones we love. It is, by a long shot, participating in experiences we know are not real—reading novels, watching movies and TV, daydreaming, and so forth.

I spent several years in high school playing an online game called Pern MUSH. It was a text-based game (MUSH stands for Multi-User Shared Hallucination) set in the world of the Pern novels by Anne McCaffrey (terrible novels, actually) where rooms and characters were described by paragraphs, and one wrote sentences (‘poses’) to describe what one’s own character was doing. In this game, role-playing was the goal (rather than gaming with a D&D-style system), so players would develop long, intricate character histories and spend hours sitting in common rooms, talking and describing their characters’ social interactions with those around them. All goals in the world were social: to join specific groups, participate in activities, perhaps rise in leadership, or earn privileges to play characters of greater stature.

The game allowed me, a shy teenager, to participate in a world of adults, where my ability with language allowed me to be a valued member of a number of miniature communities. I lived as a Harper, a Dragonrider, a Beastcrafter, writing songs, making friends, even having virtual romances. The multiplication of selves was the fundamental drug of the MUSH experience, and it was, honestly, fantastic. Naturally, I cared far more about the experiences there than I did about most of the rest of my days.

Bcg makes me wonder: was I constantly testing the outside world for control of my life during that time? I think I must have been, because things suddenly began happening that began to divorce me from my online lives. I got a job that made me feel confident and independent. I got involved in Drama—a place of more visceral multiplicity of self. My job started to teach me how to talk to people.

Was there any harm in spending all those hours on the computer? It was teaching me something and it certainly made me happy. Honestly, it reminds me of (and I hope you’ll pardon me for being crass) Ross Douthat’s article in another Atlantic about pornography. He notes: “Indeed, the best way to deter a rapist might be to hook him up with a high-speed Internet connection: in a 2006 study, the Clemson economist Todd Kendall found that a 10 percent increase in Internet access is associated with a 7 percent decline in reported rapes.” Surely pornography is at the very least a less noble sexual relationship than others, but it is vastly preferable to sexual aggression along the lines of rape. I’m tempted to push the analogy: perhaps online relationships via WoW or Pern MUSH are less noble existences than ones conducted in the open air, but perhaps they’re still better alternatives than loneliness, isolation, and despair.

For me, at least, it’s hard to deny that if I were not happily married, were not happily employed, and were not plugged into a rewarding community at church, the temptation to return to Pern MUSH would be considerably higher. Which leads me to be particularly sympathetic to bcg’s questions.

All that said: doesn’t it lead me to wonder whether, as HB suggests, I’ve been taught a bunch of false things about how to define success and failure? Or—since it’s me talking—that I’ve chosen the wrong things to prioritize? It strikes me whenever I list the things that make me happy how focused they all are on my individual pleasure. A wife to make ME happy by virtue of her personality and beauty, a job to make ME fulfilled and amply funded, friends to fill up MY social meter when I desire company… If I didn’t have all these things, would I be a failure? Or would I be the product of a set of priorities that are needlessly askew?

Christianity strikes me as offering a real alternative. It is not how satisfied you are, how many friends you have, how often you can “win” at anything that matters, it claims. In this world, the very people who think they’re winning are, in fact, losing. If all people would realize their dependence and look to God for fulfillment, people would realize their fundamental equality to each other and be granted a source of undiminishable happiness that, like the loaves and the fishes, only grows as more people are sustained by it.

This is a compelling post, HB, and I unfortunately don’t have much time to comment, but I do want to register some skepticism about your analysis of alcoholism. I’m not sure you’re wrong, but it’s all quite unclear to me, and I don’t particularly want to give you the benefit of the doubt on this.

I have for a long time been confused about what alcoholism is. I have surely known or known of or interacted with many people over the years who identified themselves as or were identified by others as alcoholics — some of them heavy drinkers, some “recovering” who never go near it. It has seemed to me that the word means different things to different people. Poking around wikipedia seems to confirm this, and suggests medical definitions as marginally helpful as “drinking despite adverse consequences.” (though the DSM-IV, it should be said, carefully distinguishes alcohol abuse from alcohol dependence, according to the wiki.)

Some proclaimed alcoholics, as it has seemed to me, just really like being buzzed, and try to be so as often as possible. But I certainly have also encountered alcoholics who are unquestionably diseased, who seem to exist in something almost like a psychosis. I don’t know how much this observation is of results of damage done over years of alcohol abuse, or how much it is of something that underlies the abuse, but it’s unmistakable in either case, and talking to such a person can be like talking to a sleep-walker — someone who talks to you though they are not fully conscious — not just to someone who is drunk.

And I’m not sure whether a “genuine alcoholic,” to use your terminology, is made by years of alcohol abuse (perhaps coupled with a predisposition) or is more deeply different from the start. Both cases are conceivable to me — I’m reluctant to dismiss the latter since I’ve heard so many stories of eventual-alcoholics having a first drink in their teens and immediately loving it, of drinking themselves silly and then not being deterred from doing it again right away, which strikes me as a very strange response to the physical effects.

There is, at least, something very powerful at work in the person who, though he might clean up and go years without a drink, and be happy and productive during that time, nevertheless might one day catch a strong whiff and then be unable to stop himself short of oblivion. It’s not just unrestrained appetite, I mean. It’s real madness. The effects of over-drinking are just too damned unpleasant, and immediately and obviously unpleasant. It is not a mere peripheral unpleasantness that arrives at the heels of indulgence — it is a mad dash for oblivion.

Maybe I don’t understand the extent of your body/soul distinction, or I’m just not sold on it (are all madnesses diseases of the soul?), but your second asterisked note seems suspect to me.

A conversation that I had with Rachel and Michael the other night on the nature of alcoholism make me skeptical that it is one entity or that all those who suffer from it share one specific trait. It seems more likely that when we speak of an alcoholic person we should really speak of multiple different types of people who find different routes and circumstances to the same substance; for some of those people alcohol represents a seemingly unavoidable stimulus to anesthesia while for others alcohol remains by conscious choice more of a perpetual companion. I think that the original question of whether morality is involved when considering alcoholism may have different answers when thinking of these different routes and circumstances.

Great post. I’ve got too much of a headache to really contribute much at the moment, but as someone who has the unfortunate privilege of watching people “detox” from all manner of abused drugs on a weekly basis, I can say that despite the actual medical fact that only withdrawal from alcohol and barbiturates are likely to kill, patients certainly FEEL as if they are going to die when withdrawing from the others as well.

“Withdrawal from opiates isn’t that hard, and certainly isn’t life threatening, in contrast to, say, alcohol.”

This is an EXTREMELY inaccurate and uneducated statement. I personally don’t even have enough willpower to detox from caffeine, let alone something that at the very least gives me explosive diarrhea and crippling stomach cramps, incredible body aches, and a headache bad enough that it puts all migraines and flu’s to shame, as well as variable other horrible symptoms. Given that these symptoms will last a week or more before one’s body gets back to normal (and it never REALLY gets back to normal, most brains’ pleasure receptors get burned out and never again are able to feel the same levels of pleasure that they felt from the same activities pre-drug use, but that’s another story), it’s no wonder that people trying to detox on their own aren’t able to do it.

I also have to disagree with:

“They may not be able to quit anytime they like, but they’re not fish who have been hooked. And that condition may be a disorder, but it’s one of soul, with at best a slight bodily component.”

This also sounds shockingly absurd to someone who speaks with true alcoholics on a regular basis. “A fish who has been hooked” is actually an excellent way to describe an alcoholic, because even if it was moral lassitude that got them there in the first place, a true alcoholic really is incapable of “getting off the hook” on his own, and at best can hope for “hook-free” periods interrupted by horrible relapses.

I’d highly recommend all who read this attend an AA meeting to get a better understanding of what alcoholics are truly like. It’s really eye-opening.

I am no alcoholic loving softy: I respect self-discipline, thoughtful living and confronting one’s fears and troubles head-on above almost all other characteristics. However, once a “drinker” becomes a true alcoholic, there is no point in even thinking that way: you might as well say that there is some moral component to my having red hair. And being a “drinker” is a slippery slope that has many variables: genetics, social milieu, life stressors/tragedy, good or bad coping mechanisms taught during one’s childhood…it’s just not simple enough to say that even the majority of drinkers are culpable for some moral failing…who am I to judge when I can never walk a mile in their shoes?

I’ll try and come back to say more when this stupid headache goes away.

I would not disagree that the disease model of addiction/alcoholism is highly flawed & incomplete, not least because it can downplay individual responsibility, but it may go too far in the other direction to say this:

HB: “And then my own and others’ experiences with alcohol have made me believe that the genuine alcoholic—someone who physically is unable to resist the urge for alcohol—is at best a rare breed, and instead most people’s choices develop into the habit of drinking however much they drink. **They may not be able to quit anytime they like, but they’re not fish who have been hooked.** And that condition may be a disorder, but it’s one of soul, with at best a slight bodily component.”

These are very, very difficult things to speak about with anything like final clarity. But I would say that the truth may lie somewhere between the polarity you set up in the starred sentence, and that consequently your soul-not-body assertion may be too strong in turn. The ‘either-or’ kind of thinking, the setting up of such strong dichotomies, may be quite inadequate here. (The strong body-soul dualism may be highly questionable in general. But we’ll save that for another time.)

Robbie: “There is, at least, something very powerful at work in the person who, though he might clean up and go years without a drink, and be happy and productive during that time, nevertheless might one day catch a strong whiff and then be unable to stop himself short of oblivion. It’s not just unrestrained appetite, I mean. It’s real madness. The effects of over-drinking are just too damned unpleasant, and immediately and obviously unpleasant. It is not a mere peripheral unpleasantness that arrives at the heels of indulgence — it is a mad dash for oblivion.”

This is exactly right. And beyond the short-term unpleasantness, the really difficult longer-term question is why people choose to utterly destroy their own lives and those of others for a high that gets progressively *less* pleasurable (And to be clear: they ALL DO.) The frequency with which addicts destroy themselves suggests the need for an account that does not portray addiction as simply either routinized bad judgment *or* as a physical condition like heart disease. Addiction at its worst is indeed a kind of madness. This itself is obviously a metaphor, not a clinical term that can offer us full rationalistic satisfaction, but that may be precisely what one needs in order to understand the relevant phenomena. And with all due respect, HB, it can be a very difficult thing for an outsider to understand. I’m grateful for Rachel’s comments to that effect. The tough-love, “Get it together, man!” mindset just doesn’t work with hardcore drunks or junkies.

I have to give a nod to Martin G’s point as well. Generally in AA meetings you have two broad sets of people: those who think of themselves as “born” alcoholics, who never drank or used drugs with anything like success (or did so only very early in their ‘careers’); and “made” alcoholics, who drank fairly successfully for a long time until entering a major life crisis (death of father, loss of mate, etc.). This is an important and oft-noted distinction at meetings. My discussion above is obviously much more applicable to the “born” alcoholics. This is a fuzzy distinction too, but it’s a place to start. I’ve known people who shot heroin for years before they became junkies, and I’ve known people who were off to the races after their third time. The existence of such radically different responses to such an addictive drug suggests the existence of some significant underlying physiological differences to me. I don’t think acknowledging this entails abandoning all notions of personal accountability.

Clearly, I needed to do a preliminary post explaining the dialectical point at which one must utterly agree with the addict’s knowledge and must know what it means to say, “yes, I am a soldier for self-destruction, and that’s good.” It’s a rich point on its own, I feel, and would have inoculated myself against fears on several people’s parts (including Robbie, I think?) that I am at all unsympathetic with those who find themselves to be addicted to drugs or alcohol. (Video games hit a little too close to home for me to admit wholehearted sympathy quite yet.) In any case, I’m very sympathetic, probably to the point of being a drug-addict-and-alcoholic-loving softie. Also, I prefer, always, to think in terms of ethical distinctions among choices and habits that are good or bad, rather than moral distinctions among things that are right or wrong. So, while I hope that we all acknowledge that we’re using judgment here, I am not in any way being judgmental (which is shorthand for “condemning”) towards any person or group.

Then again, I didn’t do myself any favors with my lack of clarity in a few key passages of what I did write. So, let me do some preliminary mop-up work.

Rachel: I freely admit to being uneducated on this issue, at least in the respects of personal experience and medical training. However, although it wasn’t entirely clear, I was citing Dalrymple’s argument, when I said, “withdrawal from opiates isn’t that hard, and certainly isn’t life threatening, in contrast to, say, alcohol.” I was also summing up a book’s argument in two sentences, and being kind of sloppy at it. I think Dalrymple may have had a caveat or two in there about the death question (I’ve returned the book to the library), and from doing some hasty internet research it appears that those rare deaths from opiate withdrawal require complications such as other ill health or old age. And I was being too terse (and certainly misrepresenting Dalrymple’s precision on the subject) in saying that withdrawal “isn’t that hard,” without making clear that of course it takes about three days of very intense sickness. I in no way meant by this statement, “suck it up,” or any such nonsense. The experience is very painful; the thought of it is another significant deterrent to my trying opiates (irrationally, since trying them is unlikely to get me addicted); and thus I am quite sympathetic to someone not wanting to choose to undergo significant amounts of pain voluntarily. But it lasts a matter of days, has similar symptoms to many survivable diseases, and is undergone regularly (and repeatedly) in and out of jails, without treatment, almost never killing anyone. I should have said it “isn’t that bad,” because “hard” implied a choice, whereas I meant to focus on the objective symptoms, not a particular person’s ability to endure them.

It seems from your citing of willpower that we agree that the root issue is one of choice, however difficult, not disease, which was the larger point for which I was referring to Dalrymple. In the context of this argument, I’ll stand by the proposition that the symptoms of withdrawal are scary and painful, but not that bad. I’ll talk about the alcoholics question below.

Martin G: The point I particularly wanted your (and Rachel’s and any other doctor’s) opinion on, and failed to highlight, was Dalrymple’s claim that addiction to opiates is not a disease because it’s not, itself, amenable to medical treatment. I feel on uncertain ground here, doubly so because I can’t do much but point to his arguments. I hesitate to do so with this link to a brief summary because Dalrymple really is a rhetorician. Still, the distinction between calling addiction a disease or not seems important, since it provides a clear separation from the example you cited, “are STDs totally divorced from morality?” That’s easier to answer: as diseases, STDs are divorced from morality, but their transmission, being subject to human choices (either by two or one persons, usually), is not. The trouble with addiction is that it doesn’t appear to be thusly distinguishable (not transmissible, requires varying degrees of effort to get addicted, requires an outside substance to exist, allegedly not susceptible to treatment), leading me to suspect that calling addiction at root a medical problem (which is what using the word disease does) is fundamentally inaccurate. I suspect that you and Rachel agree with me on this point? But I’d like some help with the slightly technical aspect of it. I mean, is this a valid claim to make about what medicine calls a disease?

You Know Who: I’m no dualist, hence my saying that for a certain category of men the soul has a larger role than the body when it comes to dependence on alcohol. To distinguish between the body’s and soul’s respective roles in certain instances is not to embrace dualism. Also, I’d be curious as to what parts of my post evinced a “’get it together man!’ mindset.”

Robbie (et alia): The “they” in the starred sentence refers to the “most people” of the previous sentence, and “that condition” in the last sentences is the condition of most people to alcohol.

“And then my own and others’ experiences with alcohol have made me believe that the genuine alcoholic—someone who physically is unable to resist the urge for alcohol—is at best a rare breed, and instead most people’s choices develop into the habit of drinking however much they drink. **They may not be able to quit anytime they like, but they’re not fish who have been hooked.** And that condition may be a disorder, but it’s one of soul, with at best a slight bodily component.”

I meant to distinguish the “rare breed” from most people precisely because I am as chary as you all are about saying that the genuine, by which I mean physically dependent, alcoholic doesn’t exist. But for those most people on the other side of the line, including those who drink even to the point that quitting might be hard, hooked isn’t the right metaphor. To speak more directly from personal experience: I’ve gotten to the place where I wanted a drink every night; where it was hard to resist; where I felt that I needed a drink at that particular instance, even though it was unwise, such that I couldn’t say that I could quit whenever I wanted, because I didn’t. I don’t think that’s alcoholism, although I probably would have been scored close to it by some measures. I think this not only because I have found that particular attitude towards drink to have gone away, but also because I was aware of the series of choices that led me towards and away from that point. I think that it would have been possible for me to keep drinking in that same manner and it would have gotten harder and harder to change my habits the more I drank in that way. But that would, I think, have been a result of my choices, which is what I’m reserving for the soul, in contrast to my physical need. I don’t mean to be too hard or fast here (where is desire seated? seems to me like an interaction between the body and soul? and when does intense desire, an intense lacking of something, become need?), but just to point out that, for me, it would have taken a lot of choices (actions of the soul) to get to a point resembling that category you describe of someone mad for alcohol from the start (in a way that implies a non-chosen behavior, seemingly endemic before habits could be formed, and thus quite plausibly found in heredity, if not simply the body).

Likewise, I’ve observed some people I know who drink heavily and have been called alcoholics by others. Although I haven’t walked in their shoes, nor have I seen them try to detox, I have seen them steadily apply themselves to drink, as O’Brian says, and it seems pretty clear that they were choosing each time they did so. Even for these people, as there was for me, there’s the watchfulness of “is this alcoholism?” which has become a pretty successful word in its 150-year history. These people might be “drunks” but it’s not at all clear that they’re powerless, or that all drunks were thought of as powerless. Rather, these folks are using the new word for an older meaning: “I’m a person who likes to drink a lot, and that’s socially frowned upon, and I [do or do not] care.”

By contrast, I’ve known some people who were just like Robbie described; one person in particular singlehandedly keeps me from denying the category every time I think of him because he was so clearly other. I also have some familiarity with AA, and although I haven’t attended a meeting, I think their arguments are highly illustrative of the huge ethical component to alcohol abuse, even for people with some measurable physical dependencies. Which brings us back to the question: whence this self-destructive behavior? Choices or not-choices?

Rachel and YKW put the answer interestingly at ”both” when they point, alternately, to people who have gotten past the point of choice being efficacious, after long periods of substance use, and thus become like fishes, or to people who were made into alcoholics. (Incidentally, this is precisely the process by which Dalrymple describes people getting themselves addicted to heroin; it takes lots of effort, often more than a year.) That category seems pretty plausible to me, but it seems grossly inaccurate to say that these folks suffer from anything other than a self-imposed injury (stated in the most morally neutral way possible; I have no interest in blaming, just attributing causes). These folks seem like they’re people who started on the same path I’m familiar with: liking drinking, choosing to drink more, drinking lots more, then hitting a point where they suddenly lost… what? The language of AA says, “we admitted we were powerless over alcohol—that our lives had become unmanageable.” Seems pretty darn ethical to me. They lost their ability to choose moderately when it comes to alcohol. This is the language of denying their agency. And, of course, once they deny their agency with respect to alcohol, and forswear it entirely (as immoderate an act as ever there is), they begin to rebuild their lives with respect towards other things that remain within their ability to choose properly. I’m willing to admit that there are physical components to such self-professed alcoholics’ conditions (it is a poison, after all), but I find it hard to believe that this particular category’s physical condition is essentially different from someone who has sliced off a finger: it’s physical damage as a result of chosen behaviors (leaving aside the question of mistakes). I think it’s simply accurate to point to choice in such cases as Rachel and YKW describe (drinking past a point of no return) as being primary. Thus, I’d even put these people in my non-rare-bird category of people for whom their relationship towards alcohol is a result of a disorder of soul, which is amenable to education and habituation.

And that’s why I want to reserve “genuine” alcoholism for something that has a physical source: if the source of the damaged body and disordered soul is choice, then a person starts from an inherent position of agency, not powerlessness, and only loses this capacity for choice by making choices. It’s not at all clear to me that it’s useful to call a long history of bad choices a diagnosable medical condition, or even an “-ism” of any sort, both of which seem to destroy or deny that capacity for choice. If there are indeed people for whom certain physical safeguards aren’t present, or certain physical defects are, then that seems a condition where capacity to choose is indeed undermined, if not destroyed entirely, and where it would be appropriate to pinpoint a single source (an -ism, a sickness) as opposed to a series of thousands of particular choices. The person who’s drunk himself past his ability to choose moderately with respect to alcohol has a condition now, yes, and it may need to be treated medically and otherwise in its own way. But I worry about calling his overall condition, encompassing the present defect’s source and history, one unified thing.

Except poetically. The language of addicts is extremely poetic, by necessity, and I’m all for people doing what Martin describes: coming up with proper understandings of who they are and what they’re wrestling with. But why the fuck mix up quasi-medical, inaccurately connotative language with your poetry? David Simon, or one of his characters (it’s not clear) describes a need for heroin as a snake, both within and without of the addict. Robbie talks about madness. I don’t think all madness is a disease of the soul. I wouldn’t even call it a disorder, since there’s been put before me the idea of divine madness, and drunkenness itself is a kind of madness. All useful language: we do lose control of ourselves at times, addicts do feel particular fears, they do feel powerless. But saying “my disease wants me dead,” is to get closer to Nate’s multiple selves, which is, I think, ultimately poetic, not discursively accurate. It gets there with some baggage. Maybe it’s helpful baggage for that particular addict. But I think it’s rather importantly wrong about the actual sources of the disorder, and as such is kind of dangerous to be teaching on a widespread basis. We’d be better off teaching folks about their capacity for choice, I think, than that they’re prey for choice-destroying medical conditions.

Well, I’ve done some self-destructive things by writing this long, so answers to Nate and bcg and others will have to wait. Definitely chose to do this, though.

Just another clarification, towards YKW and Robbie, who both worried about my too-sharp distinctions: I’m not dissing poetry or its importance in understanding this phenomenon. “It is a mad dash for oblivion,” seems right to me, too, and an experience I’m pretty familiar with, personally, in certain things. (Yes, lots of caveats about my lack of experience with addiction; but that’s the beauty of poetry—I do know about mad dashes to oblivion.) The particular way in which madness overbears choice seems like something we can get close to discursively, perhaps if only to say, “the exercise of choice is primary, ahead of bodily compulsion, for most people.” I’m perfectly willing to say that many people choose madness, or set themselves, by means of choices, on a path towards madness, including such exalted people as the Pythia. But I’d just want to be clear that it’s choices that get such people most of the way there.

And, again, for the record, by asserting choice to be first in time and some other sense, I’m not at all trying to condemn addicts or tell them to get over it. I’m quite sympathetic to having an overborne capacity for choice; just want to know what does it.

I think you’re making a lot of sense, HB.

There are a couple empirical points that may help one to decide on the claim that addiction to opiates itself is not amenable to medical treatment. I will leave all discussions about counseling and other treatments to others more suited to it, but I can speak about the pharmacology of the matter. In fact, bless your heart because I am studying for a pharm exam which occurs on Tuesday and opiates as well as opiate addiction drugs are prominent material. Writing may be studying for once.

We have drugs that can attenuate the negative (and positive) effects of physical addiction. We have drugs that nullify the effects of the original offending substance. We also have drugs that are taken to punish the patient if he uses the substance again. We even have drugs that claim to treat the patient’s desire to use the substance at all. That last category is probably the most interesting, but this drug only applies to nicotine addiction as far as I know. For the purposes of this discussion it seems to me that we are asking whether this drug can live up to its claim to treat desire.

Some drugs treat the effects of a substance. If one is interested in weaning a patient off of heroin gradually then a drug like methadone may work. Methadone acts just like heroin, but it has an extremely long life in the body so it will take longer for the patient to need another dose. This is useful because a patient can go to a methadone clinic before work and not have to spend the rest of his day taking time out to feed the addiction to stave off withdrawal. The idea is that by getting away from a virulent substance (heroin) by switching to a more controllable and reducible substance (methadone) the patient can get away from addiction entirely while maintaining a normal life of work, family, etc.. There are other tactics along similar lines. One can prescribe a drug like pentazocine which acts similarly to heroin but has a ceiling on its euphoric effects. The aim is similar to methadone therapy in that the patient is being weaned off heroin with another less virulent drug in order to avoid the withdrawal that is so incredibly debilitating.

Another approach is to use a drug that blocks the ability of a substance to have any effect at all. Naloxone and naltrexone are two drugs that simply block the ability of opiates to work on the body. The aim here is to dissuade a patient from using heroin by removing the positive effects heroin provides.

For many years patients were prescribed drugs that punished them for using a drug. Anabuse is a drug that is prescribed to alcoholics. It mimics the bad GI effects of some antibiotics when mixed with alcohol, so that when a patient on Anabuse drinks alcohol he will have the same horrific nausea and vomiting that occurs when someone on the antibiotic Flagyl has if he drinks alcohol.

All of these drugs and tactics treat the physical symptoms of withdrawal or prevent the positive effects of use. None of them treat the desire to use the drug in the first place. Chantix, a drug that is used to treat nicotine addiction, claims to be able to do this. But does it? It acts on the brain to provide the same low level positive effect that nicotine provides while at the same time blocking the ability for nicotine to do the same. This means that if a patient has a cigarette while taking Chantix the cigarette will not be able to provide the usual pleasurable effects. To me, though, this sounds like combining the effects of pentazocine (to provide a little benefit in order to ease withdrawal) with naltrexone (to stop the benefit from the original substance) - neither of which claim to treat addiction itself. I think therefore the claim that Chantix treats addition to nicotine itself is false and misleading.

At the end of the day all the drugs do are treat the physical defects that come from using another drug.

Getting away from the factual nuts and bolts and into opinion I think that all of this goes to support the original claim that addiction is not a disease itself capable of medical intervention. Moreover, the above drugs only work if the patient has made the choice to leave the drug behind in the first place. Absent of this conscious choice methadone won’t stop him from using heroin, and if he stops taking pentazocine, naltrexone, naloxone, Anabuse, and Chantix then the original substance is as powerful and pleasurable as ever. Entering into addiction involves some level of choice, however small, and leaving addiction involves a nearly heroic level of choice. Choice and abandoning or asserting fully aware personhood seem paramount in both.

I don’t want to leave off this topic before commenting on something that is very crucial to why I think drugs are used in the first place. Drugs are typically substances in nature that are physically shaped (literally) in such a way that when introduced into the body can mimic or replace the body’s native substances which control how we feel about the world. Opiates like heroin work at the same sites in the brain as our own natural chemicals that are present during all sorts of pleasure. When one goes running, or makes a friend, or actualizes a long sought achievement and is happy the native opiates are active and are serving as the indicators to the happiness. In a manner of speaking then, by injecting heroin one is injecting what it feels to be happy. Also, happiness is not a static state of being but is more aptly described as an activity. A substance introduced intravenously is being mistaken for an activity by the body (and therefore by the person). I want to pause on how confounding an idea this is: a substance can serve as a phenomenological analogue to actual activity. It is no surprise then that many people whose lives are lacking those things which make the soul sing turn to drugs. This is not a categorical reason for who turns to drugs and why, and I am not a reductionist who wants to conflate pleasure with happiness, but I think it is consonant with the situation which spurred HB to post in the first place and why drugs hold the powerful place in so many lives.

What is “medical intervention”? Is administering powerful hallucinogens and talk therapy medical intervention?

I think what Martin G says is true, that “a substance can serve as a phenomenological analogue to actual activity”; and I also think “confounding” is exactly the right word for that.

How do powerfully psychoactive drugs affect our understanding of the disease-of-the-body/disease-of-the-soul distinction?

It would take someone far better acquainted with the interstices we’re bridging here to state something definitively, but my sense is that the chemicals confounding our senses are still on the bodily side. Much as our stomachs and blood sugar can affect our souls—making us irritable or complacent or stealing our consciousness—so do such chemicals and their imbalances alter our perceptions and habits. The movement of a chemical into our receptors for it may cause a perception of happiness, but it is not itself that perception. Moreover, the fact that some sort of balance reasserts itself after such physical overwhelming—as has been pointed out, such pleasures diminish rather quickly—points, I suspect, to a higher ordering that certainly looks like it’s seated in the soul to me. Of course, I am aware that the receptors are said to “tire out” as they are repeatedly and injudiciously flooded with chemicals, and I’m sure they do, but that very ability to grow used to such stimuli seems to me, if not a proof of the soul, then at least a mark of it.

So, I’d just want to be careful about using the word phenomenological quite as Martin did, although his description is indeed very helpful. Phenomena seem to me, by definition, to be seated in the soul: the appearance of a thing has to be observed by something in order for it to be an appearance at all. So, while it seems right that these substances are analogues for true activity, I’m not sure they are so phenomenologically. I’m not sure, I say, because this problem seems hard. Martin calls these substances indicators of happiness in a non-opiate-affected brain, and that careful language seems in line with his distinction between pleasure and happiness. The substances can point to a phenomenon’s or activity’s likely presence, but they can’t tell us what such experiences or activities are. We have to inquire of the soul for such words to even make sense.

Also, I think talk therapy is not medical, but of course Rachel is the expert on this very subject. Medicine seems to require a substance, be it a drug or a scalpel (setting aside the medicine/surgery distinction). Talk therapy is the psychologist’s side of things, usually, and while psychiatry can use it quite a bit, I understand that it remains rather controversial. I submit that this controversy has to do with the difficult lines we’re trying to draw here—that some doctors don’t think having conversations with what we’re calling the soul can treat what is fundamentally a chemical or bodily malfunction.

[for the record, I know that I am addressing for the most part what HB has read, not what he is necessarily asserting. No worries!]

Is addiction at its root a disease? Even if it involved (perhaps a long period of) very bad and probably immoral choices? Even though it can’t really be medically or surgically managed? Even though it involves willpower?

Absolutely. Just because it is not amenable to treatment does not mean it is not medical: Mad Cow Disease or Kuru, Huntington’s, ALS, aggressive cancers, traumatic amputations, and traumatic brain injury (“concussions”) are all examples of very real medical diseases without effective medical treatments. They are not all infectious in etiology, nor must they be genetically linked. But at some point something goes wrong to make the body disordered in some way. THAT is what makes something medical.

Even if someone’s repeated, poorly judged behavior led to ultimately developing the full-blown disease, there is something in the brain’s chemistry (as Martin described nicely as he studied for his pharm lecture via a post here) that changes after repeated use that makes the addiction become a true, irreversible physical ailment that will forever change that individual’s body for the worse, thus guiding their behavior accordingly.

HOWEVER, WE KNOW THAT MANY OTHER THINGS ALSO CHANGE THIS EXACT SAME CHEMISTRY (I’m particularly talking about the limbic system), MEANING THAT (for example) GOING TO WAR, SEEING/DOING HORRIBLE THINGS AND THEN RETURNING TO THE U.S. WITH PTSD CAN TURN A NORMAL BRAIN INTO AN ALCOHOLIC BRAIN, PRACTICALLY OVERNIGHT. We know this both by observation of behavior as well as studying functional MRI scans and the abnormal biochemical content in brains of people with these diseases after they die (chemicals that your brain used to make are no longer made, or they are diminished in quantity, and some particularly important types of brain cells die, never to return). This is rigorously scientifically proven fact, not in the realm of theory.

We have no idea why this happens. But we know it does, we know the biochemistry and pathology behind it, and I see it every day. Therefore, how do I know that every single alcoholic and drug abuser I treat didn’t have some sort of triggering event, or series of events? I can tell you for certain that every addict I have ever encountered so far has had some sort of horrible, life-altering experience or experiences, be it abusive parents, rape, near-death experiences, etc. This is true for the white collar cocaine abusers as well. This may not be temporally related with them beginning to abuse drugs, but it certainly may make it so that when they (for example) go off to college and start binge drinking with their frat it quickly becomes impossible for their brain to turn back.

This leads me to ultimately say that I have no choice but to give such patients the benefit of the doubt that in the end their brains are diseased and need what (admittedly ineffective, just in the case of diseases we haven’t cured yet) medical treatment I can offer instead of a diagnosis of “immoral loser.” There but for the grace of God go I.

“How does willpower play into all this?” HB rightly asks. I don’t have a good answer to that, other than to say that unless one is a true saint, there’s only so much we can expect willpower to do. This gets back to Nate’s great remark about how God should be enough, and indeed faith, a strong support network of friends and/or family(such as AA), and a “natural tendency” (whatever THAT means) towards strong willpower are really the only three things that have ever really been shown to give an addict any chance at remission. But this doesn’t change the nature of the disease itself, it just modifies to what extent a person can tolerate suffering. This is true of every disease, especially when physical or emotional pain is involved.

And yes, “talk” therapy is a treatment just like medicine. It is INCREDIBLY powerful at treating very real medical (as in, something objectively different can be seen in their brain when imaged or examined under a microscope) diseases such as anorexia, obsessive compulsive disorder, depression, etc. Psychologists are just as much medical professionals as doctors, they just provide a different service. I’d say that it’s equivalent to physical therapy (which I think we can all agree is a medical intervention?), but it just trains the *brain* to work better, in the same way that PT can train an injured * leg* to work better as well.

Where does the soul fall in all of this? I have NO idea, and don’t think it’s in the human realm of understanding. Unless one of my favorite metaphysicians (my husband comes to mind) can enlighten me.

hb,

I come bearing gifts from academe!

In the halls of academic Continental Philosophy they call that soul and body talk dualism; a dirty, dirty word. To talk about what you’re calling the side of the soul, Continentals retreat into Phenomenology (Husserl and Heidegger, etc., etc.), wherein the medical facts are set aside (“bracketed”) and focus is paid only to the phenomenal experience of living within certain essential parameters (parameters such as having a body, having memory, having a sense of single identity, having a sense of will). Thus, phenomenologists say that there is a phenomenology of being an alcholic, being a junkie (or, driving a car, using a computer, etc.). Even though phenomenologists will always protest that they’re not doing natural science and can’t make causal predictions, they will do a study of a particular “existential” condition and identify certain pathological relations within that condition. It’s not a totally satisfying approach, because they won’t talk about the body as such, only the experiences emanating from the body, so for instance they’ll examine what it feels like to have a brain tumor, but they won’t try to make causal statements about the brain and memory.

Phenomenology is mostly interesting as an antidote to scientific reductionism. Daniel Dennet makes a good distinction about reductionism, though. He says there is greedy and non-greedy reductionism. Greedy reductionism is saying that the brain is explained at only one level: chemicals, synapses, atoms, etc. The thing is that modern science and medicine isn’t that reductionistic (in the greedy sense) anymore. Behaviorism (a greedy reductionism at the level of “operant conditioning” that explicitly denied phenomenology’s position) gave way to the cognitive systems perspective. Cognitive is actually fairly compatible with an Aristotelian perspective, as long as you’re willing to admit to what this one guy (Solms) calls dual-aspect monism. Basically, this makes the nervous system the soul, with two aspects: one bodily and one psychic. Neither is “in charge”; they’re two aspects of the same thing. To me this is a quite fine solution. When we talk about change of heart, power of will, efficacy of talk therapy, etc. we can just be talking about the way that the brain is a sensitive organism looking for guidance from the world that it takes in and integrates. I’ve also heard (literally heard about in idle conversation) about the possibility of a neurological willing system, so high-order that it effectively is a “free” will. But phenomenology, cognitive science and Aristotelianism are in agreement that free will isn’t really that interesting a concept. Appearance of free will, on the other hand…

Finally, I happen to know that in psychology beyond the stereotype of psychoanalysis (PA isn’t very healthy these days, partly because of some weird institutional organizing principles, e.g., 7-year training!) the major disagreement is over whether talk therapy should address the client’s “brain” or the client’s “soul”, except that all psychologists are monists, so they’re really talking about the same phenomena. The existential-phenomenological perspective deals with the client’s “situatedness” and tries to identify behaviors as aspects of an existential “lifeworld”. In pure EP the focus is on a now that brings the past along with it. So: “how does your bad childhood manifest itself in your beliefs and behavior now? By becoming aware of your fundamental patterns in the present, how can we change them in the future?” On the other side is Cognitive Behavioral Therapy (what some EP people call “Cock and Balls Torture”), which is almost the same thing as pure EP, except that the focus is on how your brain has become “wired” to have certain “irrational beliefs”, and how it can be reprogrammed to take on different beliefs. I know less about CBT (because I don’t live with a practitioner), but one technique they favor is something called “stop-thought”. I’ve seen a handout, and it literally counsels you to practice interrupting your “bad thoughts”. You can even start off by recording a tape to mechanically interrupt your thoughts while you think them! CBT has also introduced a therapy for PTSD that involves looking at flashing lights while you talk about your trauma, with the idea that the brain becomes distracted enough to allow traumatic memories to be revisited and thus neutralized (the military wants to put soldiers with PTSD into videogame war simulations to achieve a similar effect).

In practice, though, many practicing psychologists will say, “now I’m going to do EP”, “now I’m going to use CBT”, and in general what they’re working on with the client is increasing “mindfulness”, basically: do you know what it is that you do? Are you are aware that you’re doing it now? Why do you do it? How can you change? Anyway, I imagine this would be beneficial for a lot of people, not just the “losers”. I saw something recently that put the problem of poverty in succinct terms: the people with the least resources (mental/reflective, economic and temporal) need those resources the most.

That last sentence wasn’t a complete thought.I meant to say that many people who go to AA or court-ordered counseling are being forced to truly reflect on themselves for the first time in their lives, after the damage has been done. Some people say the same thing about prison, that it was the first time that they were able to stop and think. With AA and some halfway-house communities people may be experiencing a caring community for the first time as well. I know I’ve overheard two AA guys talking, and reflected that for them AA wasn’t the solution to their alcholism, but a systems solution that gave meaning to their entire lives. If this is true, then we need to provide these practices and institutions prior to crises.

Whether it ought to be is a fine topic for discussion, but I will definitely say that medicine these days is not about providing meaning to lives.

I can see the lawyers having a field day now…

“Dr. Sullivan did not provide standard of care by failing to give her patients’ lives meaning. Therefore you should rule in favor of my client for MILLIONS OF DOLLARS!!! WHOAHHHAHAAA (that’s supposed to be an evil cackle)!”