I want to be an addict

Jonathan Chick reviews
Addiction is a choice
by Jeffrey Schaler.
Chicago: Open Court Publishing Co.

People can give up smoking or harmful drinking without the assistance of counsellors, doctors or programmes. To Dr Schaler, this means that their way of consuming these substance is therefore under their control in the same way as it is for others of us who change a habit. He decries those who 'keep on telling the public that addicts physically cannot stop doing whatever it is that they do'. He says an old word, 'addiction' has taken on a 'new-fangled meaning', that the addicted person 'literally cannot stop'. This is easily disproved, he says, quoting experiments and examples where people deemed addicted stop when circumstances change.

I think he has set up a straw man. Addiction researchers and therapists do not use such absolute terms. A more typical view would be as follows. There are some people who drink alcohol or use drugs who find it more difficult to alter their patterns than others who use, or who are subject to motivational forces which are rather different. There is a continuum of difficulty to change. A mosaic of factors - learnt habits, social forces, genetic predispositions, and drug pharmacology - interact to influence drug consumption. What we perceive as choice presumably has something to do with the balance in this mosaic of positive and negative incentives.

In a book entitled 'Addiction is a Choice', the reader might expect a central discussion of what choice is. The issue is whether our behaviour is determined by our chemical memories and the stimuli we meet; whether the experience we have of making choices is an illusion. Dr Schaler sets the 'free will model' as the opposite of 'the disease model', but skirts round the free-will conundrum, except for page 68-69 tucked away in a chapter entitled 'Who are the Addiction treatment providers'. Here he leaves us with the enigmatic statement: 'Acceptance of the free-will model does not require taking a position on the philosophical question of free-will and determinism. A determinist could accept the free-will model, as long as the determinist recognised a practical distinction between voluntary and involuntary human action (which determinists do).' Clarification, please.

Dr Schaler is concerned that in some US courts an offender's claim to have been addicted has changed the Court's judgement. I do not know of such cases in Europe, where a guilty verdict in a drug or alcohol dependent person would only be modified if there was definite evidence of hallucinations or delusions, or dementia. However, the medical report may affect the Court's disposal - for less severe crimes offenders may be offered the option of treatment as part of probation, or sentence is deferred while the progress of the offender who has chosen to take treatment is monitored. Dr Schaler also believes some US Courts acted wrongly in mandating offenders to treatments involving A.A., which at times he seems to see more as a religious movement than a treatment.

The book is a set of essays. Some are polemical. In others he cites from the peer reviewed international literature, though his summaries are not always balanced. For example, he quotes Davies' 1962 paper 'Normal drinking in recovered alcohol addicts'. Although he includes the later 20 year follow-up in his bibliography, his text does not mention that only two of Davies' original seven stayed clear of serious alcohol problems. In our Edinburgh two year follow-up study, 'Advice versus extended treatment', which he quotes elsewhere, he would have seen that only 6 out of 152 sustained problem-free drinking. Dr Schaler quotes our study as one which supports his thesis that 'addiction treatment is a scam'. In fact, our study showed that over the two years the treatment group accumulated less social harm than the advice-only group.

You will not find 'genetics' or 'heredity' in the index. However, he lampoons it in his straw man's credo: 'Credo of the Disease Model - 8. The fact the addiction (alcoholism) runs in families means that it is a genetic disease.' He credits the 'disease concept' proponents with little intelligence! Any farmer knows that the expression of a gene depends on its interaction with the environment - different soils or climates produce different harvests from the same gene. Genetic research tells us that a drug's effects on the brain are not the same in all individuals. The reward/aversion payoffs associated with that drug may differ depending on the genetic signature on brain cells, as well as on the past experience of that individual and interacting social and psychological factors. The strength of associations which are laid down in the brain for a given drug will vary between individuals. Dr Schaler does not attempt to review this evidence. This will frustrate many of his readers who will have heard of the advances in this field, be it the twin and adoption studies, or perhaps the mice whose 5HT1B receptor genes had been experimentally knocked out and who showed exaggerated nervous reaction to stress, high alcohol intake, high cocaine injecting and impulsive behaviour (Crabbe et al, 1996).

I share Dr Schaler's concern that commercial clinics can abuse the disease concept, persuading employers or families to coerce the 'sick person' into treatment which she does not wish and perhaps do not even need. Like him, I shudder at the way 'denial' is used as a defining symptom of illness by some clinics. If I deny that I have diabetes, does that mean I am likely to have diabetes?

As part of his attack on 'the sanctity of the Therapeutic State and the economic interests of the growing treatment industry', Dr Schaler exposes 'The Project Match cover-up': 'The study showed that no type of treatment for alcoholism was significantly better or worse than any other, and in particular, that 'treatment' by free self-help groups is at least as good as 'treatment' by paid professionals. Every effort was made to suppress these findings and to smear those who publicised them'. He believes the Project Match team feared that the results would lead to closing down professional treatments in favour of AA.

However, the results are not suppressed. They are available to all in the scientific literature. At least for clients from an environment highly supportive of drinking, what Dr Schaler says is correct: patients offered Twelve Step Facilitation (TSF) tended to do slightly better than those receiving the two other psychological treatments (Longabough et al, 1998). However, the TSF group were not simply told to go to AA meetings. They were offered 12 individual counselling sessions with a paid person who helped them clarify their motives in seeking help, discussed the AA approach , and facilitated them getting to AA meetings . When simply telling clients to attend AA was tested (versus sending them to a residential 'hospital' programme - Walsh et al, (1992)), employees treated through a company's employee assistance programme did better with hospital treatment than 'being sent to AA'. This study is not mentioned by Dr Schaler. Dr Schaler is angry at the cost of Project Match, but that is a separate matter.

In the Project Match chapter, Dr Schaler gives AA as an example of the approach he favours - encouraging 'individualism and autonomy'. Elsewhere he attacks AA as a 'religious cult' promulgating the dangerous notion of the 'disease model'. (Perhaps AA groups vary?)

Maybe it is useful, at times, for people to conceive of their predicament as linked in part to some variant in their physiology. It cannot be a question of fact whether their plight is a disease. Disease is only a concept. It can be defined in dozens of ways (Rezneck, 1987). But Dr Schaler is right to warn of the danger that people might use the disease concept to absolve themselves from responsibility.

Certainly, some of us in a given circumstance will find it harder to resist a particular desire than the next person. However, society expects us to be informed about the risks and to avoid putting ourselves into high risk situations if someone else could be harmed. We need to be reminded of harmful consequences of too ready use of the disease concept - and Dr Schaler's book helps to keep a balance.

References:-

• Crabbe JC, Phillips TJ, Feller DJ, Hen R, Wenger CD, Lessov CN, Schafer GL (1966) Elevated alcohol consumption in null mutant mice lacking 5-HT1B serotonin receptors Nature Genetics 14: 98-101

• Longabough R, Wirtz PW, Zweben A and Stout RL (1998). Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction; 93:1313-1334

• Reznek L. (1987) The Nature of Disease London: Routledge

• Walsh DC, Hingson R, Merrigan D. et al (1992) A randomised trial of treatment options for alcohol-abusing workers. New England Journal of Medicine 325, 775-782

• Dr Jonathan Chick is a Consultant Psychiatrist at the Royal Edinburgh Hospital and Senior Lecturer in Psychiatry at Edinburgh University. He has advised government bodies in UK, Brazil, Australia, Canada, and USA on public health and treatment issues related to alcohol, health, and social problems. His research in early detection and intervention for problem drinkers and relapse prevention treatments for alcohol dependence is recognised internationally. His study on counselling for problem drinkers in the general hospital is the third most cited paper in the field of alcoholism treatment research in the world literature.