This article is generating a lot of debate around the web.
The implications of this study, both clinically and politically, are in many ways promising. But I’m not sure about the rational choice model.
I think most human behaviour, including healthy behaviour, is instinctively in response to our social and physical environment.
Rational thinking is hard work, it’s needs conscious pre-frontal effort which the addicted reptilian part of our brain can so easily overwhelm. In any case the evolutionary function of our monkey-mind reasoning it to get what the lizard brain wants.
Most of us, myself included, are so crap at reasoning – subject to powerful emotional and logical biases. It is the highest order parts of our brain/mind that needs to be engaged – that part whose job it is to find meaning, purpose and value in life.
That part of the brain is not rational – it is beyond reason. Our best and worst choices in life are rarely rational.
There is an idolatry of reason in Western culture going back centuries – an Enlightenment hangover – in modern form appears as homo economicus – the rational self-interested actor – who consistently evaluate the cost and benefits of actions and lifestyle choices – a principal theme of neoliberal capitalist economic and political theory.
The profound risk of the rational choice theory is that it implies addicts consciously choose the consequences of their behaviour and therefore are entirely and individual responsible for their resolution. “You chose this life, you fix it.”
It also means that there is no point funding treatment because addicts as rational actors can stop any time they want – the increasing tendency of people in the addictions field to promote libertarian models of drug use carries with it profound risks that threaten both harm reduction and recovery agendas.
Ideas of rational choice plays right into the hands of the drug warriors. At the heart of the moral model of drug use is the concept of rational choice which comes out as “You choose to do ‘bad’ things which makes you a ‘bad’ person.
“We can help you make the right choice, (which we know you can do because you are a rational actor consistently evaluating cost/benefits of actions and lifestyle choices) by raising the stakes of using. If we make using bad enough by promoting disease, violence and chaos in your world, then eventually you will come to your senses and make the right=good=rational decision to stop using.”
“If not at least others will see the world of hurt you are in and make a rational choice to not do what you have freely brought upon yourself.”
I think what the researchers are trying to say by using the the idea of rational choice is that it makes sense to use drugs when you live in such shitty, stressful, hopeless social environments – it appears to be a rational choice to medicate yourself. Therefore instead of focussing and blaming the individual look at where they live and what can be done about that.
I have a lot of sympathy for this social justice perspective on addiction – I do see addiction as much a social and environmental phenomenon as an individualised brain disorder which itself can be seen as just a neural map of the addict’s dismal outside world. The good news being, if you can do something about the outside world (even if its just the little part you have influence over – who you hang out with) then the inside brain wiring tends to fix itself – albeit slowly and perhaps never without lasting damage.
The researchers thinking looks like a rejection of the “disease model” in favour of a social model of addiction but personally I think that is a big step forward.
The biomedical disease model tends to privilege the pharmacological effects of the drug on the individuals brain over the behavioural, psychological, social and environmental aspects of addiction. The addiction is located irrevocably in the individual “diseased” brain. If you buy too deeply into the biological disease model then you see only biomedical solutions and as Bill White pointed out a relentless focus on “disease” can be powerfully stigmatising of both current users and people in recovery.
One of the great ironies of the this field that those who reject the “disease” model often promote biomedical techno fixes as the only viable solution, whereas proponents of the “disease” model tends to promote addressing in a holistic manner the behavioural, psychological, social, and environmental aspects of addiction, but often look askance at psychotropic medications that can soothed a fevered brain and pave the way to recovery.
The traditional 12-step disease model was originally meant to be a functional metaphor – an antidote to blame and stigma of the the prevailing moral model – an appeal to see addiction as a social and health issue – “We are not bad people trying to be better -we are sick people trying to get well.”
It certainly can be helpful for people to think of their condition as like a lifestyle disease such as diabetes or heart failure requiring long behavioural changes and commitment to self-care such as dietary changes and exercise. In the case of a 12-step approach to addiction the long behavioural changes being how and who you spend time with and commitment to self-care such as abstinence and the emotional and spiritual exercise of fellowship. But in and out of the rooms it has become hopelessly conflated with the prevailing brain disease model – and it’s all become very confusing.
As the researcher says:
“The key factor is the environment, whether you’re talking about humans or rats,” Dr. Hart said. “The rats that keep pressing the lever for cocaine are the ones who are stressed out because they’ve been raised in solitary conditions and have no other options. But when you enrich their environment, and give them access to sweets and let them play with other rats, they stop pressing the lever.”
He is referring to the delightful 1970′s Rat Park experiments of Bruce Alexander – who after a long hiatus has recently returned to the addictions field with his book the Globalisation of Addiction which presents what I can see is one of the most powerful models of addiction (and recovery) yet. The dislocation theory of addiction – which he argues is a rational/instinctive/understandable/meaningful response to dislocation – which can be psychological social, political, cultural, environmental or spiritual. I think this theory deserves to be the foundational theory of addiction and recovery far more than the confusing disease model or the scary rational/moral model.
The incredible power of recovery programs and 12-step is that they help address this dislocation – helping people relocate within the world and within themselves.