The Role of Choice in Addiction and Recovery
By Steve K.
In the field of addiction studies there is an ongoing debate in relation to how much voluntary choice is involved in addiction to alcohol and other drugs. During an AA discussion group meeting that I attended very recently different viewpoints were expressed in relation to this topic. The majority of the people involved in the discussion considered themselves to have lost all control during their active drinking careers. However, not everyone was so certain about this and the idea of choice, particularly in relation to their recovery, was important to some people in the meeting.
The two models relating to addiction that represent the positions of ‘choice’ vs ‘compulsion’ are, respectively, the ‘moral model’, and the ‘medical/disease model’.
Simply put, the ‘choice’ or ‘moral’ model suggests that people make decisions about payoffs and pleasure, particularly in the short term, and the decision to use alcohol or other drugs is often most attractive at the time and in the circumstances. It’s a view that’s given to explain people’s decision to stop using when the consequences of doing so become too unpleasant, or when their circumstances change.
The ‘disease-concept’ advocated by mainstream medicine views addiction in the following way:
Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to harmful behaviours seen in people who abuse drugs. The disease of addiction affects both brain and behaviour, and scientists have identified many of the biological and environmental factors that contribute to the development and progression of the disease.
Recognizing Addiction as a Disease Act 2007
The above models are viewed by many as opposing each other – the ‘choice’ or ‘moral’ model suggesting that addiction is the result of voluntary action, and the ‘medical model’ suggesting that addiction is the result of a compulsion, and therefore, not voluntary.
The Twelve Step Perspective
The 12-Step approach strongly suggests that addiction is the result of a ‘merciless obsession’, which then renders the sufferer virtually no control over the choice to ‘use’ or drink:
The fact is that most alcoholics, for reasons yet obscure, have lost the power of choice in drink. Our so called will power becomes practically non-existent. We are unable, at certain times, to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago. We are without defense against the first drink.
Alcoholics Anonymous, 3rd ed, p.24.
The 12-Step approach is viewed as strongly aligned with the medical model of addiction. It is also often considered responsible for creating the ‘disease-concept’, which isn’t strictly true.1 It is more accurate to say that Alcoholics Anonymous (AA) adopted the medical viewpoint and language of the time (1930’s) in line with its members’ experience of addiction to alcohol. A point made clear by the recovery historian William L White:
AA’s use of medical metaphors served as a reminder of its belief that the alcoholic could never again safely drink alcohol. 2
In addition, AA views alcoholism as primarily a spiritual illness, and, confusingly for many, conflates this idea with the medical viewpoint. Personally I’m ok with the integration of spiritual and medical (“mind, body and soul”), as I can understand how spiritual disconnection, in a secular sense, can contribute to the development of addiction. Think of the native peoples of North America whose displacement and disconnection from their homelands, cultural values, traditions, and spiritual practices created feelings of painful and meaningless existence, in turn leading to great problems in relation to addiction and mental illness. Spiritual disconnection through active addiction is also a common consequence according to many sufferers of the condition.
The Middle Way
For me, the ‘choice vs compulsion’, ‘black or white’ distinction in relation to addiction is too simplistic. Addiction is complex involving various bio-psycho-social-spiritual influences that impact upon an individual’s ability to make healthy and rational choices. I do think that as addiction develops the power of choice is significantly diminished and corrupted. The experience of most addicts “will abundantly confirm this”.3 However, I don’t believe that the addicts’ power of choice is completely removed either, and there is plenty of research evidence to validate this contention.4 Given enough incentive even the most addicted can choose not to drink or use in the short-term. The problem is maintaining this choice in the longer-term due to the “insane urge” of addiction.5
Five previously posted articles by Steve. These were found by typing “By Steve K.” in the SEARCH FOR ARTICLES widget on the top left of the AA Agnostica Homepage.
In respect of recovery from addiction, AA suggests that due to the alcoholic’s lack of control in relation to drinking a ‘power greater’ than themselves is necessary. The more traditional members of 12-Step groups relate to this power as a transcendent force for good and their source of salvation. However, the liberal nature of the ‘fellowship’ allows its members to relate to any power that helps and this is often the group for those with agnostic or atheist tendencies.
Ignoring the complexities of the philosophical debate in relation to the existence of “free will”6, I think that the human capacity for choice plays an important role in recovery from addiction for most of us.
Once we are broken enough by our suffering we become willing to choose recovery activity and connection. For me, this engagement with recovery activity, people and principles, which support my decision to live a sober way of life, empowers me to continue to make the right choices. My capacity to choose healthy sobriety is progressively strengthened through voluntarily attending 12-Step meetings and connecting with people in recovery and their example and support. I’ve also found that the principles contained within the 12-Step ‘program’ have greatly influenced my ability to choose continued sobriety.
In the same way that my addiction to alcohol and other drugs was strongly influenced and directed by both internal and external determining factors, so is my continued recovery from addiction. In line with the humanistic presumption of ‘free will’, I believe that we humans have the capacity to interact with the influencing forces in our lives, creating new direction, purpose and change for ourselves and others. This perspective is often referred to as ‘soft-determinism’7, which can be described as the middle ground between ‘choice’ and ‘no choice’.
This position feels right for me and accords with my experience of addiction and recovery, as well as research in relation to choice.8 It also avoids the extremes of a black or white debate and wisely chooses a grey picture instead, which as I grow older is increasingly how I see things in this mysterious existence that we call life.
References:
- AA and the Disease Concept: A Complex Connection. By William L White.
- Ibid.
- Alcoholics Anonymous, p.23, 3rd edition.
- Addiction: A Disorder of Choice. By Gene Heyman, Ph.D.
- Twelve Steps and Twelve Traditions, p.22.
- Freewill vs Determinism. By Saul McLeod, updated 2019.
- Ibid.
- Addiction: Choice or Compulsion? By Edmund Henden, Hans Olav Melberg, and Ole Jorgen Rogeberg.
Recommended Reading:
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A blog on the Marc Lewis website, Understanding Addiction: Choice Isn’t Simple.
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A book by Marc Lewis: The Biology of Desire.
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The Multiple Pathways to Addiction and Recovery. By Steve K.
Steve K. has been a member of AA for the past 28 years and lives in Cheshire, which is in the N. West region of England. He would describe himself as an agnostic, although open to secular spirituality. His home group is the Macclesfield Saturday morning AA group. He has a background in advice and counselling work, mainly in the areas of mental health and social welfare law. Steve writes for his blog 12stepphilosophy and regularly keeps fit through hill walking, yoga and swimming. He has self-published a book entitled The 12 Step Philosophy of Alcoholics Anonymous: An Interpretation by Steve K. The Third Edition is available in paperback from Amazon.
You can see the five previous articles on AA Agnostica by Steve above. Just type the title of the article into the Search engine on the top left hand side. And voilà!
I loved this thoughtful essay on choice. I think you totally hit the mark on the choice/non choice aspect of alcoholism. The further down the scale you go in addiction the slimmer the option of choice becomes. However, until death, even the most far gone alcoholic still has “choice” at their disposal for 24 hours at a time if they use the tools AA has to offer them. If this were not the case there would be no final third of the Big Book.
Thank you for your comments Micaela.
Steve, I’m going to repost here the comment I left after reading this piece on your blog:
Like you, I believe in free will, but also like you, I understand that the actual choices that are available to us are limited. I have waded through a considerable amount of philosophical writing on questions about whether there is any such thing free will. Some of it is difficult to connect with, not only because it can seem unnecessarily convoluted and largely irrelevant from the point of view of real life concerns, but also it is not clear to me how such smart scholars can reach some of the conclusions they reach. Maybe I’m not smart enough to fill in the gaps, but I simply don’t understand compatibilism, the belief (somewhat common among philosophers) that free will and determinism are compatible.
I understand the need to not fall into magical thinking and dismiss natural chains of causality, but it seems to me that philosophers who believe in rigid determinism have not caught up with 20th century science. The idea that events are determined in an orderly, predictable way by antecedent causes has been called into question by scientific evidence that has come to light in the past hundred years.
That we can’t entirely count on simple cause and effect to determine outcomes is not exactly reassuring.
There is a reason Erich Fromm titled his book about the social psychology of Nazi Germany “Escape from Freedom”. The loss of freedom is usually self-inflicted, and the driver is fear. That is surely what seems to be happening with addiction. The challenge then is to recover a basis for responsibility, and as ethicists tell us, “ought implies can”. In the throes of addiction, that we can’t seem to be able to make different choices eliminates the possibility of being responsible. Recovering from addiction and thus recovering the power of choice entails moving upstream, examining how we set ourselves up for failure, and identifying choices we can make that will enhance rather than reduce freedom.
Thanks again for your comments John.
Excellent, thoughtful essay. My personal experience was that I could stop anytime I wanted but I couldn’t stay stopped. And when I started again it was frequently at the exact wrong time. My recovery included much more than abstinence from alcohol. I had to learn not to be “one of those unfortunates who are constitutionally incapable of being honest with themselves”. Regular attendance at AA meetings, association with others in recovery and “practicing these principles” in all my affairs have contributed to 32 years of progress and, I hope, spiritual growth.
Thanks for your comments Glenn.
I think I’ve enjoyed everything I’ve read by Steve K. – no exception here.
The wealthy may enjoy an academic look at the same subject matter by two Oxforders, Nick Heather and Gabriel M. A. Segal:
Addiction and Choice: Rethinking the Relationship
Similar conclusions are reached. Alcoholics and addicts understand compulsion, but without steps, meetings, fellowship, church, or calling on God, AA founder Bill Wilson quit drinking at times for a few months. Co-founder, Bob Smith quit for eight months to complete university, two years to do his medical internship, and for four years around the time of WW I. The relapse from that last one precipitated his four year “NIGHTMARE.”
Stuff like this drives the “black and white” thinkers wacko. Our world is a complex place.
Thanks Bob! I’m always impressed by your historical knowledge.
I meant his “17 year NIGHTMARE.”
Thank you for your comments Micaela.
Steve, thanks for this. An ungrateful task to try to figure this one out within AA. For starters, everything good that happens in our life, god did for us, while everything bad that happens, we brought upon ourselves. Second, with respect to alcohol – while allergy in ordinary human terms would describe a person who has a half a glass of wine and breaks out in hives, instead, in AA, an “allergy” describes the phenomenon that I could consume the equivalent of 12 oz of pure alcohol every night for many months with apparent relative impunity. Third that in AA alcoholism is not seen as a moral failure, yet to get over whatever our problem is we need to take a moral inventory.
In this sort of philosophical environment where everything that can be, has been put on its head it is difficult to discuss free will vs “whatever”. All the more since philosophers, ever since god created Descartes, have been debating whether there even is such a thing as free will or not. Even quantum physics has gotten involved. But I guess I will throw my towel in the mix, though like Pooh I’m a bear of very little brain.
Alcohol attaches itself to opioid receptors in the brain, thereby encouraging the body to produce even fewer happy-hormones, while the reason we got attached to drinking in the first place was that our production of happy-hormones was already abnormally low, and alcohol made the opioid receptors seem like everything was finally normal.
So there is a definite feedback cycle which creates a compulsion. Do I have free will to resist that? Does it have to be an either/or answer?
Yes, this seems like a perfectly fine position to me. For all practical purposes it appears that in my everyday life I have some power to make choices – limited by various forces that may be more powerful than whatever effort I happen to be able to exert.
We seem to be perfectly at ease with the idea that while I can not lift a 200 lbs weight bar, I could train myself to do so. The 200 lbs are “more powerful than me”, until they aren’t. I can train myself. I can change. Same with alcohol. There may be circumstances where the alcohol has taken on a more powerful role in my brain chemistry than my willpower, but I can train myself.
There are certainly dangers in assuming that just because things look a certain way, that’s indeed how they are. There’s a lot of fake news distorting things, but I think with respect to my ability to choose, if it looks like I can make choices, and by acting on those choices nudge my reality in the direction I would like it to go, then there is no harm in presuming that that is indeed how it is. So long as I don’t play god, of course…..
Thanks for your considered response life-j. In relation to point 3 – ‘not a moral failure, yet we need a moral inventory’ – I’ve often thought about this apparent contradiction in AA. In my article I point out that AA conflates the medical with the spiritual (mind, body and soul), and I think this integration explains this contradiction in the literature. I suggest that we humans are complex creatures with different aspects to our natures and as such we require holistic solutions.
What I know from experience was that I could not sleep if I tried to quit drinking. Once I did not sleep for three nights and needed to drink to get back to sleep. Later in recovery I was told that to attempt to quit as I did was to risk going into shock. It took monitored medication to initially help me with detoxification. For me, quitting without assistance was not an option.
A good example of determining influences and choice. Help is often needed but we still have to reach out for it and accept it when it’s offered.
There’s no reason for a slash between ‘medical’ and ‘disease’ or a hyphen between ‘disease’ and ‘concept.’ These marks change the meanings of words. In the above instances, they destroy the meaning.
Woah. Careful.
The quote at the beginning of the piece (from UK drugabuse.gov site – The Science of Drug Use and Addiction: The Basics) is an accurate citation – apart from one crucial word. The reported quote uses the term ‘disorder’ – not ‘disease’. Also, in the UK, when journalists quote from government legislation, they never use the casual term “Act 2007”. The specific Act has to be quoted so that all readers can refer to the specific piece of text.
Moreover, the vast majority of psychiatrists (here anyway) still do not use the term disease when analysing addiction. “It’s more complicated than that” is the familiar refrain from those trained in medical science, not speculative theories.
(Apart that is from a few, flabbergasted at the baffling and powerful force that is addiction).
Yours, ill at ease with his ‘disease’.
Pedant’s Corner UK
Why don’t people quit before they become addicted? According to the Na0tional Institute on Drug Abuse,
Most of us know someone affected by substance use. Overdose-related deaths are affecting our friends, families and communities; it’s a Canada-wide problem. But those affected continue to feel stigmatized.
Approximately 11 Canadians die every day from apparent opioid related incidents.
Stigma (negative attitudes or beliefs) can have a major impact on the quality of life of people who use drugs, people who are in recovery and their friends and family.
It’s important that as Canadians, we reduce stigma around drug use, so people can get help when they want and need it.
Stigma around substance use can prevent people from getting the help they need.
AA was designed to adhere to science, now it’s trying to control it.
More people die from the “rock bottom” myth and the stigma and shame than anything else… “Once we are broken enough by our suffering we become willing to choose recovery activity and connection. For me, this engagement with recovery activity, people and principles, which support my decision to live a sober way of life, empowers me to continue to make the right choices.“
The truth is people try AA, can’t stand the theological aspects; have been misinformed of the alternatives and the science, go back out and end up coming back when they’re desperate enough to stop.
You’re right about the “rock bottom” myth. According to research I’ve read those with good “recovery capital” (health, social and economic resources) are more likely to succeed in recovery. However, whatever resources we have there’s a need for the ‘willingness’ to recover. This willingness comes from suffering and consequences at whatever level is enough for each individual. As they say in the rooms ‘we can choose when to get off the downward elevator’.
Here’s some food for thought from from the past. I ran across this quote from Abe Lincoln decades ago when I was pretending to be a serious student of U.S. History. In a speech he was giving to the Springfield, Il. chapter of the Washington Temperance Society, Abe said this to the ladies about becoming a drunk. “In my judgement, such of us as have never fallen victims, have been spared more from the absence of appetite, than from any mental or moral superiority over those who have. Indeed, I believe, if we take habitual drunkards as a class, their heads and their hearts will bear an advantageous comparison with those of any other class.” Absence of appetite obviously is connected to our genetic endowment and would affect our choice making. Abe goes on to compliment the intelligence and compassion of the alkies of his day. There may be no scientific evidence to support those two claims but genetic predisposition is real.
The Lincoln remarks were insightful, especially in light of the fact they were made over 150 years ago. AA members overplay the hand that “only an alcoholic can understand an alcoholic,” and presumably, alcoholism.
The reality is that there are hundreds of thousands of alcoholics on bar stools right now who have little understanding of themselves. People like Silkworth, Nora Volkow, and others deserve more credit that we give them.
This Lincoln guy was wise. Did he ever amount to anything??
Bob – The answer to your question is YES! He made it all the way up to Postmaster of New Salem,Illinois.
John B.