Addiction

Addiction
A Philosophical Perspective

Candice L. Shelby
University of Colorado Denver, USA
© Candice L. Shelby 2016
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Title: Addiction : a philosophical perspective / Candice L. Shelby,
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For Makenna and Nicholas (in alphabetical order)
Contents

Preface viii

Acknowledgments x

1 Introduction – Dismantling the Catch Phrase 1

2 Some Philosophical Questions (and a New Theory) 10

3 Addiction and the Individual 35

4 The Ecology of Addiction 60

5 The Culture of Addiction 79

6 Addiction and Meaning 101

7 Phenomenology and Its Implications 122

8 Possibilities for Change 143

9 Conclusion 165

Notes 178

Bibliography 200

Index 203
Preface

In 2001, my father dropped dead of a heart attack while shaving. His

doctors had told him for 50 years that he needed to quit smoking, and
he did, at least a thousand times. Pipes, cigars, plastic straws ... all led
back to cigarettes. Increasing blood pressure readings had no effect on
the puffing. In 2006, my sister died at a bus stop from cardiac arrest,
brought on by a fractured skull, which happened as a result of a fall
during a seizure, which happened because not enough drugs were in
her system to keep her upright. In 2009, it was my mother, following
three months on life support after aspirating into her lungs, as a
result of taking an overdose of prescription drugs that were brought
into the hospital by outside friends. My mother and sister had both
been through innumerable addiction treatment centers, and my sister
through two years of prison, with no effect whatsoever. These experi-
ences left me with a firm belief that addiction is not what the treat-
ment industry says it is, and it certainly isn’t reliably treated with the
approaches typically offered.
Although most contemporary clinicians working in the addictions
recovery field typically refer to addiction as a “biopsychosocial disorder,”
when it comes to action, the profession seems deaf to its own characteri-
zation. Instead of addressing the triad of biological, psychological, and
sociological disturbances that according to their own definition addicts
suffer, what we see in the addiction treatment world is a proliferation of
treatment centers based on 12-step programs. These programs are self-
described as “spiritual,” which may be the explanation for why little
high-quality medical or psychological treatment makes its way into
these facilities. Instead, most are staffed by former addicts with little
formal education. When patients of these centers relapse following their
release, they are invited to return for another “round of treatment.” My
mother did, over and over again, to the tune of hundreds of thousands
of dollars of my grandfather’s and my father’s money. The response? “It
works if you work it.” Regardless of how much is spent by patients’ fami-
lies, or what claims are made on the front end by the rehab facilities,
few people make successful life changes based on the model of having a
disease for which one needs treatment. Nor, despite popular belief, do a

viii
 Preface ix

significant proportion of those who try 12-step programs succeed over

the long haul. If addiction is a spiritual disease, then work needs to be
done to shore up the spiritual cure. I think that what we need to do to
increase addicts’ chances of living happy, productive lives goes much
deeper and is much more radical than most have imagined.
Acknowledgments

People have asked me many times over the years why, if everyone else
in my family of origin is dead due to one addiction or another, I am
a tenured professor writing a book on addiction rather than living
under a bridge with a needle in my arm. The reasons are mostly people.
Mitchell Aboulafia, while a professor at the University of Houston-Clear
Lake, encouraged and supported me in the study of philosophy, and
in making the decision to apply to graduate school. He has remained a
great friend and advisor. Likewise, Richard Grandy, Mark Kulstad, and
Steven Crowell at Rice University convinced me that I had something to
contribute to the intellectual world, and helped make that claim come
true with years of continuing support. My colleagues at the University of
Colorado Denver encouraged and supported my work, and many internal
grants awarded by the College of Liberal Arts and Sciences and by the
university made it possible for me to take the time to learn an entirely
new area of philosophy. Mark Bauer pushed me in both his Philosophy
of Biology class and in personal exchanges. Likewise, the international
Code Biology community provided me with the opportunity to interact
with accomplished scholars and exposed me to sophisticated ideas,
without which I would not have been able to move forward. Kathleen
Gargan arranged invitations for me to speak at national meetings of the
LifeRing Secular Recovery organization as I was trying out new ideas
about ways of understanding and addressing addiction. Finally, Matt
Pike provided me with endless hours of discussions, helpful suggestions,
and invaluable critiques of my ideas.
With respect to the production of the book, many heartfelt thanks
go to my editor, Liz Stillwaggon-Swan, whose quick work, insightful
commentaries, and sharp eye improved the manuscript immeasurably.
Esme Chapman answered questions, offered guidance, and provided a
gracious and patient presence at Palgrave Macmillan. Walter Freeman
supplied me with photos of myself that I can actually share. Finally, I
would have been nowhere without my research assistant, Rachael Boice,
who began our association as a graduate assistant, but became at many
points in the process my lifeline. She researched, read, pushed, prodded,
and kept me accountable to my plan. Without her, this book would not
exist. I am forever grateful.

x
1
Introduction – Dismantling the
Catch Phrase

Human addiction involves a complex dynamic interaction of many

systems in which physical responses, emotions, self-judgment, social
relations, and a variety of institutions are all critical players. Even when
addictive problems are not treated merely as personal failings, the
rehabilitative path tends to focus on the individual, and at most on
the individual and her closest circle of support. Addictive patterns tend
to be separated from their social and civil institutional elements. More
recently, as social theorists have begun to examine the social structures
that contribute to addictive patterns, a similar mistake is made: those
structures are pointed to as “the real cause” of problems in this area.
Addiction is a deep-seated and systemic human problem, and yet it
continues to be treated piecemeal, both in research and in treatment.
In the scientific research literature, it is treated purely as a biochemical
disorder involving characteristic brain changes. Although numerous
species have been known to compulsively self-administer certain drugs
in laboratory settings, (1) animal addiction does not happen in the wild,
despite reports of some animals apparently becoming intoxicated on
fermented fruit when they come upon it, and (2) even when animals
do exhibit addictive behaviors and brain changes in laboratory settings,
there is no reason to believe that their compulsive lever pressing or
morphine water drinking involves the angst, remorse, or psycholog-
ical trauma that human addiction does. Although other mammals’
physiological reactions may be able to tell us something about human
addiction, the phenomenon exhibited here, limited as it is to char-
acteristic brain changes and compulsive repetitive behavior, would
not count as addiction in the robust sense in which it is addressed in
this book.

1
2 Addiction

Understood better as a process than as a state, addiction is essentially a

temporal phenomenon, involving the whole person and long stretches of
time in at least these two ways: (1) addicts’ wishes to avoid use and their
plans for using are temporally distinct, and (2) it takes time for human
addiction to develop, and to dissipate. No one is instantly an addict,
even when he or she seems to be hooked on a substance or activity from
the first time he or she indulges. What’s more, even though neurosci-
entists can point to changes in structure and function in the brain that
occur when people become addicted, these results require interpreta-
tion. Scans themselves are pictures; they cannot provide evidence that
the brain changes they document are caused by the addiction, rather
than resulting from addictive behaviors that are caused by something
else, as yet unanalyzed. One thing that is clear is that addiction develops
over time and in an extremely complex way that involves not just brain
chemistry, nor just behavior, and certainly not just spiritual dysfunc-
tion. Rather, it develops as a pattern that is determined by and pervades
the whole life of a person.
Addiction, as it is treated in this book, is not simply substance abuse
or chemical dependence, regardless of whether those chemicals come
from the inside or the outside. As we consider it here, addiction requires
self-consciousness and human social experience, in addition to a brain
with neural systems and neurotransmitters associated with seeking,
learning, and pleasure. Thus, for us, the models of addiction devel-
oped using laboratory animals, although not without usefulness, are of
limited value. Laboratory animals are incapable, for example (at least
as far as we know), of experiencing what this book will refer to as the
“semantic” level of addiction, since they lack the requisite conceptual
tools, and they lack the sophistication necessary for the social construc-
tion of the meanings of their behaviors and feelings. At the human
level, the set of relations defining the addict’s global scheme of concepts
is shaped by his addiction, and undergoes a revolutionary shift when
the addict enters into remission. What’s more, even in humans, and
even when all of these elements are present, it is not clear where the
line demarcating addiction lies. Some people use “addictive” substances
or engage in gambling or overeating every day, yet do not feel, nor do
others see them as addicted, while others use these substances or engage
in these behaviors only infrequently, but feel addicted and are character-
ized in those terms by those close to them. With addiction we seem to
be faced with what is known in the philosophical tradition as a sorites
paradox: we can agree when someone clearly is an addict (living under a
bridge begging for money for heroin), and when someone clearly is not
 Introduction 3

(never had a taste of an addictive substance or activity), but just where

the cutoff point is seems impossible to say in a nonarbitrary way. And
this is not simply an academic matter. Although psychologists, neuro-
scientists, and addiction counselors certainly have criteria, necessary
and sufficient conditions, and checklists to help them separate addicts
from nonaddicts, these tools address particular aspects of addiction, and
various tools will characterize the same person in different ways.
The problems with consistently distinguishing addicts from nonad-
dicts arise because until now there has been no single, coherent theory
of human addiction. Rather, there are in operation at least two primary
definitions, or rather, there are many variations on these two types of
definitions. For over forty years, the phenomenon has been widely char-
acterized on the one hand as a disease. That language, largely because of
advances in imaging capabilities, has come in recent years to be basically
the received view. As we will see, first because of discoveries about how
the brain’s reward pathways can be changed by repeated exposure to
certain drugs and stimulating activities, and also because of later discov-
eries regarding the actions of certain neurotransmitters, as well as sali-
ence detection pathways, addiction research talk has come to be framed
increasingly in physical terms. Certainly in some ways that is a good
thing, as increasing focus on physical characterizations of the “disease”
has lessened the stigma and blame associated with addiction. But does
it make sense? Do brain changes necessitate addictive behavior? Are
humans whose brains are changed in particular ways incapable of self-
determination? Given how many people recover from addictions, the
answer seems to be “no.” If brain changes aren’t responsible for behav-
iors, then are researchers correct in defining addiction in terms of the
brain changes involved, or should we instead be defining addiction also
in terms of individuals’ experiences, or in terms of their behavior, or
all of these? Although the latest edition of the Diagnostic and Statistical
Manual (DSM) of the American Psychiatric Association speaks of a set
of symptoms that result in drug taking despite bad consequences,1 it
is not clear whether this definition is focused on the symptoms that
result in behavior that creates problems, or on the behavior that creates
the problems. If it is the first, then we need a specification of those
symptoms, and if the behavior is the crux of addiction, then we are left
with a quite peculiar disease. It is a disease the recovery from which,
as addiction researcher Gene Heyman puts it, is not correlated with
the kinds of things that are correlated with recovery from “the diseases
addiction is said to be like, such as Alzheimer’s, schizophrenia, diabetes,
heart disease, cancer, and so on.”2 Recovery, or, put more objectively,
4 Addiction

transition out of addiction is instead correlated with ordinary concerns,

such as care for children or parents, professional responsibilities, and,
quite reasonably, fear of judicial prosecution. If it is a disease, it is a
disease that puts hundreds of thousands of people behind bars every
year, and recovery from it is associated with all kinds of things other than
treatment.3
There are further problems with conceiving of addiction as a disease,
particularly as the term “disease” seems to be popularly used in connec-
tion with self-help programs, and in particular, with 12-step programs.
How could submitting one’s will to God, taking a moral inventory, and
making amends, all of which are involved in these treatment frame-
works, operate to cure a disease? Conventional wisdom among those
who practice this form of cure says that addiction is a disease of the
spirit, but again, it is unclear what that can mean in modern terms. What
are other diseases of the spirit? Evil? Immaturity? Greediness? None of
these characteristics are spoken of in contemporary terms as diseases,
or as spiritual. In fact, nothing else denoted by the word “disease” in
English concerns the spirit. Although this characterization of addiction
is commonplace in the recovery community, we would have to do some
serious work to account for it without abandoning all that science has
given us.
Standing in contrast to the disease model(s) of addiction is the choice
model, of which philosophers, psychologists, and behavioral economists
have developed numerous versions. The element tying together the
various types of choice theory is rationality. Theorists here either attempt
to explain how addicts can be rational in repeatedly choosing something
that is harmful to them, or they try to explain how a rational being can
consistently choose irrationally. This view has more in common with
the spiritual disease model than it does with the physical disease model
because both the choice view and the spiritual disease view suggest that
mind (or spirit) is separate from body, and that it is free choices that are
responsible for the havoc that addiction wreaks. The physical disease
model, in contrast, which focuses on physical dependency and brain
changes, suggests that the addicted person is much less free with respect
to her addiction. None of these views in isolation is able to provide an
adequate account of all the complex interacting aspects of addiction.
In order to understand this phenomenon and have any hope of devel-
oping broadly successful approaches to helping those who suffer from
it, we have to undertake a much deeper and broader investigation of
the pattern that is addiction than has been done in the past. We have
to consider it from genesis to expression in the world, and from unique
 Introduction 5

experience to social context. We need to employ a completely different

framework from any that has been offered before.
The analysis has to provide an account of how a psychological and
social issue can be at the same time a physical reality. It has to provide,
in other words, some way of understanding the relation between the
mind and the body. According to one perspective, minds are believed
to be nothing other than the brain in action. This perspective raises
the question of how mental experience can happen, given that minds
seem to be very different from the gray and white goo that sits inside
our skulls, even if understood at a deeper level as an ongoing electrical
storm. However, to suggest that minds are completely different sorts of
things than bodies is to make mentality a mystery, seemingly coming
from nowhere, and having no way to connect to the physical world.
This is a problem first introduced by René Descartes 300 years ago: if
I can clearly and distinctly conceive of myself without appeal to my
body, then it seems that my mind is all that I need to be me. My body
is a substance with which I am “mixed,” but it is not me. I am my expe-
riencing mind. But if my body is so indubitably an extended material
thing, with no trace of the mental in it, then how can my mind and
brain/body work together to provide me with the human experience
of living as an embodied individual? And more importantly for our
purposes, how can a person, a mind independent of body, be addicted
so that she feels driven by forces that are nevertheless based within
herself? A physical sort of answer to these questions would seem to drive
us to a deterministic understanding of addiction, since, if all mental
experiences are caused by the brain’s cells, or the molecules comprising
those cells (or pick your level), then whatever choices, yearnings, or
fears that one has must be caused by those tiny parts. So, the argument
goes, if minds are brains and addicted brains are dysfunctional, then
it is not clear how the addicted person could do anything about it.
Whether one became addicted or transitioned out of addiction would
seem to be the result of purely physical causes. The dualist response, in
contrast, would seem to make addiction a free choice. That characteri-
zation, though, dismisses the sense of helplessness and yearning to not
be addicted that addicts often describe themselves as having. A better
response would show that there need be no difference in kind between
mental events and physical events, and that emotional, physical, and
cognitive elements can all be ways of understanding the patterns that
constitute the life of an addict.
The central argument of this book is that, to understand addiction
correctly, we need to dismantle the catchphrase. We need to see that
6 Addiction

addiction, rather than being one thing, whether a way of thinking or

a physiological condition, is a set of interacting physical, mental, and
social patterns that develops, persists, and dissipates as the patterns from
which it emerges and with which it interacts undergo changes. Human
beings, with our conscious lives and the problems that arise from them,
are natural processes embedded in our environments, experiencing
further, emergent natural processes. Our minds are neither soul-like enti-
ties, as Descartes would say, nor are they a fundamental but unknown
kind, to be discovered by a radically new kind of science. However,
neither are our minds identical with the brain’s neurons, neurotrans-
mitters, and electrical impulses, otiose in itself and thus eliminable as a
category.4 The philosophical problem of the mind’s relation to the body,
like a number of other philosophical puzzles, seems to arise from adher-
ence to an old, substance-based metaphysics. From a complex dynamic
systems approach resting on a metaphysics sometimes described as
structural realism, rather than on a physical object ontology, it will be
argued that these problems need not arise. From the perspective that
will be presented in this book, human beings are neither responsible for
their addictions in the way that we are responsible for choosing between
a banana and an apple, nor are we determined by physical forces to
become alcoholics, smokers, or gamblers. We are singularly complex,
dynamic, self-aware organisms, emerging from lower-level complex
processes, within the context of an environment that simultaneously
shapes us and is shaped by us. We are susceptible to addictions, some of
us more than others, due to processes beyond our control, but we have
power to avoid them and to overcome them as well – again, some more
than others. Understanding human addictions from a complex dynamic
systems perspective, with its characteristic features of emergent proper-
ties, hierarchical organization, and “lever points,” places at which small
changes in inputs can result in large changes in the system offers us the
opportunity to see how it is that an addicted mind could change itself,
and how a wide variety of approaches can be used to help that process.
Even though it is an analysis of addiction, this book begins with and
rests crucially on a metaphysical position. It begins with the premise that
mind emerges from the physical, but not in the same way that wholes
result from parts. This means that emotional and psychological experi-
ences need neither be explained away nor accepted as brute independent
facts. Physicists have for decades accepted the concepts of emergent
entities and complex dynamic systems, but neuroscientists and philoso-
phers have been slow to come around. The advantages of taking that
approach, however, are many. For instance, even if we trace the brain
 Introduction 7

down through its neural systems to its individually acting neurons, with
their particular shapes and internal and external chemical properties,
and trace those in turn even further to their molecular makeup, we are
not going to see how the nonmental creates the mental, as we see how
bricks create a building. But there is a way to understand how the mind
and the brain are connected in a single physical system: by conceiving
of mind as an emergent process, arising from physical processes, but
with autonomous causal and other properties of its own. Assuming this
kind of emergence theory allows us to understand the mind as a process
both arising from and contributing to more complex processes, and we
can understand addiction as a process organized from simpler biological
processes within the context of larger personal and social processes. As
Terrence Deacon frames it, this discussion is going to be about “proc-
esses dependent on processes dependent on processes.”5 Adopting this
view of our physiological and psychological selves, together with some
reconfigured attendant concepts of meaning and value, will allow us to
understand addiction in a different and far more complete way than has
been done before.
This means that we can and must address addiction at many different
levels of analysis, because there is no question of one “level” based at the
“root” of addiction, no one way of understanding what causes it, how
it feels, or how it can be treated. The very concept of causation that we
will have to employ will in and of itself require serious rethinking. This
is not to deny the tremendous importance of recent scientific develop-
ments in understanding the neural pathways, neurotransmitters, plas-
ticity, and synaptic changes characteristic to addiction. Quite on the
contrary, each of the individual levels of organization at which addiction
has been analyzed is valuable, both in its own right, and in terms of its
connections to other levels of organization. This book therefore begins
with a philosophical discussion of just what addiction is, outlining the
conceptual clarifications that need to be made in order to coherently
carry forward our discussion. Chapter 1 introduces the framework that
is used to understand the interrelations of the various levels of organiza-
tion at which addiction manifests. From there, we turn in Chapter 2 to
a discussion of the latest theories of addiction as a biological process,
examining the physiological events and changes characteristically asso-
ciated with addiction. Chapter 3 addresses addiction as a psychological
phenomenon, examining some empirical theories that try to capture
which environments and behaviors predict addiction. In this chapter, we
also consider some theoretical explanations of how and why addiction
arises, focusing principally on attachment theory and trauma theory.
8 Addiction

Chapter 4 addresses the history and social construction of addiction,

expanding the irreducibility thesis yet further, examining the contexts
in which addiction emerges as a diagnosis and a social phenomenon.
Whatever the physiological, psychological, and/or spiritual nature of
addiction, no one gets addicted or recovers from addiction in a vacuum.
Human beings are essentially social animals; without others, one cannot
become an addict any more than one can become a person.
All of the systems so far discussed also contribute to the system of
meanings that shapes the addict’s world, and to the ways in which his
world is different from the worlds of individuals who are not addicted.
Chapter 5 focuses on how the set of meanings that form an individual’s
world can change as one becomes addicted. It also provides an account
of how one’s system of meanings changes when “something clicks” and
one sees the world in a different light, shifting into a new gestalt. This
chapter also explains why those who are not addicted often see those
who are as irrational, ill, or spiritually bankrupt. The phenomenology
of addiction, the subject of Chapter 6, is the least examined aspect of
the syndrome, and understandably so, because the qualitative descrip-
tion of the experience of addiction and recovery varies so much from
individual to individual that it is difficult to derive generalities. Even
less effectively have the theories that are currently on offer been able to
explain how we can consider this wide range of experiences as cases of
the same phenomenon. Nevertheless, this may well be one of the most
important chapters of this book, as we move beyond third-person objec-
tive explanations of what might be going on in addicts to first-person
accounts in order illuminate our understanding of both addiction
and recovery of a multidimensional, complex human phenomenon.
A full exploration of this phenomenology shows the inadequacy of
the accounts of addiction offered to date. Chapter 7 considers where
promise exists for transitioning out of addiction and into a happier,
fuller life. While addiction cannot simply be arrested, as some recent
headlines have claimed, by “addiction vaccines,” talk therapy, or any
other single-pronged approach, understanding the richness and variety
of the physiological effects, environments, and ideological frameworks
in which addiction survives or fades can assist us in finding positive
ways out of an increasingly pervasive problem.
Finally, the concluding chapter explains what this multilevel, dynamic,
and complex analysis means for understanding addicts’ attitudes and
actions, and shows how this view provides a coherent position from
which to develop more sensitive, insightful, and successful research
agendas and treatment approaches than have so far been offered.
 Introduction 9

Standard linear causal approaches will be shown to be inadequate both

for assessing why a person got into addiction, and how he might get
out of it. Although we are very good at giving causal analyses after the
fact, direct attempts to change an addict’s behaviors, attitudes, and feel-
ings have been notoriously unsuccessful. One cannot stop addiction by
merely identifying “triggers” or negative emotions, any more than one
can end it by administering drugs, either those that act as antagonists to
the addict’s drug of choice, or those that make him violently ill in its pres-
ence, although any of these methods might help in a given case. Neither
can we expect to overcome the social structures from which addictions
emerge and within which they make sense – at least not completely,
and not immediately. Because addiction is a process, and indeed not
a single process but a complex system of processes that are essentially
constrained by and that constrain larger and smaller dynamic systems,
exposure to a variety of causal influences, sometimes oblique in nature,
promises to be a more helpful approach to easing the addict’s suffering
than any single direct attempt to control addictive responses. Addiction
is an irreducibly complex reality, and we shouldn’t expect something
different of the processes that can effectively address it.
2
Some Philosophical Questions
(and a New Theory)

Conversations about the worst social ills facing our age often focus on
global climate change, or on the stunning inequalities between the rich
and the poor. Many people, though, point to the escalating problem of
addiction as our most challenging, both because of its personal costs
to health and relationships and because of its economic costs to our
own generation and to that of our children. So much has been said
about addiction and its related social ills in the past few decades that
one might think that the concept is clear and our attitudes uniform. The
pervasive “war on drugs” refrain, popular over the past 40 years, seems
to suggest that everyone is on the same page. Terms such as “addiction,”
“disease,” “compulsion,” and “recovery” are thrown around as though
everyone were in agreement about both the existence and the meanings
of these occurrences in human lives. In fact, though, the ideas behind
these terms are more problematic than they first appear. In fact, each is
the subject of controversy.
Some significant ground clearing is called for, then, before discus-
sions can begin about how we as a society might want to address the
increasingly pervasive phenomenon of addiction. Let us start by consid-
ering a variety of responses to the simple question of what addiction
is. Over the past 40 years or so, a generally unchallenged and standard
view has arisen that addiction is a psychiatric disease. The Diagnostic
and Statistical Manual of Mental Disorders (DSM)1 has included addic-
tion among its categories of mental disorders since the 2nd edition
was released in 1968. Since it has come to be coded in accordance
with the World Health Organization’s International Classification of
Diseases,2 even the medical and insurance industries officially accept
the characterization of addiction as a mental disorder, or disease, along
with depression, anxiety, and schizophrenia. I say “officially,” because

10
 Some Philosophical Questions (and a New Theory) 11

although the language of disease is the current mode of discourse, testi-

mony from addicts consistently suggests that social behavior doesn’t
necessarily follow its talk. Even in the face of general acceptance of the
disease model, addicts continue to be treated with derision, blame, and
distaste, not to mention legal prosecution. This issue is discussed in later
chapters.
For the moment, note that labeling addiction a disease does not in
any case resolve anything. A name, as philosopher William James noted,
is not a stopping point or a solution. Rather, it is a beginning: attrib-
uting a name to a phenomenon simply opens the door to begin asking
questions. “You have tonsillitis” does not suggest that the meeting
with the doctor is over; instead, it suggests the directions in which she
might begin to look for treatment options. Likewise, labeling addiction
a disease (rather than, say, a moral failing) provides direction for asking
questions, some of which will penetrate to the very foundations of our
assumptions about humanity and mentality. What would it mean for
addiction to be a mental illness? In most cases that we would call illness,
or disease, we find a genetic aberration, or a viral or bacterial infection, or
a failure or defect of an organ or system. In the case of addiction, none of
these necessarily exist. Although arguments for a genetic predisposition
to addiction have been made (to great media fanfare3) and supported
by adoption and twin studies,4 there is no gene for addiction, and the
impact that genetic factors can have is a topic of some controversy. One
might argue on other grounds that addiction is a disease, though, for the
evidence is clear that as addiction progresses, changes in brain function
and structure do occur. Not everyone agrees, however, that structural or
functional changes occurring in brains imply that addiction is a mental
illness, since it can be argued that nearly everything we do changes our
brains, and some activities that we choose to pursue, such as learning a
new language or meditation, make beneficial structural and functional
brain changes. Moreover, connecting brain changes, which are phys-
ical changes, to mental illness is not such a short step as is generally
imagined. We could take this line of reasoning even further, and ask
what makes anything count as mental at all, but we will for the moment
leave aside the deeply philosophical issues and accept for the moment a
general conception of this category.
The DSM IV-TR, the psychiatric profession’s authoritative reference
volume,5 might be expected to give us a good definition of addiction.
The manual does not take the approach of definition, however, but
instead provides behavioral criteria for diagnosing what it calls Substance
Use Disorders, divided into two subclasses, Substance Dependence and
12 Addiction

Substance Abuse, with the first intended to cover more serious cases
than the second. The first, as we will see, refers to behaviors that are
represented by neuroscientists in physiological models. The DSM’s
approach on the one hand seems sound, since a definition of some-
thing as diverse, complicated, and vaguely bounded as addiction would
inevitably be contentious and not much help for diagnostic purposes. At
worst, given the pervasively popular mind/brain dualistic metaphysics,
such a definition would be doomed to either circularity or incoherence.6
On the other hand, the DSM’s checklist method for determining addic-
tion by characterizing two things, neither of which is identical with
what is generally understood by “addiction,” leaves the discipline’s
highest authority in the awkward position of authorizing the diagnosis
and treatment of a generally recognized “disease” without ever saying
what it is.
The criterion method for diagnosis illuminates an important truth,
however, which is that there are no bright lines demarcating where
addiction starts and where it stops, and there is no definitive list of kinds
of addiction that might exist. Substances only begin to tell the tale, if
current research is any indication.7 First, gambling was recognized as
an activity that, as engaged in by certain people, exhibits the hallmarks
of addiction.8 Then research indicated that there could also be addic-
tion to food,9 then video games,10 then shopping, tanning, and other
non-substance-related foci characterized by similar behavior patterns.
The newest version of the DSM, the 5th edition, proposes revisions that
include adding the category “behavior addictions,”11 and foregoing the
current subcategories of substance abuse and dependence, in favor of
the new category “addiction and related disorders.” So, as research on
addiction takes off, so does the scope of the phenomenon included
under the rubric. What might count as an addiction in another 50 years
is anyone’s guess. The line keeps moving.
Even within the set of specific addictions included under the DSM
IV-TR’s list of substance disorders, there is no clear line separating
addicts from nonaddicts. According to the DSM IV-TR, the “essential
feature” of substance dependence, the more serious of the two subclasses
of substance use disorders, is “a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues use
of the substance despite significant substance-related problems.”12 This
description includes so much that it is of little help, although with
respect to the most general and paradigmatic cases, it seems to capture
what is wanted. The description delineates neither necessary nor suffi-
cient conditions, however, for what could be meant by “addiction.” It
 Some Philosophical Questions (and a New Theory) 13

does not capture necessary conditions, because it excludes any cases in

which drugs or alcohol are used without “significant substance-related
problems,” as happens in early nicotine addiction, for example. The
mere fact that a teenaged smoker has not yet experienced chronic lung
illness or high blood pressure, or even any difficulty ceasing the practice
(because she hasn’t tried) does not justify a conclusion that the teen is
not addicted. And it seems that that same teenager could smoke mari-
juana for some time, despite significant substance-related problems,
without being addicted to it. The teenager’s substance-related problems
might have to do with school authorities or parents, indicating that the
roots of her problems lie in defiance rather than in addiction. If addic-
tion is a disease, then we need to figure out on what grounds and of
what type it is.

Choice theories

At the other end of the spectrum of characterizations of addiction are

choice theories. The most forthright of these theories is put forward by
psychologist Gene Heyman, in his book Addiction: A Disorder of Choice.13
According to Heyman, the key component to the DSM IV-TR’s definition
of addiction is the criterion noted above, that “the individual continues
use of the substance despite significant substance-related problems.” So,
behavior, rather than the cluster of physiological and cognitive symp-
toms indicating this behavior, is the key to the concept of addiction.
Drug seeking is voluntary and rational, says Heyman, and neither a
genetic predisposition to addiction nor the neural changes that come
with the chronic abuse of certain drugs proves otherwise. Based on four
large epidemiological surveys, he argues that most addicts stop using
drugs by their mid-30s without seeking treatment, most likely because
of adult “responsibilities, incentives, penalties and cultural values that
stress sobriety.”14 That is, addicts freely and with reason choose their
addictive behaviors, and we can tell that this is true, because when
incentives shift, so do the behaviors, at least when they are unaccom-
panied by other mental disorders. On this account, addicts can control
themselves, but choose not to, as long as the utilities are in their favor.
When the utilities change, suggests the research that Heyman cites, so
does the behavior, all other things being equal.
But that may be just the point: whether all other things in the cases
of those whom we might label as “addicted” are equal. Those who seek
treatment for addiction in clinics, for instance, are less likely to achieve
and maintain abstinence than those who do not, and it may be that
14 Addiction

the additional presence of some other non-drug-related mental illness

accounts for the lack of success of those addicts who seek treatment
in clinics. More than twice as many people who are diagnosed as drug
dependent are likely to seek treatment if they also meet the criteria for
another mental illness, and that number is probably conservative.15 The
question arises, then, why so many of those who don’t have compli-
cating diagnoses simply quit their drug use by their mid-30s. Other than
the fact that using drugs interferes with other things that most adults
value, Heyman admits that he has no account of this large remission
rate. The fact may simply be that he is begging the question here with
respect to addiction. Of course, it is true that most people stop drug use
when they mature beyond their reckless teen-to-twenties mentality. But
are those people really ever addicted? Perhaps they fit the DSM IV-TR’s
category of substance abuser, but not that of substance dependence.
And perhaps they even fit the criteria for dependence for a time, but
nevertheless fail to fit our conception of addiction, since dependence,
as we noted above, isn’t sufficient to establish addiction. Heyman and
many others cite a highly influential study that showed that 90% of the
large number of soldiers who returned home from Vietnam with opiate
dependency stopped using or “became controlled opiate users” once
they left the wartime environment.16 While disease-model researchers
would say that these were precisely the users who weren’t true addicts
(the conventional wisdom is that about 10% of the population will at
some point suffer addiction), Heyman believes that this study, together
with numerous others that illustrate, among other things, how incen-
tives can change drug-dependent behavior,17 shows that people are
addicts by choice.
Heyman’s is not an uninformed, “free will” argument. He is familiar
with the body of brain scan studies showing that brains change with
repeated drug use. What he denies is that the brain changes observed
in persons identified as addicts rob them of choice, and he denies this
for at least two reasons. First, note that those changes follow the drug
use – they do not antecede it, and second, there is no reason to believe
that these observable changes preclude choice. Like numerous thinkers
from a variety of disciplines, Heyman is unimpressed by arguments that
the brain determines the mind in any straightforward way, or that one
can read mentality from physicality. What is more, if the brain’s plas-
ticity allows for changes consistent with becoming dependent on drugs,
Heyman argues, that same plasticity can allow for it to change back, and
it often does. We consider the arguments regarding the specific brain
changes that are used by neuroscientists and research psychologists to
 Some Philosophical Questions (and a New Theory) 15

define addiction, and to argue against the choice model, in the next
chapter. For the present, what is important is that at the root of the
disagreement between the disease and the choice models of addiction
is the nature of the addict’s failure to control his behavior. What causes
a person to continue using a substance or participating in an activity
when that indulgence is accompanied by problems clearly related to
use? Is this failure voluntary or involuntary, or somewhere in between?
It would seem that either the addict must be compelled to continue
to use – that is, he is simply unable to stop, as those who uphold the
disease model maintain18 – or he is unwilling to do so, as choice theo-
rists believe. Even Heyman notes that, his arguments against the disease/
compulsion model of addiction notwithstanding, many addicts struggle.
Although he is quicker than many to blame addicts for their use, and to
attribute to them excuse making and self-indulgence rather than inca-
pacity, he does recognize that many times addicts hope and believe that
they will not use in the future. They make plans not to use, and yet they
do. Others, such as neuroscientists George Ainslie and John Monterosso
who have no vested interested in Heyman’s position, have observed in
addicts strong inner turmoil and intrapersonal bargaining,19 in which
sufferers agonize over their plight, recognize what is good for them and
what is bad, plan not to use, and have every intention of not using in
the future, yet, when confronted with an opportunity, repeatedly do
exactly the thing that they have judged to be bad for them. People will
often, these researchers note, even while saying such things as “I know
that I shouldn’t do this,” take a drink, light up, or place a bet. So, is the
addict compelled in these cases to indulge her addiction, or does she just
repeatedly make bad choices?

Compulsion or weakness of will?

Let us consider the last possibility first, that addiction is persistent

choosing to use a substance or engage in a behavior. The addict on this
account is not totally without control. She does know the difference
between what is good for her and what is bad, and she is not forced
to choose the worse, but nevertheless does so. This phenomenon is a
familiar one in human history, recognized in philosophy long ago by
Aristotle, who called it akrasia, or weakness of will. As opposed to the
virtuous citizen, who restrains his indulgence of pleasurable things to
within a moderate range, the akratic character, Aristotle tells us, knows
the good and wants to do it, yet, irrationally, is led by his weakness to
do something else.20 The akratic character is therefore not wicked, since
16 Addiction

he knows good from evil, but neither is he guided to action by what he

knows to be best. The akratic character gives in to some call other than
that of reason, perhaps appetite or emotional impulse. That this kind
of weakness is recognized is clear from social institutions put into place
in both ancient Greek and current American culture for the specific
purpose of shoring up people’s resistance to overindulgence in pleasur-
able goods. The Greeks, for instance, held out Temperance (or moder-
ation) as one of the four cardinal virtues valued in any good citizen.
Today, commercially sold food plans, such as the Jenny Craig system,
as well as public policies, including citywide bans on supersized soft
drinks, serve to discourage overindulgence.
Contemporary philosophers, in contrast to the ancients, often focus
on the irrational nature of akratic behavior. Rather than recognizing the
good but not being able to constrain oneself to follow it, on this version
the akratic person behaves paradoxically, for he intentionally does what
he judges not to be best. According to philosopher Donald Davidson’s
formulation, for example, “In doing x an agent acts [akratically] if and
only if (a) the agent does x intentionally; (b) the agent believes there is
an alternative action y open to him; and (c) the agent judges that, all
things considered, it would be better to do y than to do x.”21 That is,
knowing full well that another act is better, the agent chooses to do the
worse. But to act intentionally, Davidson also says, just is to do what one
deems better.22 In some way, picking what one judges to be the better is
the very essence of choice. So, we seem to be faced with a puzzle. The
akratic choice is not really paradoxical, though, according to Davidson,
because the two judgments involved are of different sorts – the judgment
of intentionality involved in (a) is an unconditional judgment, while the
judgment involved in (c) is a relative judgment, a judgment involving
all things considered. Addictive thinking on this account amounts to
judging indulgence to be the better choice in this case despite the fact
that one’s reasons, all things considered, argue for avoiding indulgence.
According to Davidson, one ought to act on the basis of all available
reasons; the akratic error is to fail to do so. On this version of akrasia,
then, one acts irrationally, on the unconditional judgment of the good-
ness of just one option, rather than acting on a judgment made in light
of all things considered.
The question that this analysis immediately raises, though, is what
would make someone fail to take into account all available reasons.
Clearly, the addict does fail in exactly this way. According to the DSM
IV-TR criteria, that is in fact the essence of addiction: the addict continues
to choose to use despite substance-related problems. Akrasia as an
 Some Philosophical Questions (and a New Theory) 17

explanation of the irrational actions of an addict (or anyone), though,

doesn’t do any work, since it completely fails to address the question of
why one might act irrationally. It simply says that this is what the akratic
character does. What is going on, if the addict could choose differently,
and should, but doesn’t? Aristotle’s understanding seems to be informed
by an analogy with physical weakness, so if it is to be of any use here,
we are going to have to work out how that analogy could be put into
play. Some theorists have suggested that emotion could cause an agent
to act intentionally against her better interests. This seems likely true,
but in this case we will need an account of emotion if we are to complete
the analysis, and here’s why: if, as some philosophers suggest, emotions
are judgments themselves, brought about by reasons (“I’m angry at you
because you spilled my coffee on my lap”), then they would seem to be
reasonable, and then one’s action wouldn’t be akratic. If, on the other
hand, emotions are not judgments or reasons of any kind, then how
can they enter into judgments? That is, how can one decide on the basis
of an emotion to do something that is against one’s better judgment if
emotions aren’t the kind of things that can enter into reasoning, or, by
extension, into judgments? It would seem from this line of reasoning
that the philosopher has produced a reductio ad absurdum against his
own way of thinking (not that that’s unusual). Notice, though, that
these problems only arise if we assume that humans are rational beings
motivated to action by judgments based on arguments. That assump-
tion is clearly false, however appealing it might be. Humans are not
philosophers, any more than we are Econs, the rational consumers that
traditional economics assumes in its models. Psychological and biolog-
ical considerations will have to enter into any viable analysis of choice,
judgment, or, what concerns us here, addictive behavior.
Philosopher Neil Levy agrees that weakness of will isn’t an estab-
lished phenomenon in need of a philosophical account. He moreover
agrees that the concept fails to explain anything regarding why people
do what they, in their considered opinion, judge to be suboptimal. In
his view, weakness of will isn’t in itself a psychological kind at all.23 Of
the two kinds of analyses that we have just discussed – judgment-based
and desire-based weakness of will – his view has more in common with
the former than the latter. But for Levy, the judgment is influenced by
what has come to be known as “ego depletion.”24 We will consider this
idea in much greater depth later, but the general idea is that intellectual
energy (which, as it turns out, is physical energy25) is a limited resource,
and so if much is used by one set of tasks, there is less left for others. In
the current case, when one has been exercising self-control in one area,
18 Addiction

or has otherwise used up energy doing the multitude of tasks required

of us each day, one “takes the easy way out” when the urge to indulge
arises. More specifically, the brain switches from using the more accu-
rate but difficult sort of deliberative reasoning, which some have called
intellection, or System 2 thinking, to the more primitive, but energy-
efficient, quick, and inflexible kind of thinking, which some have called
intuitive, or System 1 thinking.26 In making this switch, one sets up an
easier problem, or frames premises and conclusions in such a way that
spurious arguments are accepted. One does not deliver an “all things
considered” decision.
To return to the issue then – we say that the addict is one who either
does not or cannot choose not to use. If we were not to accept either
of the versions of weakness of will – that she either simply does not do
what she judges best or that she changes her judgment – then what we
would be left with is that she cannot choose otherwise, but is compelled
to indulge in addictive behavior, despite significant negative conse-
quences. This is what many addiction theorists believe. The true addict,
many say, “can’t help himself”; he is “overwhelmed” by his urges. Not
only do we find this kind of language in current literature but we also
see it as long ago as 1890, when philosopher William James character-
ized addiction in this way:

The craving for a drink in real dipsomaniacs, or for opium or chloral

in those subjugated, is of a strength of which normal persons can
form no conception. “Were a keg of rum in one corner of a room
and were a cannon constantly discharging balls between me and it,
I could not refrain from passing before that cannon in order to get
the rum”; “If a bottle of brandy stood at one hand and the pit of hell
yawned at the other, and I were convinced that I should be pushed
in as sure as I took one glass, I could not refrain”: such statements
abound in dipsomaniacs” mouths.27

On this depiction, an addict is one who is so overpowered by desire, or

compulsion, that nothing conceivable could stop him from using, given
the opportunity. In the scientific literature, as we shall see in detail in
Chapter 2, accounts are given of this compulsion in terms of dysfunc-
tion of the dopamine-driven reward systems of the orbitofrontal cortex,
in which judgments of salience and value, as well as inhibition and self-
control are centered, respectively.28 These kinds of accounts suggest that
agency is compromised, if not obliterated, by a physiological condition.
Thus, absent a medical intervention that can break these sensorimotor
 Some Philosophical Questions (and a New Theory) 19

connections, the addict will, like an automaton, be doomed to repeti-

tion of the addictive behavior. But how can we make sense of a compul-
sion that comes from the inside? So what if someone’s brain is flooded
with this or that chemical? How does that fact translate into his being
compelled, as one would be if another person grabbed one’s hand, stuck
a knife in it, and thrust the knife into a passerby’s chest? Certainly
the law does not accept that a probationer’s return to drinking after
being ordered to stop is excused on the ground that the probationer is
addicted. So, what can be meant by “overpowering urge” or “compul-
sion” or “out of control”?
Philosopher Bennett Foddy suggests four things that might be meant
when someone says that a person is compelled, and he rejects all of
them as reasons for believing that no control exists in addiction.29 Let us
consider them one by one. First, someone might say that those who are
addicted act compulsively because they “appear to be insensitive to the
costs of their drug use.” This is a criterion for addiction used in the DSM
IV-TR. Second, one might characterize an addicted drug user’s actions
as compulsive because she regrets her drug use, and yet fails to curtail
it. Third, one might say that people who are addicted are compelled
on the grounds that they “report feeling strong desires which they feel
unable to control.” Finally, many neuroscientists would say that addicts
act compulsively based on the fact that “their actions have identifiable
neurological processes as their root cause.”30 Although Foddy is right
that the factual basis of some of these claims is far from established, let
us consider whether any of the reasons given would actually provide
legitimate grounds for characterizing an act as compelled, were the facts
to be as presumed.
First, note Foddy’s claim that even if true, none of these reasons offers
“uncontroversial proof” of compulsion, according to what philosophers
mean by that term. Given that nothing stands as uncontroversial proof
of anything in philosophical discourse, this point should not particu-
larly move us, but the fact is, none of these reasons seems even good
grounds for calling an act compelled. Returning to the list then, the first
basis for saying that someone is compelled in her action (the one found
in the DSM) seems to be beside the point. Many people are insensitive
to the costs of the use of their credit cards, but we would not for that
reason say that they are compelled to use them. There is no relevant
difference between this case and the addictive case, and so this interpre-
tation can be rejected. The second reason for calling an act compelled –
that the individual regrets it, and yet does it again – certainly seems
true of addicts; in fact, this is the characteristic that George Anslie finds
20 Addiction

central to addiction, as we saw earlier. However, just because someone

regrets an act and nevertheless does it again, this does not even suggest,
much less prove, that the act was compelled. Procrastinators provide us
with a great example of people who repeatedly do something that they
regret (some, not all, regret their procrastination) and yet do it again,
admitting when queried that nothing compelled their behavior. This
in fact adds to the remorse that they exhibit. A third reason for saying
that someone is compelled is that the person feels compelled. Unless
compulsion is like pain, though, and unmistakable, rather than like any
of the variety of visual and cognitive illusions that we all experience,
believing that we’re seeing or feeling one thing when we’re really seeing
or feeling something else, the mere fact that someone’s desires appear
to be uncontrollable is no sure sign that they are.31 What is more, those
who struggle with addiction often in fact do control their desires when
the context demands it. All we need to observe to convince ourselves
of that fact are the multitude of nondrinking alcoholics awaiting a DUI
trial. Finally, as for the fourth reason Foddy says one might give for
saying that addictive behavior is compelled, we have already considered
it above: the fact that addiction can be correlated with changes in the
brain in no way proves that addictive behavior is compelled. In fact,
this is precisely what is at issue in the debate between defenders of the
disease model and those who uphold a choice model.

Source of the conflict

The problems and puzzles we have run into in attempting to define

addiction all seem to derive from presuming some version of either a
dualistic or a reductionistic metaphysics. On the one hand, if mind is
a separate thing from body (dualism), then there would seemingly be
no constraints on human freedom. What, after all, could constrain our
freedom, other than thoughts, if the mind is not subject to physical
laws? The fact that neural correlates of certain mental processes have
been or may be discovered, as several contemporary philosophers have
argued, does not mean that these neural processes are identical with the
mind, or that they determine the mind. In fact, such determinism would
be impossible on a dualist conception of reality. As René Descartes would
have it, given the distinction between mind and body, judgments are
mental processes and not physical ones, so addictive behaviors would
have to be the result of choice, unless people are to be thought of as
zombies, driven by mindless physical appetites, but they are not. For
those who accept any version of dualism, humans are minded beings
 Some Philosophical Questions (and a New Theory) 21

who make judgments and choices. Those who accept the choice model
seem to be committed to something like this. The level at which addic-
tive behaviors should be judged, given this kind of view, is the psycho-
logical, with the possible exception of those who think of addiction as
a “disease of the spirit.” In that (quite popular) case, more is involved
in addiction than just psychological categories and consistently poor
choices, but whatever is involved, it is something beyond physical deter-
mination. In this case, as well as in the cases of other choice models,
the proper manner of address and treatment of addictive difficulties
is through the addict’s character, his motivations, his beliefs, and his
psychological attitudes.
If, on the other hand, actions, ideas, beliefs, and emotions just are,
or are causally determined by, constantly oscillating neurons shooting
neurotransmitters at one another in a perpetual electric storm, then we
have a very different story to tell. Everything, human and otherwise,
this account suggests, is just part of the causal matrix that constitutes
the natural world. Numerous philosophers and neuroscientists have
reached this conclusion on the grounds that humans are not free, for
example, in ethical matters, but merely enjoy (or suffer from) an illu-
sion of free will.32 Taking this approach, and simply leaving the story of
addiction at the level of neurotransmitters and reward circuits, though,
would, at its extreme, leave humans in the unenviable position of being
something akin to confused zombies (that is, zombies under the illu-
sion that they aren’t). Addicts on this account would be helpless to do
anything about their problem, because not only are they compelled
by the brain changes that define their addiction; what is more, even
the causes of any desire they might have to avoid indulgence would
be determined by physical processes over which they have no control.
This view, in other words, taken to its logical conclusion, requires that
we just give up the idea that mentality is something real, with causal
powers and other characteristics of its own. On this view, there is no role
for the psychological per se, because psychological categories can always
be reduced to physical ones.
Rather than either of these alternatives, I argue throughout this book
that the body and the mind of the human being comprise one organic
whole, and that even though “parts” of the person may seem to be in
conflict with one another, particularly in addiction, the same can be
said about the mind itself. The story that addicts have to tell is often one
of deep conflict, but the conflict is between competing impulses in the
whole being. It is not a conflict that can be helpfully resolved through
accepting dualism. Neither will it be resolved, however, by trying to
22 Addiction

explain the phenomenal aspects of this specifically human experience

through looking deeper and deeper into the “parts” of the organism. It is
not the case that some ultimately precise understanding of the neurons,
synapses, and neurotransmitters, or the molecules from which they are
constituted, will finally tell us how addiction is born, or how it might go
away. The relations between these elements are just as important as the
elements themselves. Systems do not merely consist of sets of parts. In
fact, the very language of parts and wholes (“mereology”), as we will see,
fundamentally misdirects our thinking and thereby underlies at least
some of the difficulties that consistently come up in attempting to help
those suffering from addiction issues.
As philosophers James Ladyman and Don Ross have put it, the
attempt to “domesticate” our conception of the ultimate nature of
reality, conceiving it in terms of “homely images of little particles,” is
a forlorn project. 33 There just are, they say, “no little things and no
microbangings.”34 Even more to the point, according to a naturalized
metaphysics, that is, one that comes from and answers to science: “it is
no longer helpful to conceive of either the world, or particular systems
of the world that we study in partial isolation, as ‘made of’ anything
at all.”35 The “things” we see and use every day are no more and no
less real than the smaller parts that we use to describe them. But those
smaller parts, which can themselves be understood in terms of even
smaller parts, are no more fundamental than the things that they consti-
tute. None of the parts is more fundamental than any of the others. In
contrast to the typical conception of physical things as substances of
either one or two (or more) kinds of “stuff,” in this metaphysics, all enti-
ties are ultimately constituted of moving relations.
Humans, like all organisms, belong to an even more particularly speci-
fiable type of system. Like stock markets and rain forests, humans are
complex, dynamic, open systems, constituted of interconnected, inter-
dependent agents that are in constant interaction with each other and
their environments, adjusting to changes as they make changes to the
world around them. These systems are marked by a number of char-
acteristics. For one, they behave chaotically, so that small changes to
inputs can make dramatic changes later in the whole system. Because of
this, unlikely events, such as mass extinctions or market crashes, are not
all that unlikely; they occur much more often than would be predicted
by a normal bell curve. In an addicted person, small changes can have
surprisingly large changes in a person’s entire orientation toward her
substance or activity of preference. Further, systems of this kind don’t
just act automatically, since their elements are not fixed, but rather are
 Some Philosophical Questions (and a New Theory) 23

adaptive. They are constituted of entities that change their strategies

as they accumulate experience, making these systems truly dynamic.36
Finally, systems of this kind exhibit continually developing diversity and
specialization in emergent hierarchies of organization. To understand
the true nature of addiction, and to ameliorate the problems caused
by it, we will have to completely reconceive of the nature of human
beings and our relation to the world around us. We will have to purge
ourselves of the prejudices that come with presumptions of mereology,
reductionism, and linear causation, in favor of a conception of reality
that allows for the real existence of many emergent levels of “things,”
each possessing its own types of behaviors, properties, and relations.
Critically, the framework of our thought must be shifted from stuff to
“goings-on.”

A different way to think

Addiction on the current account is neither a set of choices nor a disease

nor a psychological or social entity of any sort, although it concerns
biological, psychological, and social systems alike. Addiction, rather, is
a more or less stable process that both constrains and is constrained by
the larger and smaller processes that constitute and constrain certain
human lives. To begin to understand this, it is important to note that
neither humans nor any other organisms are composed of parts, prop-
erly so called. The organs that we identify in human or other organic
bodies wouldn’t be those organs outside of the systems in which they
are involved, and the cells that constitute those organs (and the mole-
cules that constitute those cells) are both synthesized by and create the
organisms and the lives to which they contribute. That is, the tissues
and organs that we identify functionally in organisms are intrinsi-
cally tied to the organism from which they develop and to which they
contribute. They are not independent things that together make up the
living thing, in the way that parts of a mechanism are first manufac-
tured and then put together to make the machine. And it’s not even that
the organism exists first, and then the organism “tells” cells which kinds
of organs to form, as in so-called top-down causation. This can’t be the
case, because the organism doesn’t exist until the cells that constitute
it have developed, so there is no “top” to cause the smaller units to do
anything until it has formed. For that reason, the term “self-organizing,”
often used with respect to such systems (and for other, inorganic ones,
such as whirlpools and cyclones), is to some degree misleading. While
certainly it is true that nothing else organizes such systems, the term
24 Addiction

suggests that there is a “self” that does the organizing. This, we have just
said, is not the case. “In fact,” as anthropologist Terrance Deacon says,
“the coherent features by which the global wholeness of the system is
identified are emergent consequences, not its prior cause.”37 That is, the
organism that is the whole (the “self,” or the “top” of which we are
speaking) can’t be the controller of the system, because it is itself emer-
gent from that system.
Even with ordinary inanimate objects, according to the best that
current science can tell us, there are no ultimate parts; rather, there are
only processes.38 As was suggested above, Ladyman and Ross hold that,
contrary to standard views, “[p]recisely what physics has taught us is
that matter in the sense of extended stuff is an emergent phenomenon
that has no counterpart in fundamental ontology.”39 In every case,
macrosized objects emerge from molecules in motion. These molecules
themselves consist of atomic-level (and lower) processes, with the
“whole,” or higher-level processes, interacting with other processes in
the environment, until the point when the object’s processes disinte-
grate. It doesn’t matter whether we’re talking about mountains, skate-
boards, or solar systems. All physical things not only can be understood
as processes but moreover are so understood by those at the forefront of
our science. This idea is not new. In fact, one could say that it is as old
as the ancient Greek philosopher Heraclitus, who said, in opposition to
his Ionian contemporaries, that “it is impossible for a man to step into
the same river twice.” But the idea that processes are ultimate is one that
human beings resist intuitively, and with good reason: things around
us seem to be stable, substantive, and persisting. Thus, the process
view of reality has been resisted philosophically at least since Aristotle
asserted, contrary to Heraclitus, that all material objects consist of quali-
ties inhering in a substrate. And the process view has been resisted in
the modern world since Descartes unequivocally distinguished thinking
substance from material substance. It is just easier, personally and scien-
tifically, for us to think of the objects around us (and, by analogy, of the
microentities of which they are constituted) as things. After all, that is
what experience teaches us as children, and that is the level at which we
usually interact with things. However, it is also easier for us to think that
the sun rises and sets than it is to think that the earth rotates, but that
doesn’t make it true.
Even if it is true that all things are ultimately processes, the question
remains why this fact could possibly help provide a fuller understanding
of addiction, a phenomenon that clearly occurs at the macrolevel.
One response is that if addiction is a process, then it is a temporal
 Some Philosophical Questions (and a New Theory) 25

phenomenon, emerging and disappearing as conditions warrant, and

not a permanent, or even semipermanent characteristic of a human
being, part of her “character” or “nature.” One is not an addict, despite
the fact that people often speak in that way. We are human beings,
which, as Deacon and cognitive scientist/philosopher Mark Bickhard,
among numerous others, argue in accord with the present view, means
that we are complex dynamic systems, more or less stable patterns of
activity, constrained by and constraining other patterns. Emergent
from complex systems of this type are psychological states, tendencies,
and behaviors. In people with addictive problems, we find a pattern of
internal and external interactions, a dynamic pattern, sometimes more
and sometimes less stable, depending on conditions in the lower-level
patterns from which the higher-level ones emerge, and dependent as
well on the social conditions into which it emerges. By “stable” I mean
not healthy and fine of mind, but rather entrenched, deeply habituated,
statistically relatively unlikely to change.
The patterns that constitute both human beings and their addictions
seem to be constrained, or kept from undergoing certain changes, from
both below and above. For instance, as we will see in Chapter 3, the
conditions necessary for developing an addictive pattern seem to run in
families, with some part of that being attributable to genes, and some
part to the environment shared with parents, but those patterns them-
selves are emergent from lower-level ones and dependent upon higher-
level ones. Inherited properties are not all about genetics, and genetics
is not deterministic. The influence that genes have on addiction is a
function of any number of concurrently existing (or missing) epigenetic
factors, and so destabilizing addictive patterns of behavior is from this
perspective perfectly possible. Further up the macrolevel scale, we will
see that in some cases the environment counters the tendency to develop
an addictive pattern, because it affords no opportunity to use addictive
substances, or even just because there is simply strong social discourage-
ment against indulging in them. Given this mutuality of causal connec-
tions, language of directionality is misleading, and ultimately, incorrect.
Nevertheless, in an effort to be consistent with common discourse, we
might reasonably say that addictive patterns of action are shaped both
from the “top down” and from the “bottom up.”
But, one might ask, how could patterns possibly constrain patterns? It
isn’t the patterns that constrain other patterns, we’re inclined to think,
but what the patterns are made of – that is, our tendency toward substance
thinking suggests that patterns couldn’t themselves cause anything, or
prevent anything (another type of causation), because patterns are only
26 Addiction

abstractions. Surely it is the things that are arranged into patterns that
count. Quite the contrary is true, however, as the history of science
shows. Mark Bickhard reminds us of example after example of Cartesian
substance metaphysics being replaced with process models, as when
the phlogiston theory, according to which a fire-like substance was
released in processes such as burning and rusting (explaining why the
things burning or rusting became lighter) was replaced with the oxida-
tion theory. Similarly, with respect to heat, the caloric theory, according
to which the presence or absence of a substance (caloric) was said to
account for something’s temperature, was ultimately replaced with
the molecular motion analysis. What is more, those who are versed in
quantum physics tell us that there are no ultimate particles, but only
processes of quantum fields, in which what are more easily described
for purely heuristic reasons as particles are instead actually “excitations”
of parts of a quantum field. Again, we think in terms of particles, but
that doesn’t mean that they actually exist as we think of them, even
within the theories of which they are constitutive. In all these cases, it
is patterns of interactions rather than substantial things that ultimately
came to be understood as comprising the events and objects around us,
and the things that we call causes.40
It seems, then, that patterns of organization can and do have causal
efficacy. As Deacon puts it, “[b]ecause there are no material entities that
are not also processes, and because processes are defined by their organi-
zation, we must acknowledge the possibility that organization itself is
a fundamental determinant of causation.”41 On this view, at least in
one sense, the reductionistic physicalists are absolutely right: nothing
is left out once we describe every bit of matter in a system, since what
is left out is not a thing at all. What remain once material substances
are rejected are the patterns of organization ... and the constraints that
those patterns create for others, at higher and lower levels of organ-
ization. Interestingly, it is precisely because of this structure that
process ontology can’t be defended empirically: there is nothing one
could observe that could prove such an ontology to be the right one.
Everything that can be observed is just the stuff that we ordinarily think
is there. What is at issue in this case is whether the patterns themselves
actually count as entities in themselves, exhibiting causal powers attrib-
utable to their own level of specificity. The patterns do count, and they
have been overlooked for far too long, in favor of a mistaken emphasis
on the things that are involved in patterns and that are caused by them.
Substance metaphysics is unwarranted not because it has been proven
false, which would be impossible, but because its implications for trying
 Some Philosophical Questions (and a New Theory) 27

to do certain kinds of science make it untenable. Any assumption that

renders impossible what we are already in fact doing successfully, can
be taken as false. As we have seen, the assumption that substances
underlie all properties and relations has had unacceptable consequences
in a variety of areas of scientific study. The reasonable conclusion is
not that we should keep the phlogiston hypothesis, for example, and
continue to try to make sense of the fact that metals become denser
when fired in light of that hypothesis. Rather, the reasonable conclu-
sion is that we should abandon the ontology that includes phlogiston
in favor of one that supposes the process of oxidation as its start. Mutatis
mutandis, we should not continue to try to make sense of such things
as mind/body relations in light of substance metaphysics; rather, we
should abandon that ontology in favor of the more functional process
metaphysics.

Why care about metaphysics?

As unlikely as it might seem to someone who doesn’t normally think

in philosophical terms, the ontology that one adopts turns out to be
relevant to thinking about addiction. One reason that might be cited
in favor of accepting process ontology, as we have said, is that under-
standing both humans and their addictions as processes, rather than as
things, emphasizes their temporal nature. Humans are not in general
addicted throughout their lives. Babies, if born addicted, are treated in
their earliest days so that they are not addicted in the years to come
(although having experienced the pattern could be a factor strength-
ening the probability that they will experience addiction again). Most
people, happily, are not addicted at all in their earliest years. In fact,
most people who develop addictive patterns experience this shift in their
teens and twenties, and, on behavioral notions of addiction at least,
there is significant research to show that most people do not remain
addicted late into adulthood, even without treatment or groups.42
Again, of those who enter treatment, many people recover from addic-
tion, and live without that pattern in their lives for the remainder of
their lives. Thinking of addiction in terms of processes allows us to think
more freely about the possibility of disrupting it. One way that it does
this is by allowing the addict to think of herself as an ever-changing
being, with many open-ended possibilities. Particularly when we think
of people in terms of complex systems, wherein small changes in one
part of the system can result in large changes elsewhere, the process
model is particularly hopeful.
28 Addiction

The main value of a process ontology for this and other types of
analyses, however, is that it allows for a consistent conception of the
phenomenon of emergence, and hence for a way to conceive of mind as
neither distinct from, nor as reducible to, but as on a continuum with
body – one set of patterns essentially upheld by and integrated with
others, operating in mutual causal loops. This shift in conception is vital
to our having a proper understanding of the nature of organisms, and
minded human organisms in particular, but most particularly for our
purposes, it is important for our understanding the specific character
of addicted humans. Organisms are natural beings, but they are not the
same as nonliving natural beings, even when the latter are involved in
complex dynamic systems. Organisms bring about an increase in order,
or a decrease in entropy, as they self-maintain and develop, whereas it is
the natural tendency of their nonliving molecular components to move
toward a decrease in order, or an increase in entropy. The peculiar prop-
erties characteristic of living beings, as Deacon demonstrates in a metic-
ulously worked-out model, are emergent from properties of nonliving
beings.43 That this must be so is clear from the fact that the first lifelike
process “was not reproduced, it had no parent, and therefore it did not
evolve. It emerged.”44 And mind similarly emerged out of organisms
interacting with their environments. The mental and physical patterns
particular to addiction are also processes that emerge in minded organ-
isms when the conditions are just so.
As important as it is for properly understanding life itself, and, as we
will see, value and even mind, the concept of emergence is not currently
generally accepted in either philosophy or psychology, although in the
physical sciences it is held in higher favor. In philosophy, the theory
of emergence has a long and mottled history. In order to explain and
defend the perspective of this book, which depends centrally on this
concept, it will be necessary to see how emergence, as it is understood
here, is distinct from the version that quite rightly fell out of favor. So
what do we mean by “emergence”? Nothing mysterious, nothing inex-
plicable in terms of purely physical laws. In general, we shall begin by
saying that the concept of emergence used here refers to a property or
entity that exists as a function of two or more things that are themselves
of a different character from the whole. Philosopher J. S. Mill defended
this notion as long ago as 1843, although it was his student George
Henry Lewes who coined the term “emergence.” According to Mill, the
principle of the Composition of Causes (causes that work together to
create an outcome – such as bits of metal of a particular weight coming
together to make a slab of metal whose weight is the sum of the bits)
 Some Philosophical Questions (and a New Theory) 29

is sometimes contravened. This is the case, for example, in chemical

reactions. Mill says that “[t]he chemical combination of two substances
produces, as is well known, a third substance with properties different
from those of either of the two substances separately, or of both of them
taken together.”45 Consider for example, NaCl, or table salt. Sodium, a
metal, and chlorine, a dangerous poison, when bonded together make
one of the most widely used food seasonings. But nothing that one can
say about the components, either taken separately or together, could
explain this result. Numerous philosophers following Mill defended
emergentism, including C. D. Broad, who argued for the emergence, or
irreducibility, in the case of the mind.46
Many difficulties led to emergentism’s falling into disrepute by the
middle of the 20th century. Some of the main problems are evident,
upon reflection. First was the challenge from the logical positivists, that
emergentism is an explanatorily bankrupt mystery theory, similar to
vitalism, the explanatorily empty belief that the reason that organisms
live is that they are imbued with a “life force,” an “élan vital.”47 The
problem according to this challenge is that allegedly emergent prop-
erties are meaningless, in that they fail to answer the scientific ques-
tion of how is it that two things, each with properties of their own, can
together become a different thing with new and different properties.
To say that the novel properties emerge (or that a new entity emerges)
is on this view to say nothing more than that the object has the prop-
erty (or that the entity exists) because it has the property (exists). If,
for instance, sodium and chlorine are entities with their own intrinsic
properties, then they are what they are, and whatever results from them
must be traceable to those properties. If the theory of emergence is true,
however, then something new, with new properties, emerges when the
two elements are bonded together in a certain way, and those proper-
ties operate according to a set of principles that are not the ones that
describe the behaviors of either of the constituents. But according to the
“empty explanation” criticism, to say that these new properties emerge,
and are not explicable in terms of those characterizing the original two
substances, is simply to say that it is a brute fact that the new properties
exist.
What is more, philosopher Jaegwon Kim argued that explanations in
terms of emergence as so far described are subject to two further powerful
criticisms48: first, if emergent entities and properties are dependent
upon microlevel entities and properties, and if they are at the same time
supposed to cause changes in the microlevel entities, then the concept
of emergence would seem to involve a vicious kind of circularity. One
30 Addiction

class of things causes another class of things, which things in turn exert
causal influence on the things that caused them. Second, emergent enti-
ties and their properties would seem to be causally redundant, for since
they result from the microentities on which they rely, any causal effi-
cacy that they exhibit can actually be traced down to those microlevel
entities. So, if emergent entities and properties can be causes, it is only
because of the lower-level entities and properties to which they can be
traced. But in that case, only the lower-level things can be counted as
real. As Kim notes, one way that the above problems can be avoided is
to employ emergent properties conceptually, as levels of (mere) descrip-
tion that might be useful for gaining insight into various aspects of
phenomena in which we are interested, but not to accept them as real.
If emergent properties aren’t taken to be real, with causal efficacy of
their own, then the paradoxes and puzzles disappear. Unfortunately,
however, so do the explanations that we seek.
Another way to avoid the flaws of traditional emergence theory, and
the way that will be defended here, is to deny the foundational assump-
tion of a substance-based world in favor of a process-based one. In
particular, the kinds of processes with which we are concerned here are
those that organize around maintaining far-from-equilibrium systems,
that is, those that operate contrary to the general tendency toward
increasing entropy. A simple example of a self-maintaining system is a
candle flame:

A candle flame maintains above combustion threshold temperature;

it melts wax so that it percolates up the wick; it vaporizes wax in the
wick into fuel; in standard atmospheric and gravitational conditions,
it induces convection, which brings in fresh oxygen and gets rid of
waste.49

This kind of process is, of course, dependent upon lower-level processes

(molecules of oxygen and wax, for instance, in addition to higher-level
processes such as combustion and convection). Life is another, much
more complex instance of self-maintenance, emerging from nonliving
processes. Organisms are constantly engaged in processes of organizing.
They incessantly generate new “appropriately structured and appro-
priately fitted molecular structures,” employing energy and materials
from the outside to fuel their internal processes. These self-maintaining
systems are thus essentially dynamic, persistently and successfully
pressing back against “the ubiquitous, relentless, incessantly degrading
tendency of the second law of thermodynamics.”50 And not only do
 Some Philosophical Questions (and a New Theory) 31

individual organisms reverse entropy by maintaining themselves but

they also reproduce themselves by replicating both the patterns that
constitute them and the materials subserving those patterns. What
is more, organisms decrease entropy globally through evolution by
adapting to their environment, coordinating with the other elements
in their ecosystems. Increasing complexity and increasing order is the
natural dynamic of these systems, the pervasive exception to the second
law of thermodynamics.
Seeing things this way requires a flip in what we see as the foreground
and what we see as the background. In traditional substance meta-
physics, things take the foreground, and their relations make up the
background. This fundamental reversal of the direction of natural proc-
esses is a defining characteristic of emergent transitions. Such transi-
tions arise naturally from two or more ordinary processes undoing each
other’s efforts, with each process constraining the other in a way that
has the overall effect of causing a wholly new pattern to emerge.51 This
new dynamic pattern, constrained by the ordinary, entropy-producing
patterns from which it emerges, as we have said, decreases entropy, as
it utilizes its environment and changes to be able to use it even more
effectively. With this emergence of a self-maintaining pattern comes the
emergence of function, for the asymmetry of an organism’s relations
to other things in its environment extends to the internal processes
contributing to that maintenance as well. An activity or process can
only be a function in the context of a goal, just as relative value can only
exist in the context of an aim. Contributing to the self-maintenance of
a far-from-equilibrium system that would not continue to exist without
self-maintenance activities is the essence of a function.
What is more, self-maintaining processes, particularly those that are
also self-organizing, such as living processes, define a distinction between
“self” and “not self.” Some processes are essential to the self-mainte-
nance, and others are not. Those that are essential to the processes of
self-maintenance will count as “parts” of the “self,” even if the self that
we are talking about is no more than a “persistent and distinctive locus
of dynamical organization that maintains self-similarity across time and
changing conditions.”52 That is, even if the self isn’t actually an entity,
but more like an abstraction, there will nevertheless be a locus around
which a dynamical pattern maintains something analogous to an identity
over time and in an environment. And even without an identity in the
strict sense, a dynamical system distinguishes between external things
that contribute to the system’s continued existence (“good”) and those
that threaten that existence (“bad”). The functioning of the system’s
32 Addiction

own subprocesses, as well, can either contribute to (functioning “well”)

or detract from (functioning “badly”) the system’s continued self-sim-
ilarity. Thus normative properties (value), including function, emerge
naturally from nonnormative ones, according to this process-based view
of emergence, but only relative to the system(s) in question. These are not
objective properties in the world, but neither are they reducible to the
subserving ordinary processes that obey the general principle of entropy.
When lower-level processes are related in such a way that individual
self-undermining processes counter one another, the system as a whole
moves toward increased development and stability, and establishes rela-
tionships of value with respect to other processes
“Normative function,” says Bickhard, “is just the bottom of a long
hierarchy of normative emergences. All of mind and mental and social
phenomena are fundamentally normative, and they all emerge in a hier-
archy with biological functional normativity at its base.”53 Like func-
tion and value, mind on this kind of process ontology emerges from
the asymmetries inherent in biological processes. Mind is not, however,
directly reducible to biological organization or function, any more than
value and function are reducible to the components of the systems to
which those properties relate. The reason, in fact, that we have had such
a hard time philosophically accounting for the existence of mind is that
“we have stubbornly insisted on looking for it where it could not be, in
the stuff of the world.”54 To see how mind relates to body, we need to
look to what is not there; we need to look not to stuff, but to constraints
created by opposing patterns of action.
Philosophers and cognitive scientists attempt to map living dynamics
and cognitive processes directly to simpler physical processes, and thus
to try to reduce the mental to mechanistic processes occurring between
unchanging substances with no structure.55 They try to trace one kind of
phenomenon to a categorically different kind. It is no wonder that the
“explanatory gap” is such a puzzle! Ordinary processes do not mechani-
cally produce mental activity in any direct or additive manner, and if
you try to understand the relation in that way, you will inevitably come
face-to-face with a chasm. Microscopic work is necessary for macro-
scopic phenomena, but it is not sufficient. Mental processes arise, as
do organisms themselves, from self-maintaining systems adjusting to
changing conditions in the environment, and the mental processes that
emerge in this way are patterns of activity irreducible to their constit-
uents. Mentality is thus naturally describable as intentional, a set of
higher-order processes involving the further processes of information
reception, preparation for action, and many, many others, at various
 Some Philosophical Questions (and a New Theory) 33

levels of organization. There is no limit, in principle, to the orders of

organization that can emerge from the same basic system.
Here is where we return to addiction. Addictive mental dispositions
to repeat behaviors, to find salience in particular objects and activi-
ties, and to undergo particular types of psychological experiences are
simply higher orders of organization in complex dynamic systems based
completely in natural processes. Addiction involves complex patterns
of interaction from the molecular to the cellular to the systemic, from
the organismic to the environmental. It involves physiological, psycho-
logical, and higher and lower orders of complexity. It even includes the
social and the abstract. Addiction is an irreducible reality.
Once we move away from trying to understand its features as either
the chemical-electrical functioning of neurons or as the intentional,
experiential phenomena that only those who are addicted can know, we
can escape both from radical reductionism and from brute, inexplicable
dualism. “Mental states don’t exist, any more than do flame states,”
says Bickhard, rather provocatively. His point is that neither mental
states nor flame states are things; they don’t have that sort of ontological
status. Rather, they are both processes,56 emergent from other processes
and interacting with other processes to produce yet more encompassing
processes. None of these are separable from the others, so “top-down”
and “bottom-up” characterizations of change are the result of funda-
mentally wrong thinking. Every process serves as a constraint, or limi-
tation on possibilities, on those with which it interacts. Thinking of
mental states or biological states as states drives misconceptions all the
way down the line, creating profound implications for how we under-
stand addiction.
As we shall see, understanding human mental and physical life in terms
of emergent patterns, rather than in the terms of either the dualist or the
radical reductionist, will provide us with a different conception of addic-
tion than has yet been available. This alternative to the false dichotomy
so far presented to us will allow us to appreciate contributions from
neuroanatomy and neurophysiology, as well as from biochemistry and
psychology. In addition, there is room for contributions from genetics
and sociology and cultural anthropology. Addiction is a multifaceted
process emerging from both lower-scale and higher-scale interacting
dynamic patterns, open ended and at most only relatively stable. Each
of these levels of organization that contribute to addictive patterns in
organisms, from the molecular to the cellular to the mental to the social,
is a real system, with real causal powers of its own. Analyzing addic-
tion in terms of each of these levels and their interactions will help
34 Addiction

us see how it is brought about by genetic and epigenetic influences,

by attachment failures and traumas, by terrible mommies and driven,
stressed-out societies. And it will provide us with a path forward for
addressing this phenomenon without either reducing people to impo-
tent chemical systems or thrusting on them blame for choices that lead
to failed lives and social disarray.
3
Addiction and the Individual

Alcohol addiction has been referred to in print as a disease since the

end of the 18th century.1 By 1956, the American Medical Association
(AMA) had endorsed the disease model, and the view has since received
public and unequivocal endorsement by numerous influential medical
organizations, including the World Health Organization.2 Researchers
commonly use a variety of methodologies that rely on the disease model
to attempt to understand various aspects of addiction, and several
methods that have been used to study addiction suggest that the disease
model is a good one. For instance, twin studies and adoption studies have
provided evidence that genetics plays some role in addiction. Moreover,
molecular biology explains certain phenomena that occur in the brain
with repeated exposure to addictive drugs. These findings seem to make
sense of the compulsive element that is associated with many cases of
addiction, at the very least suggesting that something other than simple
choice is involved. Nevertheless, much care must be taken to situate
the cart relative to the horse in this research, and to disentangle the
many and diverse threads of addiction research, if we are to evaluate
the contention that addiction is a disease.

Psychological accounts of the disease

Because of psychology’s developmental path as a discipline, at least

two fundamentally different paradigms have come to guide addiction
research. One conceives of addiction in “folk psychological” terms,
using such words as “craving” and “anxiety,” while the other describes
it in terms of neurobiology. Despite their completely different orienta-
tions, the two conceptual frameworks are used simultaneously by many
researchers, as they endeavor to offer explanations of the psychological

35
36 Addiction

experience of addiction in neurobiological terms. Others seek interven-

tions in terms of talking therapies for certain behaviors and biological
symptoms. Mental structures and functions, though, are clearly not
physiological structures and functions. The two sets of categories do not
even overlap, and it is not clear how these two paradigms are supposed
to relate. Some psychologists say that psychological experiences are
“mediated” by neural activity, while others say that the neural activity
provides a “substrate” or “subserves” psychological experiences. These
are vague phrases that point to something that is wanted, but they do
not explain anything. What it seems to come to, though, is that due
to their differences in approach and research methods, some scien-
tists assume that addiction is a physiological phenomenon, and that
any psychological descriptions of it ultimately reduce to physical ones.
Others see the psychological categories as fundamental, and want to
preserve the independence and causal efficacy of those structures and
functions. We will see as this discussion progresses that the emergent
model of life, mind, and social groups that we discussed in Chapter 1 are
helpful in reconciling these two elements of the disease model, without
either having to reduce one to the other or being forced to assert yet
another kind of dualism.
To begin at the most obvious place, let us consider that the “disease”
of addiction is defined for clinical purposes in psychological terms.
According to what has become a fairly standard formulation among
disease model theorists,

[d]rug addiction is a chronically relapsing disorder that has been

characterized by (1) compulsion to seek and take the drug, (2) loss of
control in limiting intake, and (3) emergence of a negative emotional
state (e.g., dysphoria, anxiety, irritability) reflecting a motivational
withdrawal syndrome when access to the drug is prevented.3

Addiction here is characterized by behavioral and emotional symp-

toms, in terms of feelings and states of mind. More specifically, it is
marked by three distinct “stages,” according to Nora Volkow, director
of the National Institutes for Drug Addiction, and her highly respected
coauthor George Koob. These stages, which collectively constitute what
has come to be known as the “addictive cycle” include “‘binge/intoxi-
cation,’ ‘withdrawal/negative affect,’ and ‘preoccupation/anticipation’
(craving).”4 These stages follow on one another with increasing regu-
larity, according to the disease model, given chronic exposure to an
addictive drug, with increasing intensity, until the addict “loses his
 Addiction and the Individual 37

ability to control” his actions. The DMS-IV-TR lists four classes of drug as
capable of instituting this cycle: psychostimulants (methamphetamine,
cocaine), opiates (heroin, morphine, oxycontin), alcohol, and nicotine.
Gambling is the only activity currently listed among the addictive disor-
ders, and even that is characterized as an impulse control disorder and
not as an addiction per se. It is described, though, in terms nearly iden-
tical to those used with substance abuse and dependence, and the list is
liable to grow. Shopping, playing video games, and preoccupation with
sex are among the activities that are already being spoken of in terms of
addiction, or something very close to it.

Hedonic theories
The thing that these substances and at least one activity have in
common is that they produce rewarding experiences, and, for some
people, much greater rewards than do ordinary pleasures, such as food,
exercise, or sex. The notion of being “high” is truly significant here;
the reward experienced is above and beyond the experience of reward
achievable through those other means. What is more, the length of time
that reward is experienced through substances and activities of addic-
tion is far greater than it is for regular, nonaddictive pleasures. That is,
the pleasure of sex may be intense, but it does not last long relative to
the effects of alcohol, cigarettes, or opium. Given both of these facts,
it is not surprising that someone would want to repeat the experience.
Hedonic theories of addiction focus their attention on this feature. The
pleasure, the elevated mood, the alertness or relaxation is brought about
by the addictive substance is immediate, undeniable, and relatively long
lasting, regardless of the negative experiences that may occur in conjunc-
tion with use. Repetition of the cycle continues, because what happens
in conjunction with use does not eliminate the emotional associations of
the satisfaction that use brings. As Joseph LeDoux discovered, memory
is intimately connected with emotion; in fact, his research shows that
the emotional element of any given memory seems to be pretty much
permanent.5 When the memory itself is completely forgotten, the
emotional associations that our brains create with respect to persons,
places, things, and experiences remain intact. Even when the emotion
seems to have been extinguished, so that you no longer experience, say,
fear in the presence of a snake, it can be resurrected by certain stimuli,
such as returning to the place where you saw the snake. An addict may
in the most visceral sense continue to make the connection, “do X for
a good time,” long after she no longer remembers particular experi-
ences of use with pleasure, and even after she no longer remembers the
38 Addiction

particular feeling that is that experience of the “good time.” Emotions

are both older and quicker to move us than deliberative reason, hedonic
theories emphasize, and so a person who has been stuck in an addictive
pattern may well retain automatic positive reactions to a substance of
abuse, even when she has been abstinent for a significant amount of
time, and reason reminds her that the long-term outcomes of return to
use will be wholly negative.
Others have argued that people who become addicted may start to
indulge in the drug or activity because of the pleasure reward, but they
continue to seek out and imbibe their preferred substance or activity
because cessation results in painful withdrawal. On this theory, it is the
contrast of pleasure that explains addictive behavior. The very same
motivational system that allows highly or unexpectedly6 positive expe-
riences to condition the addict to seek repetition of a behavior can also
operate to create an aversive response to the significant displeasure that
occurs when the drug (or the “rush” from gambling) has left the system.7
On this view, it is avoidance of the pain of withdrawal that motivates
the addict. From the hedonic perspective, either the pleasure itself or
the pleasure/pain opposition is what explains continued use of addic-
tive substances and activities, as well as the return to them even after
abstinence has been achieved.

Incentive sensitization
In many studies, subjective states of pleasure and persistence in drug
taking have not been found to be highly correlated.8 After repeated expo-
sure to a drug, some people continue to “want,” or be preoccupied with,
a drug even when they no longer even “like” its effects.9 This persist-
ence of “wanting,” or sensitization, to a drug is a significant compo-
nent of the phenomenon of addiction, and one of the main factors that
distinguishes it from drug dependence. Because of associative learning
that takes place, long after exposure to the drug has ceased, an addicted
individual can remain sensitized to cues relating to drugs and activities
of addiction, as well as to the drug or activity itself. As a result, upon
being exposed to images, places, or people associated with the drug of
choice, not to mention the drug itself, the individual is strongly moti-
vated to return to drug seeking and use. Only in some cases do addicts
additionally display an ongoing positive attitude toward their substance
or activity of choice. 10 Often, in the face of directly suffering its harms,
addicts will have a consciously negative attitude toward the object of
their addiction, but that doesn’t stop the craving for it or the seeking it
out. As with an unresolved “sensitive issue” between two people, once it
 Addiction and the Individual 39

has developed, it is difficult for any discussion or activities touching on

that issue not to arouse those sensitive feelings again, and it is difficult
to avoid thinking about it when anything reminds one of it. Because
one of the things that dopamine does is motivate seeking generally,
when this system becomes sensitized, anything that reminds an indi-
vidual of the object of his addiction, whether it be feeling a particular
way, or images of drugs or paraphernalia, or people or places associated
with drug use or gambling, the response of seeking and use is thrown
into operation. This happens even without any conscious consideration
of a reward or aversive association being involved.11 And because of the
kind of automaticity that’s involved, once action in the direction of use
is launched, it is generally followed through to completion.12
What goes on in the brain for the most part, including the associative
and emotional learning that drives our motivation,13 operates largely
behind the scenes. For this reason, what certain objects or activities
signify to us or evoke in us is often not consciously recognized. Not
just addicts but all of us can consciously and “officially” tell ourselves
stories about what we’re doing and what we believe and what we plan
to do, while those stories may have little to do with what our biases
or sensitivities actually are, and little or nothing to do with how we
are likely to act. This shouldn’t be surprising – most things that we do
throughout the day are done more or less nonconsciously, from going
through the routines associated with showering and dressing, to driving
familiar routes, to clicking through the Internet news. Given this, it
seems obvious how it can happen that an addict who can resist cravings
and all sorts of obstacles as long as sobriety remains in the forefront of
his mind, can surprise himself, and find himself smoking or stoned, or
just craving doing so, upon being presented with an associated object,
person, or place.

Habit
Some research has suggested, based on such observations, that the
common phenomenon of habituation, with its attendant automaticity,
could explain the phenomenon of relapse into addictive behaviors.14
This explanation does not do as much work as the motivation salience
sensitivity approach does, however, because most habits are not expe-
rienced in terms of “triggers” that seem to drive people into behaviors.
While entering the freeway might, if I’m not paying attention, result in
my arriving at my university rather than at the dentist’s office, just the
mere sight of the freeway does not set off a perseveration with respect
to the university. Habits can generally be recognized and broken with a
40 Addiction

facility that seems contrary to the compulsivity that many believe to be

characteristic of addiction. What is more, although habituation surely is
a component of addiction, using it to explain the “loss of control” char-
acteristic of addiction would not be consistent with the disease model
that gives rise to the definition we are considering. We do not gener-
ally see habits as medical ailments for which insurance should pay to
treat us.
Several different psychological accounts have thus been offered for
explaining why addicts exhibit the behaviors that they do and experi-
ence the feelings that they describe. In attempting to determine which
of these accounts provides the best explanation, psychologists began,
as technology made it possible, to try and identify the physical proc-
esses that occur in addiction, and to use this knowledge to confirm
some of these accounts and to develop others. In this way, the disease
model became entrenched as the received view of addiction among the
scientists who study it. If addiction is the result of observable biolog-
ical factors, goes the reasoning, it cannot be a function simply of poor
choices.

Neuropsychological accounts

The hedonic, habituation, and salience sensitization models of addic-

tion, we should note, tell us nothing of why the addictive cycle ever
starts or how it works. Specialists in the biological side of psychology
have attempted to provide an answer to the second question. Through
experimentation with animal models and through use of imaging tech-
niques to study the human brain, scientists researching the physical
aspect of addiction have developed theories of what happens at the
molecular, neural, and neural systems levels when someone is addicted.
It is said by many psychologists, as was mentioned above, that the
psychological characteristics of addiction are “mediated” through the
neurological systems described in these models. Thus, we find in biolog-
ical psychology, correlative theories for each of the hedonic, salience
sensitivity, and habitual accounts that we saw above.
In order to understand these theories, we first have to have a general
picture of how the brain works and how drugs affect the brain. The
brain is a vastly complex, dynamic system comprised of many different
kinds of cells, the roles and importance of which are just beginning
to be appreciated. The cells that are most relevant to this discussion
are neurons, those vastly numerous (perhaps as many as 100 billion
in a human brain) and complex cells whose communication with one
 Addiction and the Individual 41

another regulates everything that happens in the body and processes

all of our experiences. Neurons are electrochemically charged cells that
communicate with one another through chemical signaling. They receive
inputs from receptors located on their many dendrites, or spikey exten-
sions, and send outputs to other neurons through their axons. Once
they receive sufficient excitatory inputs and reach a critical threshold
of excitation, they “fire,” or generate an action potential. The outputs
of these firings are neurotransmitters, chemicals that in turn bind with
receptors on the adjacent neuron, contributing either an excitatory or
an inhibitory influence to that neuron. Neurons are vastly complex and
dynamic in their own right, and are differentiated in millions of ways,
as are the spaces between them, the synapses. Neurons release their
specific neurotransmitters into these synapses, where they either bind
onto the cell on the other side of the synapse or are reabsorbed into
the releasing cell. These hundred billion neurons all fire in their own
patterns, or oscillations, and in connection with other neurons, in inces-
santly shifting patterns that are constrained by interactions with larger
patterns of this continuous electric activity. Not only new inputs, such
as sensory perceptions and drugs delivered to the brain, but every single
experience that we have, whether internal or external, changes the
brain, because whatever it is, whether a calculation, a stomach churn, or
the most fleeting emotion or thought, it involves the electrical discharge
of neurons and all the complex changes that that entails.
Next, it is important to note that a neuron’s firing does not influ-
ence the neuron across the synapse on just one occasion; rather, when
a neuron’s firing stimulates another to fire, it also causes a long-term
potentiation (LTP), a disposition for those two neurons to be synchro-
nized. This tendency of neurons to become sensitized to the firings of
others with which they have connections is part of the mechanism
thought to make learning and memory possible; it is what is meant by
the commonly used phrase “neurons that fire together, wire together.”
This kind of synaptic strength adjustment is at the foundation of brain
plasticity, a phenomenon that has become central in neuroscience
research over the past two decades. Plasticity is important in the disease
model of addiction because much, if not most, of the learning that we
do happens unconsciously, particularly certain types of learning, such as
associative and procedural learning.15 Part of what happens in addiction
is that people develop habits through synaptic strengthening, as well as
making strong emotional, conceptual, and active associations to smells,
sounds, people, and things associated with their addictions.16 What is
more, past experiences, by the way they shape our brains, shape our
42 Addiction

expectations (largely in terms of associations), and in turn, those expec-

tations shape our perceptions and responses even more than new inputs
do. This is because the networks of neurons in our brains are also recur-
rent. That is, there is feedback communication among neurons as much
as there is feed-forward – in fact, inputs of the former kind may be ten
times more numerous as those of the latter. This means that repeated
similar experiences shape how we understand the world to be organized,
and that in turn influences how we perceive new sensory and bodily
inputs. In addiction this might mean, for instance, that the addict feels
happy and sees a certain street corner as promising and positive in a way
that others who have never bought drugs on that corner would. Another
example is a smoker trying to kick the habit, who stops at a convenience
store and walks out with a pack of cigarettes without ever really thinking
about it. These points will all be relevant as we discuss the various ways
in which the disease model of addiction has been elaborated on and
defended.
Let us return, then, to the DSM-IV-TR’s descriptions of substance abuse
and dependence disorders. Four major classes of drugs, as we have said,
are outlined in the volume: psychostimulants, opiates, alcohol, and
nicotine. These drugs, and the four major brain systems on which they
are thought to operate in addiction, including the opioid attachment-
reward system, the dopamine-based incentive-motivation apparatus,
the self-regulation areas of the prefrontal cortex, and the stress-response
mechanism, provide the foundation for biological psychology’s expla-
nations of what addiction is, how it occurs, and why addicts remain
vulnerable to relapse even after lengthy abstinence. The reward/learning
network seems to have evolved to process natural rewards, motivating
us to seek such things as food and sex, essential for species survival.17 But
just because a system evolved for one thing does not mean that that is
the only thing that it can do. Fingertips, for instance, evolved for touch,
and much later, they came to be used for reading Braille. Addictive drugs
and some activities not only take advantage of the naturally occurring
reward/learning systems in the same way that Braille reading does the
sensitivity of fingertips but these drugs and activities also engage the
relevant systems much more powerfully than do any natural rewards.
What’s more, use of these drugs can also change the structure and func-
tion of these systems.
On the received view, then, addictive drugs and activities take advan-
tage of, or “hijack,” the neural circuitry that is normally involved in
experiencing pleasure, in learning, and in incentive motivation.18
According to a vast research literature, reward processing depends on
 Addiction and the Individual 43

dopamine-using systems in the so-called mesocorticolimbic system.

Dopamine is the neurotransmitter associated with feelings of reward or
the anticipation of reward when it is found in this particular part of
the brain, although it plays other roles in other brain areas. The meso-
corticolimbic system is the emotional processing area of the brain,
constituted of the prefrontal cortex, the thin sheath that wraps around
the outside the cerebrum, together with certain nuclei of neurons that
lie beneath the cortex. Specifically, the reward circuit has been shown
to include centrally the ventral tegmental area, which projects to the
nucleus accumbens, the amygdala, and the prefrontal cortex. Each
of the four classes of addictive drugs works in a specific way, but the
relevant effect in each case is that it increases synaptic dopamine in
this particular system, either directly or indirectly. Since neurotransmit-
ters work something like locks and keys, any given neurotransmitter
can only bind with a specific kind of receptor on adjacent neurons, the
one that “fits.” If no receptor is available, the chemical remains in the
synaptic space. Opiates, for instance, operate by mimicking endogenous
opiates, or endorphins, locking onto opioid receptors. Psychostimulants,
however, block dopamine removal from the synapse by locking onto
the dopamine transporters, thereby leaving an overabundance of
dopamine in the synaptic cleft. Alcohol works by blocking GABA recep-
tors, preventing this inhibitory neurotransmitter from doing its job of
slowing dopamine production, and also onto NMDA glutamate recep-
tors, resulting in the overstimulation of neurons. Nicotine, by contrast,
blocks the receptor for acetylcholine, thereby promoting continual firing
of the neuron and prolonging the production of dopamine. In all these
cases, what ultimately happens with addictive drugs is that they increase
dopamine in the emotion-generating areas of the brain, bringing about
a powerful sensation of reward, along with influencing the motivation,
the valuing, and the choice-processing areas of the brain.

Neuroscience of hedonic theories

So much about the operation of specific neurotransmitters in the brain’s
reward/learning circuits is generally accepted as conventional wisdom.19
But exactly what the role of the dopamine system is in the phenomenon
of addiction is much less clear. According to hedonic hypotheses, for
example, administration of the drug results in highly positive reinforce-
ment, since drugs of addiction (and the excitement of gambling, etc.)
result in the production of significantly more dopamine than natural
rewards do, for more extended periods. According to Koob and Volkow,
administration of addictive drugs increases dopamine levels in the
44 Addiction

striatum, including the nucleus accumbens area.20 Increases of dopamine

in this area, and particularly when those increases come quickly, are
associated with heightened pleasure, euphoria, and so on. According
to the “opponent process theory,” every overly high dopamine event
is attended by an opponent lowering of dopamine, which serves to
restore homeostasis.21 The counterbalancing process, however, because
it is slower and lasts longer than the original reward experience, is
unpleasant. Ultimately, with chronic exposure, the body adapts to the
infusion of excess dopamine by losing some dopamine receptors and
making other changes in the neurons in the reward circuit areas.22 The
upshot is that the down-regulation part of the opposition increases
over time. As that happens, more of the drug is required to achieve
the same level of reward, and the cessation of reward is met with yet
further lowered dopamine and serotonin levels.23 Serotonin is another
neurotransmitter associated with mood. Lack of it in certain areas of the
brain is associated with depression. Moreover, since the reward system is
less sensitive after the down-regulation that comes with persistent drug
taking, the pleasurable effect of natural rewards is lowered overall. In
psychological terms, as we saw in the section above, on this “opponent
processes” or “positive-negative” model, people initially take drugs to
achieve pleasure, and then after the brain adapts, transitioning them
into addiction, they take drugs to avoid symptoms of withdrawal.
The problem with this kind of theory is that it does not account for
the relapse phenomenon, which often occurs after extended periods of
abstinence. After such abstinence, the brain will have up-regulated back
to its natural condition, and so avoiding withdrawal wouldn’t seem to be
a motivation for using. Another hypothesis, though, might address this
issue. Not only the reward system but motivation and learning pathways
as well are co-opted by addictive drugs on the standard view. According
to some versions of what might be called the overlearning theory of
addiction, the sum total of dopamine available in the critical brain areas
isn’t the only thing inciting addiction. Because there is a constant feed-
back loop between expectations and experiences, and because the brain
is constantly adjusting in order to deal with its environment, the reward
that one experiences is also influenced by one’s expectations. Learning
depends on prediction, and learning that results in the tendency to
approach one’s substance or activity of choice approaching behavior
depends on reward (although learning that depends on aversive conse-
quences certainly does not). Brain-imaging experiments have shown
that when one receives a greater reward than expected, as happens with
substances associated with addiction, or when one wins a bet, or nearly
 Addiction and the Individual 45

wins, more dopamine reaches the target area, the anterior cingulate part
of the cortex, in which novelty detection, reward values, and error sign-
aling are processed. When one receives the amount of reward expected,
the anterior cingulate remains unchanged, and when one expects a
reward and does not get it, or gets less reward than expected, or even
just gets it later than expected, less dopamine reaches that area of the
cortex.24 So, the theory goes, since drugs and activities of addiction
produce much more dopaminergic activity than do natural rewards,
people repeat them until they become automatic. At this point they
behave like lab rats: when the stimulus (stress, discomfort, or whatever)
is encountered, they hit the reward button.

Neuroscience of habit
Actions that are at one point considered and chosen become overlearned.
That is, certain stimuli come to habitually evoke certain responses,25
such as reaching for your toothbrush evokes the action of reaching for
the toothpaste, much more powerfully than anything else can evoke
toothpaste reaching. Addiction on this kind of theory is just a strong
kind of habituation, since it involves the brain areas involved in all
habituation.26 Since habits are characterized by insensitivity to conse-
quences (they aren’t goal directed; rather, they’re just what we do given
a certain stimulus), some say that habitual learning could account for the
transition from conscious choice to automatic action that occurs in drug
taking. This definition certainly fits the language sometimes employed
with respect to addicts and their “drug habit.” However, although these
strong implicit memory associations would explain a lab rat’s repeat-
edly pushing a lever to self-administer drugs, it is insufficient to explain
human addiction, the service of which, as we have said, often requires
significant planning far down the road from actual use.27 For this reason,
it seems that addiction cannot be just a matter of habituated responses,
although that element certainly does appear to be present.

Neuroscience of incentive sensitization

The final psychological theory that we considered above, which seemed
to offer the best explanation for the aspects of addiction involving
perseveration, craving, and relapse in the face of “triggers,” was the
incentive salience sensitivity hypothesis. This hypothesis focuses on
how certain cues come to evoke excessive motivation for drug taking,
which we saw earlier referred to as “wanting,” as opposed to “liking.”28
Incentive salience sensitivity is a function of the orbitofrontal cortex,
according to neuroimaging studies. The orbitofrontal cortex provides
46 Addiction

internal representations of the salience of external objects and events,

assigning each of them a particular value. This is an essential system
when operating normally, for it is what allows organisms to choose
between different goals. As we said earlier, when a neuron fires, it not
only stimulates the firing of neurons to which it is connected but it
also creates an LTP for those neurons to fire together as well. With at
least some drugs of addiction, LTP in the nucleus accumbens seems
to be enhanced, perhaps increasing activity of glutamatergic (“go!”)
neurons.29 According to some researchers, then, the fast-working and
large increases in the amount of dopamine in this area categorize the
drug experience “as one that is highly salient, an experiential outcome
that commands attention and promotes arousal, conditioned learning
and motivation.”30 It is this incentive sensitization process that is
thought to subserve the motivated seeking that we have seen to be char-
acteristic of addiction, while learning systems provide the associations
determining what one seeks and how. How prone an individual is to
sensitization can be a function of a number of factors, including genes,
hormones, past trauma, stress, patterns and amount of drug exposure,
and even age, with teens being more susceptible to these changes than
adults. We have reason to believe, then, that this kind of change, as well
as those associated with pleasure and habit, is very individual, and is a
function of far more than the mechanisms that neuroscience alone can
describe.

Some caveats concerning research methods and the

disease model

All theories have a backstory. The development of the addiction model

is no exception. The fact that the AMA spent so much time in the 1980s
establishing its position that addiction is a disease had much to do with
practical matters, such as getting insurance companies to pay for treat-
ment. That was surely not the AMA’s only motivation, but the medi-
calization of many conditions previously considered to be just normal
parts of human life was happening at the time, both extending the
medical field’s purview and making it more profitable. But there were
scientific reasons for the development of the disease model as well. As
research techniques improved over the mid- and late 20th century, it
became possible to understand much more about how the brain func-
tions, and about how various drugs affect that functioning, and this
seemed to offer promise for developing interventions. This is important
because some of the studies that we have considered seem to suggest
 Addiction and the Individual 47

that addiction amounts to a phenomenon that can be seen in the brain,

and that can be fixed by changing either the way that particular cells,
usually neurons, or subneural structures (such as receptor sites), or
certain chemicals, interact. Moreover, the disease model presumes that
just a few brain systems are implicated in addictive patterns, so that if
sufficient focus is placed on these isolated locales, we will understand
addiction and be able to treat it. Much of the evidence for this view is
grounded in the imaging techniques that have become so popular in
the past couple of decades, and that indeed have created a remarkable
ability to see structures and certain functions in the brain in a mercifully
noninvasive manner. There are a number of problems with the assump-
tions of the standard view, however.
First, we must consider the assumption that there is a causal relation,
or an identity, between the brain changes that advanced technology
now allows researchers to track and the phenomenal experiences that
take place as a person becomes addicted. It may very well be true that
nicotine blocks GABA cells and so stimulates dopamine cells to keep
firing (or prevents them from ceasing to fire), and it may be true that
nicotine users experience pleasure at ingesting nicotine. It may further
be true that chronic nicotine users as a group show a diminished sensi-
tivity in nicotinic receptors relative to nonnicotine users. And it may be
the case that after chronic use, nicotine users experience a diminished
sense of pleasure in smoking. The claim, though, that it is the increased
dopamine available in the synapse between cells that causes nicotine
users to experience pleasure after using, and the attendant claim that
they experience a diminished sense of pleasure after some time of
chronically using, makes too quick a leap between the neurophysiology
and neurochemistry, which are objectively measurable, and the mental
phenomenon of pleasure, which is not. The “how” here would need to
be shown before we could exchange physical terms for mental terms.
This issue, in fact, is behind one of the main questions motivating
this book: how should we understand the addict’s mind relative to her
biology and environment? Figuring out this relationship is at the root
of our efforts to resolve the false dichotomy inherent in the dispute over
whether addiction is a matter of disease or of choice.
This dichotomy at one level is basically the question of whether the
physical markers that have come to define addiction for one set of
researchers are necessarily connected to those psychological markers that
define addiction for another set. That is, neurobiological researchers,
using imaging techniques and animal models, have identified physical
changes that on average, or in some statistically significant number
48 Addiction

of cases, accompany symptoms that fit the DSM IV-TR’s categories of

substance disorders. But do the brain changes characteristic of addic-
tion ever happen without someone’s being addicted? And can someone
ever be addicted without his or her brain undergoing these changes?
Every individual, as we have seen, is a self-organizing system, unique
in the macrolevel patterns that it displays, with a unique history of
development and unique interaction with its environment. Hard
science may provide us with good information that is helpful for
understanding addicted individuals’ behavior and other symptoms,
and about their brains, but we would do well to understand the
statistical nature of any claims made – causal or correlative or other-
wise – as we consider the conclusions arrived at through this model
of addiction.
A second assumption made all too often by neurobiological researchers
is that the meaning of the brain-scanning images used in research is self-
evident.31 This assumption is made much more broadly with vastly less
information in the lay population. Although an abundance of brain-im-
aging work has been done on addiction, as well as on a variety of other
kinds of functions and changes in the brain, exactly what all of these
images actually show requires interpretation. The by now “common
knowledge,” for instance, that addiction involves, among other things,
the “reward circuit” in the brain, as well as memory and learning systems,
together with motivation and salience evaluation areas of the brain, as
well as the cognitive control areas, is only common given some pretty
significant assumptions. Researchers focus on these areas, including the
nucleus accumbens and ventral pallidum, the amygdala, hypothalamus
and anterior cingulate, and so forth, because this is where imaging
studies show the brain “light up” when the associated processes are
taking place. But brains don’t light up, and individual areas of the brain
never work alone. Computers make pictures of brains just as they do of
far-away galaxies; they take some information that is not an image, and
create an image from it. In the case of functional magnetic resonance
imaging (fMRI), for instance, the images that we see in the pages of
our magazines are highly manipulated representations of the results of
detecting changes in the magnetic properties of blood. Right after an
increase in neural activity, there is increased demand for oxygen. As
this oxygen arrives in the hemoglobin, there is a small change in its
magnetic resonance, which is what is detected. The computers involved
in representing fMRI results process the myriad images taken by the
fMRI machine over a particular time span and average them together.
Then they show, by subtracting the overall activity of the brain from the
 Addiction and the Individual 49

activity of the brain in a particular area, that the specified area is more
active during that time span than other areas.
All the measuring and representing of activity through these means
is indirect; fMRI does not work by detecting the electrical activity
happening as a neuron fires, or by detecting the rapid increase or
decrease in local metabolism. Rather, it works by measuring the increase
in regional cerebral blood flow in response to the increased metabolism
that happens when a particular part of the brain is operating. These
scans measure activity in the millimeters-large size range, which means
that they are measuring the activity of several million neurons. But a
relatively large-scale picture like that, as we saw in Chapter 1 with the
movement from microlevel patterns to movement at the macrolevel,
might well be (and in fact we will say that it is) the outcome of perhaps
many lower-level patterns working against one another. So, the changes
in metabolic activity recorded are always averages, hiding the particu-
lars of what is happening at greater levels of specificity. Moreover, the
images are always superimposed on background activity, so that the
difference in activity that we attend to obliterates the context in which
this activity is happening. Scientists have no way to distinguish between
the real increase in a particular brain area’s activity and apparent activity
that may be due to some other task being done in that area at the same
time, and random activity that may be a side effect of something else.
Finally, imaging studies never speak to individual brains, but always to
“representative” brains, or statistically significant correlations between
individuals imaged. That is, these studies assume that all brains are
doing the same thing when the same parts are activated, which results
in the conclusion that the particular activity being observed must be
responsible for the experience or change correlated with it. Given what
we have said about the uniqueness of organisms, though, we ought to
be extremely conservative in reaching any conclusions about individ-
uals based on the imaging techniques used in the science that studies
addiction at the neural level.
An even more fundamental assumption made in imaging studies, but
subject to increasing resistance, is the idea that mental processes can
be localized to operations in specific parts of the brain. Connected to
the problem of the interpretation of images, but not identical to it, this
concern addresses the “modularity” assumption popularly adopted by
cognitive neuroscientists. It has long been assumed that particular tasks
are accomplished by, and particular experiences result from, activity
in a specified area of the brain. We saw this assumption operating in
the accounts of addiction given above. A number of neuroscientists,
50 Addiction

however, have begun to object to this view, noting that responses of

almost any kind are distributed over many, if not most, regions of the
brain.32 William Uttal, for instance, a highly respected researcher who
uses imaging studies extensively in his own work, is one of the most
strident critics of the localization thesis. His concern is not that imaging
tools are not useful, but rather that scientists, in their enthusiasm for
them, have failed to remain critical of the assumptions involved in
using them. He compares the kind of modularity popularly presumed to
characterize mental processing to a kind of contemporary phrenology –
the 19th-century practice of predicting a person’s mental characteristics
based on lumps in the skull.33 More careful attention to exactly how
computerized images are created, and the hypotheses employed in inter-
preting their results, would render the science using them much more
reliable.
A related problem is determining exactly what it is that a brain area is
doing when it “lights up” in an fRMI test. Some areas, for example the
anterior insula and the anterior cingulate, both cited as important in
some addiction imaging research literature, appear to be activated in as
many as 25% of the results recorded in all imaging research, according
to Russell Poldrack, director of the Imaging Research Center at the
University of Texas at Austin.34 This means that the information avail-
able, at least so far, with regard to how the brain gives rise to mental expe-
rience, is vague. There is evidence that certain brain areas are involved
in certain processing tasks, but how they contribute to this processing is
unknown. So, although it might be possible to record structural and func-
tional changes that attend symptoms and behaviors of addiction, our
assessment of the true nature of addictive patterns must be understood
in light of significant qualifications and caveats.

Other criticisms of the disease model

Critics of the disease model object to it on a number of grounds inde-

pendent of those connected to the limitations of research methods. For
one thing, some critics charge that the disease model fails at the first
task of any scientific model: to account for the phenomenon. In partic-
ular, it fails to account for the timing of addicts’ relapses and for the
planning and organizing of use episodes that happen often at signifi-
cant temporal distance from the indulgence itself. Others maintain that
addiction does not itself fit into the logical space of disease. For example,
Donald Douglas argues35 that considering alcoholism in particular to be
a disease is a function of reversing the concepts of cause and effect.36
 Addiction and the Individual 51

Although it can cause diseases, it is not itself a disease. “What kind of

disease,” he asks “can coexist with the best of health?”37 Many people
who are believed by others to be addicts and who see themselves as
addicted are in terrific health. To say that they are not “real” addicts in
this case is just to argue in a circle. Other logical mismatches between
addiction and disease concern when the individual has it: is it reason-
able to say that he has the disease when he is abstinent? If so, what is it
that makes it a disease? If not, Douglas asks, then why do so many alco-
holics drink after achieving significant periods of abstinence? Finally,
and most importantly, to say that choosing to drink is the cause of
alcoholism, while simultaneously saying that having the disease of alco-
holism restricts one’s ability to choose violates the laws of logic, and
prevents any noncircular definition of either the disease or the choice.
Coming from another perspective, other critics say that treating
addiction as a disease is pragmatically unsound. While the original idea
behind framing addiction in terms of disease was at least in part to rid
it of its stigma and to encourage addicts to seek assistance, the move to
the medical model had a hidden side. For one thing, it put the respon-
sibility for transitioning out of addiction on treatment professionals,
rather than on people with problems. This has proved to have dangerous
results: by thinking of addiction in this way people who have problems
with addiction have an excuse for not trying to control their behavior.
Particularly when someone relapses into use, if he presumes the truth
of the disease model, then he has no motivation to try to minimize it.
In fact, he believes that he can’t.38 For another, it creates a disease for
which there has been until recently no logically connected treatment.
Those who declare addiction a disease most often cite 12-step programs
as the best or the only viable approach to treating it, despite the fact that
the central focus of these programs, if you count the number of steps
that include a concept as an indication of its importance, is a “higher
power.” This approach is essentially spiritual in nature, which seems to
be an ill-fitting response to a disease as defined in the contemporary
medical world.
However, some approaches to treatment do seem to take the physi-
ological conception of disease seriously. But even here, the disease
model encourages fallacious thinking, this time of oversimplification.
A flight of hubris was expressed August 15, 2011, for instance, in the
headline “Scientists Can Now Block Heroin, Morphine Addiction.”
The press release, accompanied by video, makes dramatic claims. “Our
studies have shown conclusively that we can block addiction via the
immune system of the brain, without targeting the brain’s wiring,”
52 Addiction

said lead author Dr. Mark Hutchinson.39 Perhaps it has been “shown
conclusively” that administration of (+)naloxone, a nonopioid mirror-
image drug, prevents the immune system’s usual amplification effect
on opiates, which should allow drugs such as morphine to be used for
pain management without the additional addiction-forming euphoric
effects occurring. At least in laboratory tests, use of this drug appreciably
reduced opioid self-administration in rats (we have already discussed
the problems with extrapolation from animal models to humans). But,
although this may stop some people who must use opioids for signifi-
cant periods from becoming dependent, what has been achieved is actu-
ally a far cry from what Dr. Hutchinson claims: “The drug (+)naloxone
automatically shuts down the addiction. It shuts down the need to take
opioids, it cuts out behaviors associated with addiction.”40 Thinking
of addiction as an induced disease prompts the misleading conclusion
that it can be obliterated with chemical tricks, just as smallpox can
be prevented with a vaccine. Although such drugs can be extremely
useful tools for avoiding and managing addiction, to think of them as
cure-alls is to miss many of the interlinking levels at which addiction
operates.
In addition to logical, practical, and oversimplification problems, the
conception of addiction as a disease faces some factual challenges as
well. As we saw in Chapter 1, psychologist Gene Heyman opposes the
disease model on the grounds that it defies psychological and sociolog-
ical research results. He points out that the vast majority of people who
ever met the criteria for drug abuse and drug dependency stopped using
drugs by midlife without treatment. This, he says, does not support
the received view of addiction as a chronic disease. The studies show
that addicts who go to clinics continue to use drugs, while those who
do not receive treatment stop. But, the people who end up in studies
about addiction are mostly people who go through treatment clinics.
This gives a skewed picture of remission rates. Also, the evidence that
Heyman produces suggests that “remission” isn’t even the proper word,
for the people who stop taking drugs seem to stay stopped, as though
it were over, rather than simply being held at bay. Finally, people who
go through clinics are much more likely to have other psychiatric or
physical problems than those who do not, and so the proper conclu-
sion to draw, Heyman says, is that when addiction persists, it is because
people don’t have access to other meaningful options. Their lives involve
barriers that other lives do not. This, though, is not a picture of a disease,
although it may be a picture of a phenomenon that accompanies other
diseases.
 Addiction and the Individual 53

Yet another kind of criticism comes from Stanton Peele, psychothera-

pist and long-time writer on addiction. He believes that there are reasons
to think that the disease model, or the “alcoholism movement,” as he
first called it, has political roots.41 This movement is politically powerful,
he says, with a significant capacity to suppress discordant views and
skew the direction of research, something with which Heyman could
agree. Heyman notes that, although the four studies he cites in support
of the choice model were high-caliber research done by respected
researchers and funded by national health institutes, they never found
their way into mainstream paradigm-building outlets such as textbooks,
nor were they cited in important journal articles. According to Peele,
the portrayal of addiction as a growing epidemic is a self-serving view
promoted by the large and growing addiction treatment industry.42 He
argues that rather than medicalizing addiction, we should look to the
social factors that foster addictive behaviors and start making changes
there. These considerations will occupy us in later chapters. For now, it
is enough to note that there are significant reasons of various kinds for
resisting the received view that addiction is a medical disease.

Behavioral theories

Picoeconomics
The issues that we have just discussed, together with some others that
we will outline below, may make us skeptical of the medical model. An
alternative approach to understanding addiction focuses on behavior.
Behavioral psychological approaches, for instance, maintain that,
while addicts may not win the struggle against their urges, ultimately
no humans are, as the disease model would have it, “out of control.”
People are always moved by their own choices. However, some people
sometimes cannot motivate themselves to choose in a particular case
what they in general want to do. We considered this in Chapter 1 under
the philosophical framework of weakness of will. On George Ainslie’s
picoeconomic approach, addicts’ capitulation to temptation is a result
of two internal motivational forces competing, with one winning out
over the other as a result of proximity in time of the potential reward.43
This theory plays a touch-and-go game with free will, given some of
its assumptions, but at the end of the day, it suggests that although
addicts (and others) capitulate in the face of immediate rewards, they do
have the power to choose otherwise. To see how this theory works, it is
first necessary to agree that any agent is constrained to choose whatever
54 Addiction

option before him promises the greatest reward. This is not to be taken
as the most rational reward, because behavioral economists, unlike clas-
sical economists, include emotions among the factors that figure in our
assessment of value. This may seem like a rather deterministic assump-
tion, but as we observed in Chapter 1, it is difficult to see why anyone
would choose what she does not think promises the greatest reward. The
way to explain repeated capitulation to relapse, Ainslie suggests, is not
to presume that the person as an integrated agent makes no decision
at all, and so is compelled, as though from the outside (whether by her
brain or something else), and is in that sense without control. Nor is the
correct view that the addict chooses freely, from the privileged point of
view of a rational observer. Rather, on Ainslie’s view, the individual is
actually understood to be, or at least to act as, two separate agents, or,
perhaps better, in terms of “one person’s successive motivational states,”
each vying to determine the agent’s choice.44
Ainslie and his colleague John Monterosso found that the fairly ubiq-
uitous phenomenon of judging immediately available goods, even if of
lesser value, as preferable to greater goods available only in the future,
exhibits itself even more sharply in substance-dependent people than
it does in the rest of us. In a series of experiments performed by a host
of behavioral economists, psychologists, and neuroscientists over the
past thirty years, it has been repeatedly shown that smokers, cocaine
and methamphetamine users, and opiate users and heavy social and
problem drinkers all discounted the future much more steeply relative
to the present than did control groups.45 Although the reward might be
shunned, or at least be less valued compared to the longer-term good
(say, of a life free of addiction), when considered from a distance, when
receiving the reward was at hand, preferences suddenly flipped. While
that is true for most of us, the difference in preferences for rewards nearer
rather than further was more pronounced among substance users. For
whatever reason, drug users and drug-dependent subjects discounted
larger but delayed rewards, even when those rewards were monetary,
something presumably having little to do with their addiction, and
even when the delays were very short, these subjects discounted rewards
much more steeply than did nonusers.
Correlation, however, as Monterosso and Ainslie are aware, is not
causation, and even if there is a causal connection, the studies conducted
say nothing about which way the connection goes. Addiction could be
either the cause or the effect of the steeper discounting of future goods
characteristic of addicts. Still, this particular type of discounting, with
preference for long-term goods remaining relatively stable as long as the
 Addiction and the Individual 55

shortly available good is still at some distance, but suddenly and sharply
reversing as soon as the shortly available good becomes imminent, does
say something about substance users’ impulsivity, and perhaps suggests
something about their capacity for self-control. These unanticipated
but sharp shifts in preference, Ainslie and Monterosso argue, are best
explained by positing a conflict between two “selves” within the person,
or at least two differentially defined motivational states. The model that
Ainslie proposes presumes, first, that “mental processes are learned to
the extent that they are rewarded,”46 so people do what brings them
reward. Complicating this point, though, is that people don’t simply
prefer one reward over another, plain and simple; rather, their prefer-
ences interact with each other over time. Hyperbolic preference curves,
Ainslie says, in this clearly economically influenced model, show that
contradictory processes compete with each other for the agent’s behavior.
The self at one moment is, he says, “helpless against what future selves
may momentarily prefer,” and has no one to call upon to control those
future selves.47 Thus, although in the time subsequent to indulgence the
addict may truly value a sober future, the self is not unified temporally,
and thus the possibility exists (and the likelihood, if something is not
put in place to prevent it) that when temptation once again presents
itself, the addict’s preferences will suddenly flip, and he will find himself
once again in an addictive pattern of behavior.

Ego depletion
Another behavioral theory of addiction, introduced in Chapter 1, is the
ego-depletion hypothesis. On this hypothesis, self-control is a finite
commodity. Thus, the argument goes, if people experience too much
stress or have too many demands requiring self-control, they will have
diminished resources available for resisting temptations. A number
of experiments have been performed in this area. In one, a group of
experimental subjects were instructed to eat only healthy foods such as
radishes and celery from a buffet, while avoiding available rich desserts.
This group later persisted for a shorter time at a difficult cognitive task
than the control group, which was allowed to eat freely.48 The relevant
exercise of self-control isn’t just of a momentary nature, either, as other
studies have shown. People who have made long-term commitments to
self-control, as do dieters, for example, regularly display more depleted
levels of self-control after having to exercise significant amounts of it in
a particular situation than do those who have not made such commit-
ments. In a series of experiments that show this, chronic dieters and
nondieters were exposed to either tempting situations or nontempting
56 Addiction

situations (an overflowing bowl of snacks was either readily available

or at a distance), and subsequently were challenged to determine their
available level of self-control in another situation. In one version of the
experiment, both dieters and nondieters were offered ice cream, in an
ostensible flavor-ranking task, and in another version, dieters were put
to a difficult cognitive task. In the ice cream experiment, those dieters
who had been exposed to temptation ate more than those who had not,
but the nondieters did not show such a divergence. In the cognitive task
experiment, exposure to food temptations resulted in subjects giving
up sooner on the problems presented. In all these cases, subjects who
had exerted self-control in one area subsequently seem to have had a
depleted store of it available for later challenges.49
Addicted individuals, like chronic dieters, must exercise ongoing self-
control. As a result, when they are faced with temptation, particularly
when it is unexpected, they often give up quickly on cognitive tasks.
Individuals who have been stressed in this way are often less discerning
than they might be, for example, in the face of their own poor argu-
ments in favor of using. Since people in this situation lack the extra
cognitive resources required to think through the speciousness of their
arguments, they experience a judgment shift away from their “rational”
arguments for abstinence in favor of the case for use.50 According to Neil
Levy, the relevant dissociation is not between “wanting” and “liking,”
as was presented above, but between motivation and “any phenomenal
state at all.”51 His idea is that if self-control is an exhaustible resource,
it can be depleted by any temptation that lasts long enough, regardless
of the strength of its appeal.52 This hypothesis provides an explanation
of the otherwise seemingly inexplicable fact that addicts can abstain
for significant lengths of time, and then, in the face of something
that no one would consider a major challenge, capitulate to tempta-
tion. Maintaining abstinence for a significant time requires significant
reserves of “will power,” which in the face of repeated temptations,
makes relapse increasingly likely. On this hypothesis, it’s not a matter
of which event precipitates a relapse, but rather one of how long and
in the face of how many temptations an addict controlled her urges
before some random event or emotion was too much for the depleted
ego to overcome. This hypothesis, Levy says, also offers an explanation
of the power of “triggers.” Since every temptation requires some of the
addict’s stores of self-control, each one encountered increases an addict’s
chances of relapse. Finally, according to Levy, this theory provides the
best explanation currently on offer for distal addictive behaviors, the
sometimes elaborate set of behaviors necessary to accomplish a use
 Addiction and the Individual 57

episode that is anything but automatic. Unlike the disease model, which
has to see such activity as automated in some sense, the ego-depletion
model, seeing relapse in terms of a shift in judgment brought on by
exhausted stores of energy for self-control, can explain distal activity of
addiction as ends-means reasoning of the usual kind, engaged in once
the decision to use is made.
While both the picoeconomic and the ego-depletion theories do help
illuminate certain elements of addiction, they are no more complete
on their own than is the disease model, since they merely push the
central questions back a step. For instance, with respect to hyperbolic
discounting of the future, it is not clear whether it is this tendency that
brings about addiction or whether addiction brings about short-term
thinking. Some researchers have suggested a cyclical effect, in which
those who tend to become addicted more deeply discount future goods
to begin with, but then as they move into addictive patterns of behavior,
do so to an even greater degree.53 Ego depletion, it should be noted, is a
well-known phenomenon affecting everybody’s choices, and so by itself
it cannot provide an adequate account of addiction. Like the picoeco-
nomic theory, it offers reasons for why people might make the choices
that they do with respect to addictive drugs and activities. Neither,
however, explains what causes only some people to make choices in
what would be recognized as a particularly addictive pattern. Empirical
theories are good as far as they go, but they do not tell us what drives
the distinction between those who would be characterized as addicted
and those who wouldn’t.

So, where does it start?

Neither of the broad classes of theories of addiction offered can provide

a complete account of the phenomenon. Indeed, the opposition of the
two kinds of theories is artificial, for humans are biological organisms
that respond to changes in their internal and external environments –
and one way that they respond is by acting, making choices. Some of
those choices involve continued capitulation to indulgence in substances
or activities of certain sorts. An analysis of these patterns of behavior,
whether in terms of brain chemistry or anything else, is only the begin-
ning of an understanding of addiction. We also need an account of
who becomes addicted, and why some people seem to become addicted
easily, whereas others can use the same amount of the same substances
without becoming addicted. We also want to know why many people
have demonstrated the ability to transition out of addictive patterns,
58 Addiction

whereas for others such a transition seems impossible, no matter what

their level of motivation. Any effort to answer these kinds of questions
requires an appreciation of the human addict as a complex and essen-
tially dynamic process, historical in nature and necessarily embedded in
an evolving physical and social environment.
Many researchers supporting the disease model of addiction cite statis-
tics suggestive of a genetic component to addiction. Adoption and twin
studies, for instance, like some others that we will discuss in Chapter 3,
have indicated that at least part of some individuals’ predisposition to
addiction is to some degree a function of genetics. This is one reason
for supporting the disease model, if the conclusions drawn from these
studies are correct. The received wisdom, cited in virtually all of the
addiction literature, is that perhaps half of a person’s “risk” for addic-
tion is a function of genetics. Exactly what this “risk” means, however,
is an important question, since DNA does not determine how people’s
lives turn out. DNA contains instructions for making proteins. It is not
a set of instructions for creating a human being. Far less, then, could
DNA be specific a set of instructions that it could determine behavior
patterns. While someone might well have a genetic predisposition to
undergo the brain changes characteristic of addiction once drugs are
chronically ingested, if she never experiments with addictive drugs, she
will certainly not become an addict. What is more, as we will discuss
in Chapter 3, the expression of one’s genome is as much a function of
epigenetic factors as it is of genetic ones. There is no disconnect between
nature and nurture on our hypothesis, and so no such simplistic analysis
as that one becomes an addict because of a genetic predisposition, will
do. On the contrary, all the circumstances and events in a child’s envi-
ronment, positive and negative, have consequences for the processes of
both physiological and psychological development, and hence for her
vulnerability to addiction.54
The picture of the individual as a complex dynamic process emerging
from the interactions between numerous other interacting highly
complex dynamic processes seems to accommodate the richness of the
results that research on addiction has provided to date. Neither genetics
nor molecular biology nor neurophysiology nor psychology alone can
provide an adequate explanation of this complex phenomenon. Stress,
trauma, and social factors all play roles in the development of addictive
patterns. And while research at each of these scales of analysis is helpful
for pursuing partial treatments, no one level of explanation can hope to
provide a path to treatment for all. If one researcher on his own finds
at least two very different types of alcoholics, based on two different
 Addiction and the Individual 59

neural circuits, and if addiction occupies a spectrum on the control axis

from something very much like a habit that can be unhabituated, to a
screaming compulsion so strong that, as one addict put it, “the only
thing that would make me stop once I started drinking was handcuffs,”
why should we think that addiction is specifiable as either a disease or
as a particular manner of making decisions? And why should we think
that our analysis should stop at the individual? As we will see, things are
much more complicated than that.
4
The Ecology of Addiction

People don’t become addicts in isolation. This is not news. In addition

to the well-cited research showing that social connection is essential for
the very survival, much less for the flourishing, of children, much work
on addiction over the past two decades has focused on the importance
of childhood influences on later substance use and abuse, and of social
influences on transitioning into and out of addiction. For our purposes,
this raises a problem: how can the results of this huge body of research
showing the power of social relationships with respect to addiction be
squared with either of the classes of theory that we have discussed? The
role that other people play in increasing or decreasing an individual’s
risk of addiction and hope for living free of it seems to deny both sides
of the dichotomy.
Gregory Bateson, in contrast to the competing paradigms that we
have considered, characterizes addiction to alcohol in his “Cybernetics
of Self: A Theory of Alcoholism,” as a disorganization in relationships
between the alcoholic and his world.1 On Bateson’s view, alcoholism,
and addiction more generally, isn’t merely a question either of dopamine
levels in the brain’s reward circuits, or of associative learning, or even of
mental wrestling with temptations and arguments. Instead, it involves
the individual’s being “out of sync” with the world of which he is a part.
According to Bateson, individuals who have problems with addiction
can only be understood within the context of a whole system. He says
that the addict’s behavior and beliefs, and thus the world as it exists for
him, are intertwined in an irreducible matrix. The addict’s

(commonly unconscious) beliefs about what sort of world it is

will determine how he sees it and acts within it, and his ways of
perceiving and acting will determine his beliefs about its nature.

60
 The Ecology of Addiction 61

The living man is thus bound within a net of epistemological and

ontological premises which – regardless of ultimate truth or falsity –
become partially self-validating for him.2

The addicted individual, according to Bateson “has a take” on the world

that determines how he behaves and feels within it, and those beliefs
and feelings in turn will determine how he understands the world.
Bateson’s analysis of the addict’s predicament thus relies on framing
the human being as an essentially embedded organism whose environ-
ment influences both who and what he is, and is influenced by him, in
an ongoing dynamic circle of causation. Bateson is thus in accord with
our own hypothesis that addiction is a phenomenon emerging from a
complex, hierarchically organized system. Indeed he asserts a version
of it.3 As he puts it, “[t]he pattern of addiction occurs within a system
of continual oscillation at many interacting levels. The behavior of the
‘self’ is dynamic and is linked to the continual oscillations that such a
system displays.” 4 All organisms, as we have discussed, are complex
dynamic systems, ever-changing interacting patterns that give rise in
some cases to experience from points of view, or “selves.” These selves
are emergent dynamic patterns of action, always in interaction with
their environments. Based on this framework, Bateson conceives of
the addicted individual in terms of ecology. Addiction in this sense is a
pattern embedded in a person’s thinking and feeling that emerges from
the rhythms of her biological organism interacting with those of her
external environments, both physical and social.
This kind of approach is a person-centered, as opposed to a drug-cen-
tered, analysis of addiction, although of course no one could ever suffer
from addiction problems without drugs or powerfully rewarding activi-
ties entering into the causal matrix. Focusing on the person, though,
let us consider how those who become addicted can be distinguished
from those who do not, in terms of their relationships with their envi-
ronments. To begin, we might reflect on the questions that we left off
with in the previous chapter: who becomes addicted, and why? Drug-
centered theorists say that it is the drug that is responsible for addic-
tion. Environmental availability of drugs and addictive activities create
addicts. In that case, those who live in drug-infested neighborhoods,
who grow up in drug-using families, or who go to high school should
become addicted. Since drugs have become so readily available in public
schools, colleges, and universities, not to mention bars and coffee shops,
this theory does not seem to account for the persistent fact that only
about 10% of the population will become addicted, although many
62 Addiction

more than that will use and even abuse drugs. Mere exposure, it seems,
does not provide a satisfactory explanation of who becomes addicted,
or why. Person-centered considerations are important as well, and an
ecological approach that includes both promises even more.
If there is an answer to the question of who becomes addicted, other
than the genetically doomed, which we will show will also not suffice
as an explanation, the short answer would be “the stressed.” When an
organism is out of sync with its environment, as when the environ-
ment is unpredictable, or denies goods required for survival, such as
early nurturing, food, or water, or threatens the loss of those goods,
or when the organism faces persistent aggression and/or social defeat,
it adapts by producing chemicals that prepare it for emergency. These
chemicals, although essential for dealing with momentary stress, create
an unstable internal milieu when present chronically. In short, when
things do not go smoothly between an organism and its environment,
the organism is stressed. Long-term stress wreaks havoc on the body/
mind. An extensive literature provides evidence that emotional stress
(and particularly interpersonal or social stress for humans) is a theme
running throughout addicts’ lives, from the gestational period through
childhood and adolescence, in the transition from casual use into addic-
tion, to relapse in adults after periods of abstinence.5 Since stress seems
to be part of nearly everyone’s life, it alone cannot be identified as the
cause of addiction, yet it exerts a powerful influence on those prone to
addiction. Let us then consider the specific types and timing of the stress
that is associated with vulnerability to addiction and relapse.

Stress and development

Developing brains are most sensitive to their environments, and this

period is most influential since the ways in which a brain develops early
on will create constraints on the patterns of activity, including further
development, that happen later. From the embryonic stage through late
adolescence, developing brains are highly susceptible to stress. Given
that human brains continue to develop long after birth, doubling in
size in the first two years and continuing to grow and organize into
young adulthood, the impact of the immediate environment in which
this growth takes place cannot be overstated. “The vast majority of
the development of axons, dendrites, and synaptic connections that
underlie all behavior is known to take place in early and late human
infancy,” asserts neuropsychology researcher Allan Shore, although
he notes that critical periods in the development of certain systems,
 The Ecology of Addiction 63

such as the prefrontal cortex, last much longer.6 Since these kinds of
development do not just happen automatically, but must be stimu-
lated by internal and external environments, the types and amounts
of interaction that babies and children engage in will affect how the
emotional systems as well as other systems in their brains develop.
This development in turn influences how and with respect to which
people and things they experience pleasure and pain, attachment, and
value later in life. Early on, babies’ mental and emotional development
literally is a function of their caregiver’s rhythms. Rushes of dopamine
and endogenous opiates hit the synapses every time a baby’s regular
caregiver returns to soothe her, or reacts in an engaged way with her.
Consistent interactions of this nature stimulate the development of the
neurons that release these bonding- and pleasure-associated chemicals,
and the receptors that allow neurons to use them. Stress, though, such
as that brought on by separation from a caregiver, or by interaction with
a highly stressed or an unresponsive caregiver, reduces the amount of
the relevant neurotransmitters that is released. This in turn reduces the
development of both dopamine and opioid receptors. These two condi-
tions together imply that less of these pleasure- and attachment chemi-
cals can be used by postsynaptic neurons.7 Such truncated development
has serious consequences for the kinds of attachments and pleasures
that a person can enjoy, and ultimately for a person’s ability to regulate
her emotions and behaviors.
A substantial body of epidemiological research demonstrates that a
child’s environment in her early years strongly influences her later social
and emotional functioning. With respect to addiction in particular, chil-
dren who live through adverse life experiences have an increased statis-
tical likelihood of using illicit and prescribed drugs later, and of using
them at a younger age than do people who do not have such experiences
as children. In the highly recognized Adverse Childhood Experiences (ACE)
Study of 2003, retrospective research was done on four different age
cohorts with respect to ten categories of adverse childhood experiences
(called ACEs, these include such things as physical abuse, sexual abuse,
neglect, substance abuse or mental illness in the household, etc.). For
each ACE a person experienced, the likelihood that she would engage
in early substance use was two to four times greater than for those who
didn’t have such experiences.8 Compared to people with no such events
in their childhoods, individuals with more than five of the listed life
events were seven to ten times more likely to report drug use or addic-
tion. What is more, this study showed that there was a graded relation-
ship between the total number of ACEs and the age of drinking onset
64 Addiction

across all four age cohorts, dating back to 1900. What this means is
that the relative number of adolescents who had used alcohol increased
in proportion to the number of adverse events they had experienced
in childhood (although the absolute numbers were different in each
of the different cohorts), regardless of the generation of which they
were members. The fact that this graded number was consistent across
all the age groups shows that the effect seems to be independent of
cultural attitudes toward alcohol use, at least within the United States
and within the past century.9 From this research, it seems apparent that
adverse events experienced in childhood correlate with both likelihood
of drug use and abuse, and with earlier use of alcohol, proportional to
the number and degree of such events.
We can talk about the developmental effects that were just discussed
in another way. Consider what happens to children’s brains in terms of
memory and automated responses when they are exposed to stressful
situations, especially traumatically stressful ones. They lay down
memories of those visual, auditory, tactile, olfactory, and perhaps gusta-
tory perceptions together with the emotional inputs that are their own
brains’ reactions to those situations. The experience of father striking
mother, for example, is thus informed by the responses of the child’s
amygdala and other “limbic,” or “emotional brain center” inputs,
as much as it is by the response of the perceptual processing appara-
tuses in operation at the time. These children’s memories thus inform
their expectations, so that at the sight or sound of a similar situation,
the child’s limbic system response will charge into action, ready for
another trauma. Children who are exposed to traumatic stressors, for
this reason, according to one researcher, “exhibit profound sensitiza-
tion of the neural response patterns associated with their traumatic
experiences. The result is that full-blown response patterns (e.g., hyper-
arousal or dissociation) can be elicited by apparently minor stressors.”10
Like ex-soldiers who flinch when a FedEx helicopter shows up on the
horizon, children who are hypersensitized through trauma cannot
regulate their emotional responses to certain stimuli encountered later
in life. Hyperstressed kids experience, in addition to the ordinary effects
of drugs, the additional powerful effect of relief that such substances
provide from their uncomfortable “normal” condition. As a result,
temptation to indulge in such escapes would be difficult for them to
avoid, once they have been exposed to them, and, given the social envi-
ronments of most teens, they will be exposed to them by early adoles-
cence.11 It is no surprise, then that these are the children most likely to
use and abuse addictive substances and activities.
 The Ecology of Addiction 65

As always, however, we must ask about the direction of the causal

influence. Do these deleterious events cause early drug use and higher
rates of addiction, or are the subjects of this study prone to experi-
ence both adverse life events and drug and alcohol use for some other
reason? Further research by the authors of the “Adverse Childhood
Experiences Study” and others suggests that the first hypothesis fits the
data better. In later work, ACES’s authors suggest biochemical reasons
for the behavior patterns that follow stress during brain development.
According to one follow-up study, neurodevelopment may be affected
by trauma because stress prompts increased production of the stress
hormones cortisol and epinephrine, as well as such neurotransmitters
as dopamine, serotonin, and norepinephrine, some of which prepare an
organism to be on high alert, and others which try to return it to home-
ostasis.12 Dysregulation of what is known as the hypothalamic-pituitary-
adrenal (HPA-axis) function – the system that controls the production
of stress chemicals, in particular the glucocorticoid hormones – results
from repeated or ongoing stress. The brain adapts, to put it simply, to
always be ready for an emergency. Such adaptation, we should not be
shocked to learn, impedes children’s ability to regulate their emotions
and behavior, which may in turn lead to the use of drugs and/or alcohol
to try to cope.13 This means that the stresses a child experiences not
only change her brain chemistry in the moment, but, as with infants,
such stresses affect her brain’s development and later functioning as
well. The dopamine and opioid systems in the brain, as we discussed,
react to the presence or absence of stable caregivers. In dynamic terms,
interaction with a self-organized, stable pattern of behavior is essential
to a developing brain’s ability to gain self-regulating properties. A baby
whose distress is never or irregularly responded to by a reliable caregiver
will not develop the self-regulation patterns necessary for a healthy life.
The ability to cope with stress comes from interactions with predict-
able patterns in its caregiver. At first, the caregiver provides the comfort
that down-regulates stress hormones when stressors arise. Gradually, the
ability to affect its own biology is learned by the infant. Left in isola-
tion, though, or in the presence of an agitated or otherwise disorganized
behavior pattern in the caregiver, a baby’s ability to develop stress-
regulating mechanisms is seriously compromised.
This theory has received support from experiments using animal
models. Stress responsivity in rat pups mirrors the responsivity levels
of their mothers, as the mother’s stronger patterns of activity entrain
the offspring’s, and just a little difference matters a great deal.14 Being
separated just briefly from their mothers results in heightened stress
66 Addiction

responses in offspring, as well as in other deleterious health effects. As we

have said, these changes needn’t be life threatening, or even dramatic.
Small variations in maternal behavior, such as licking the pups less, or
nursing in a suboptimal position, makes a difference to the offspring’s
endocrine responses and attachment behavior. These changes in turn
correlate directly, as we have seen, to greater vulnerability to using drugs
of addiction, in addition to a wide variety of other biological and psycho-
logical effects.15 However, when baby rats were shown more maternal
attention, in terms of licking and grooming, the offspring expressed less
fear and anxiety, and less reactivity to stress.16 Moreover, they exhibited
an enhanced ability to self-regulate their emotional states. In addition,
when pups were handled by the experimenters in the first days of their
lives, resulting in increased licking by the mother rat once she returned
to the nest, they again showed lowered reactivity to stress, as well as
decreased memory neuron loss later in their lives.17
Perhaps even more interesting, these behaviors are transmitted over
generations. The method is not genetic inheritance, but culture. The
transmission is the result of behavioral (and specifically tactile) rather
than genetic influences, as can be seen from the fact that female pups
that suffered the same isolation, but were handled early in life, became
more attentive and calming mothers than did their isolated but not
handled counterparts.18 Similarly with rhesus monkeys, daughters that
were rejected by their mothers were found to have mothers that had been
rejected by their own mothers, suggesting again that it is the maternal
behavior and its attendant effects that are transmitted over generations.19
And, most relevantly for our purposes, similar correlations are found
between generations of human mothers and daughters.20 This does
not fit well with the genetically deterministic worldview that has been
bestowed on us by some researchers. Psychiatrist Stuart Greenspan and
philosopher Stuart Shanker comment in this regard that

[f]or a generation raised on determinist principles, the idea that the

evolution of the human mind and of human societies was the result
of formative cultural practices that guide caregiver-infant interactions
during the formative periods of development, and that these critical
cultural practices were not genetically determined, but, rather, were
passed down and thus learned anew by each generation in the evolu-
tionary history of humans, may come as something of a shock.21

Nevertheless, the evidence supports the notion that culture is the

manner of transmission of these practices. Neglectful or harsh mothers
 The Ecology of Addiction 67

beget neglectful or harsh mothers, and that has an effect on each subse-
quent generation’s ability to manage stress, and on the likelihood that
affected generations will self-soothe with substances. With regard to
human subjects as well, Greenspan and Shanker affirm the view that
early brain development is dependent in large part on the quality of a
child’s interactions with her caregiver. They say that, regardless of how
much potential a child’s brain has, unless she “undergoes very specific
types of interactive affective experiences that involve the successive
transformations of emotional experience and that are the product of
cultural practices forming the very core of our evolutionary history, that
potential will not be realized in a traditional sense.”22 The reason, on
their view, is that the potential that a child may have “does not reside
in the physical structure of the brain, but is defined only in the types
of complex interactions between biology and experience” that we have
been talking about.23 A child’s cognitive and emotional development,
and thus her vulnerability to addiction, is never a matter of her indi-
vidual brain’s genetic structure unfolding alone. Appeal to the emergent
level of personalities is essential for explaining the development of the
brain that is susceptible to addiction.
The story encompasses even more than offspring and caregiver,
however. As Paul Plotsky discussed at the Culture, Mind, and Brain
Conference held at the University of California, Los Angeles, in 2012,
it was not only the stress of separation, or even the mother’s resulting
agitated behavior that ultimately made the difference in pups’ ability
to regulate their stress responses. Plotsky had shown in earlier exper-
iments results similar to the ones we just discussed – that pups that
suffered separation or loss of their mothers early on consistently showed
later increased responsiveness to both stress and amphetamine. The
neurochemical explanation for this was that the separation resulted
in changes in dopamine transporter expression and, in turn, in signifi-
cantly increased dopamine responses to stress.24 But this change was
hypothesized to be a function not simply of the distress of the pups at
being left alone but also of the disordered behavior of the mother, which
had also suffered from the separation, upon being returned to the cage
with the pups. So far, this seems like simply another example of stressed
mothers’ effects on offspring. When the mothers in Plotsky’s experi-
ment were brought back into a two-room cage, however, rather than
into a standard single-space cage, so that they were able to build new
nests and move their pups, they returned to natural mothering, and the
effects of the pups’ “adverse event” were reversed.25 These results suggest
two things: first, that normal psychological development is not merely
68 Addiction

a function of avoiding stress, or of having a reliable social relationship,

but also of having an environment in which social relationships can be
allowed to operate normally. The environment in which an organism
develops is not an external element, a space in which genetic informa-
tion simply unfolds. Rather, the environment has been shown to be a
significant player in brain development, exhibiting the power at both
first- and secondhand to either enhance organisms’ ability to respond
to later stressors in their environments or to seriously disable it. Further,
Plotsky’s results suggest remarkable plasticity in the mammalian brain,
for a change in the environment can change the direction of develop-
ment already under way. This is evidence of both the dynamic nature of
organisms and of their personalities, which provides reason for addicts
to have hope. All too often people with addictive difficulties believe
that they are “biologically determined” to be addicts, or that once they
have suffered trauma they cannot overcome it, and that once addicted,
they’re always addicted.

The continuing influence of stress

Stress is essentially an imbalance between stimulating and tranquilizing

chemicals, and imbalance is uncomfortable. So we should expect that
stress in adult life, as well as during development, has repeatedly been
found to be implicated in drug use, abuse, addiction, and relapse.26
In numerous studies with nonhuman primates, particularly rhesus
monkeys, which are, like humans, a highly complex, socially oriented
species, social context and social stress have been shown to play crit-
ical roles in alcohol consumption, both among adolescents and among
adults.27 “Social separation,” researchers in this area say, “engages a
deficit-triggered motivational system” in primates so potent that it that
outweighs other deficits, including food and water deficits. That is, social
separation for these animals has serious repercussions – so serious, in
fact, that the monkeys won’t eat or drink water when their social bonds
are disrupted. In one study, rhesus monkeys reared without parents, in
peer-only settings, showed increased physiological responses to stress,
which we would expect, given our considerations so far. Additionally,
during times of stress, these monkeys drank significantly more alcohol
and were more likely to drink to intoxication than were their peers that
were reared in nonstressed conditions, with maternal care. But the stress
affected even the less reactive individuals. When social stress was intro-
duced to the even better adapted mother-reared monkeys, their alcohol
consumption increased to match that of the peer-reared group.28 So,
 The Ecology of Addiction 69

even those that enjoyed a nurturing environment during early develop-

ment drank heavily when faced with social stress.
An often-cited series of nonprimate experiments performed by
researchers at Simon Fraser University corroborated the importance
of environmental stress on the development and persistence of addic-
tion.29 Bruce Alexander, lead author of the studies that resulted from
these experiments, described his team’s method for discerning the cause
of self-administration of drugs by laboratory rats. Their question was
whether the self-administration so often observed in addiction studies
might not be better described as a self-medication device than as a
function of previous exposure to the drugs. In order to answer it, these
researchers sought to discover whether seeking relief from a stressful
environment, rather than the effects of the drugs themselves, could
better explain compulsive drug self-administering behavior exhibited
by rats that were “raised in isolated metal cages and subjected to surgical
implantations in the hands of an eager (but seldom skillful) graduate
student followed by being tethered in a self-injection apparatus.”30 Their
idea was, in other words, that animals raised in physically and socially
impoverished environments, with none of the stimuli or nurturing
necessary for the development of normal responses to daily challenges,
which are then attached uncomfortably to a self-injection device, might
continuously self-administer drugs not because the drugs in themselves
were addictive (the drug-centered approach), but instead because the
drugs provided relief from environmental stress.
To test their individual-centered hypothesis, these researchers built
“the most natural environment for rats” that they could come up with
in a laboratory. For rats, it was scenic, spacious, and rich. They called
this construction “Rat Park.” Rat Park eliminated the standard stresses
that lab rats typically endure, of cramped, isolated, boring, and painful
or at least uncomfortable living conditions. As it turned out, the rats
living in Rat Park had little taste for the morphine-laced water according
to which their “addiction” was measured, even when they had been
forced to consume significant amounts of morphine for weeks prior to
the experiment, to ensure that they would experience withdrawal symp-
toms if they did not take it. This was in contrast to rats raised and tested
in traditional cages. The difference between the behaviors of the respec-
tive groups of rats was significant. Under some conditions, the animals
in cages consumed nineteen times as much morphine as did the rats in
Rat Park.
To understand the extent and power of the results of the Rat Park
experiment, we should consider some of its details. The experiment
70 Addiction

set involved four groups of rats reared and tested in different environ-
mental conditions: one group was reared and tested in cages; one group
was reared and tested in Rat Park; one group was reared in cages, but
moved to Rat Park shortly before testing began; and one group was
reared in Rat Park, but moved into cages shortly before testing began.
The researchers, in short, tested rats exposed to every combination of
cage/park rearing and testing. The rats were tested continually on their
choice to drink either water or a bittersweet morphine solution, with the
solution being switched out every five days for a more bitter-tasting and
less potent version. At each level of morphine solution tried, the caged
rats, whether reared in cages or in Rat Park, drank much more morphine
than did those that lived in Rat Park during the time of the testing. This
suggests that the present state of distress is more indicative of drug use
than earlier stress later compensated for, and that even an absence of
developmental stress didn’t matter when present conditions deprived
the animals of stimulation and company.
Alexander concluded from these experiments that the drug-centered
view is mistaken: addiction is not caused by drugs themselves. If it were,
living in Rat Park should make no difference in how much rats already
dependent on morphine would drink. The conclusion that Alexander
arrived at was that typical experiments test something other than what
they are intended to test. What they actually test is the effects of labo-
ratory settings on animals, rather than the animal’s natural responses
to drugs. He says that “the intense appetite of isolated experimental
animals for heroin and cocaine in self-injection experiments tells us
nothing about the responsiveness of normal animals and people to
these drugs.” Drugs themselves do not trap mammals (including people)
into addiction, according to this research. This view, as we have said, is
corroborated by the fact that most people who take drugs do not become
addicted to them. For most who imbibe in drugs or alcohol (or gambling),
the stimulation remains just an occasional recreational pleasure. If
Alexander’s team is right, the key to understanding addiction is much
more complex than mere molecular interactions – although again, it
is true that no other thing exists – only other patterns exist, but those
patterns are themselves highly efficacious. Based on these experiments,
the drug-centered view is too simplistic.
An adequate account of addiction requires thinking much more
broadly than just about the individual, or about the individual together
with a drug. We must think of the organism, as we saw in the cases
of the development of children, as operating within an environment
that includes other organisms and patterns of activity that interact in
 The Ecology of Addiction 71

highly complex ways. It seems obvious that, as Alexander’s group seems

to have found, drugs will have a significantly more powerful effect on an
organism that is stressed out.31 In addition to the expected intoxicating
effects that everyone gets from drugs of abuse, in the case of highly
stressed individuals the “reinforcing efficacy of drugs of abuse” is greatly
enhanced. That is, the improvement in affective state that drugs can
cause in highly stressed (and thus highly uncomfortable) individuals
will be significantly greater relative to their starting point than it can be
in those who have a better starting place.32 No wonder the stressed are
more vulnerable!
The powerful effects of stress, as we have seen, can affect a person’s life
at different times, and can be of different sorts, and it seems to be just
as powerful a factor in relapse as it is in generating addiction to begin
with, or in maintaining it. But not just any stress will trigger relapse.
Context is essential to the meanings of events for all sorts of mammals,
and the context in which stress is experienced has everything to do with
whether one will relapse. Footshock in rats, for example, will stimulate
reversion to self-administration of all categories of addictive drugs, but
only when it is reintroduced within the experimental setting. In experi-
ments in which the context was changed, even when stressors such as
additional footshock or restraint were introduced, drug use was not rein-
stated.33 Once again, we see that organisms are embedded in a rich way
in their environments, and so we cannot conceive of their addictions as
merely an effect of chemicals on the brain.
In humans, although the mechanism is not clear, addiction appears to
result in both an altered stress response in general, and in changes in the
way in which emotions, conscious or not, influence decision-making.
One recent study, for instance, showed that acute stress tends to incline
people to choose differently than they would otherwise with respect to
rewards and punishments. Under stress, people tend to automatically
choose things that had previously provided rewarding outcomes, while
they fail to avoid previously experienced negative outcomes.34 People
under stress don’t, perhaps unsurprisingly, give thoughtful considera-
tion to the full range of consequences of their choices, but rather appear
to automatically respond positively to reward. Another study revealed
that even after two years of abstinence, the social stress associated with
giving a prepared speech was followed by impaired decision making in a
group of people who had previously been addicted to opiates, compared
to the performance of a never-addicted group. This correlation existed
despite the fact that the previous opiate users consistently performed
equally to the control group on decision-making tasks in situations of
72 Addiction

low stress.35 Previous states (addicted or not), as well as the external

environment – particularly the social environment – have significant
influence on the emotional and cognitive responses of addicted individ-
uals, despite a lengthy abstinence from drugs and regardless of strength
of cognitive abilities otherwise.

Genetic influence

These considerations give us reason to think that the arguments for the
“genetic disposition” to addiction are not as strong as they are believed
to be by many researchers. Although it is often said that alcoholism
“runs in families,” and that is certainly true, in the sense that if one has
an alcoholic parent, one is statistically more likely to be an alcoholic
oneself, that does not establish that alcoholism is a function of genetics.
Alcoholics who are children of alcoholics are, after all, generally raised
in the homes of alcoholics. From what we have seen above, this would
lead us to believe at the very least that the disruption that alcoholism
in the home causes would by virtue of stress alone increase the vulner-
ability of children of alcoholics to addiction. But that is not the only
thing that children of alcoholics have in common. According to the
addiction researchers who focus on genetics, “[h]eritability is the genetic
component of interindividual variation,” and the claim is that “about
50% of this interindividual variation is genetic in origin.”36 That is,
when addiction researchers say that the tendency to addiction is inher-
ited, they mean that it is genetically determined, at least halfway. The
other half is determined by environment.
There are several problems with this kind of claim. For one thing,
heritability estimates are meaningless with respect to individuals, and
so we can’t make any claims about a particular person’s vulnerability
to addiction based on this ratio. This is because, in the first place, an
individual can’t be said to vary with anything. Heritability only makes
sense with respect to a population. Reproductive and selectional pres-
sures don’t work on individuals. Population properties aren’t even a
function of the individuals in the population. They are frequency distri-
butions. For that reason, it is a category mistake to attribute a heritable
factor to an individual, although it is commonly done. In the second
place, heritability can’t be supposed to explain anything about the
specific influence of genes on a trait, because only a trait is big enough
to be selected for, and thus to make the kind of difference that can be
judged heritable or not. Traits aren’t genes, and the link between traits,
particularly behavioral traits, and genes has not been identified. At most
 The Ecology of Addiction 73

we can say that there is something that can account for observed differ-
ences. Here’s one reason why: with only about 20,000 protein-coding
genes in the human genome, there just aren’t enough genes to code
for things as specific as assignable behavioral traits, much less degrees
of those behavioral traits.37 And there’s more: in order to tell whether a
trait is selected for, you would have to have a background, or an envi-
ronment, which is identical for all the organisms under consideration.
Against this background, genetics could tell us which individuals had to
have some different genes from the others, since the difference would be
conspicuous. Even then, though, it wouldn’t tell us that the individuals
with similar traits were genetically the same, because there could still be
unexpressed genetic differences. Moreover, this kind of study couldn’t
tell us why a particular trait was observable in any particular individual,
but only why there would be differences among individuals in a popula-
tion. Heritability is a statistical measure concerned with relative differ-
ences among a single population in the same environment. It is not, as
behavioral geneticist Jerry Hirsch points out, a “nature/nurture ratio” to
begin with.38
As Gene Heyman observes, however, there must be some reason why
highly trained people say that addiction is heritable, and some reason
why they say very specific things about that heritability.39 The research
literature that we saw above concluded that genetics contributes about
as much as one’s environment in determining whether a particular indi-
vidual will become an addict, given the opportunity. There are several
reasons why most addiction researchers who focus on this question have
accepted this conclusion. First, two kinds of studies have been touted for
the “strong evidence” that they are said to provide of the heritability of
addictive tendencies. Second, much excitement has been generated by
genetics in general due to the mapping of the human genome, and the
promise that that mapping seems to offer for predicting and reversing
a variety of human problems, both physical and psychological. Finally,
there is the fact that the genetic argument fosters the disease model of
addiction, to which many researchers, as we have seen, are intellectually
wed. For these reasons and perhaps many others, researchers, clinicians,
and sufferers alike have become confident that genetics dictates a lot
when it comes to addiction.
Let us consider more carefully the studies that prompt this confidence.
One kind of study used to detect the heritability of personality traits
such as proneness to addiction involves children who have been adopted
and their two sets of parents. The idea behind this sort of study is that
since children who are adopted have one set of influences contributed
74 Addiction

by their biological parents, and another set contributed by the environ-

ments created by their adoptive parents, surely some comparison could
be made that would determine whether nature or nurture “caused” their
eventually exhibited traits. The results of two large, well-cited studies
show that both influences operate in the generation of patterns of
alcohol abuse, with one such pattern appearing to be significantly more
influenced by genetic factors than the other. The first study followed
852 Swedish men,40 while the second, a companion study, followed 913
female adoptees from the same population.41 In these studies, individuals
who had been adopted early in their lives (the mean adoption age was
eight months) were followed over several decades. Two types of alcohol
abuse patterns were discovered, one in which alcohol use patterns of
biological parents (fathers in the case of the men, mothers in the case of
the women) were significantly linked to alcohol abuse patterns in their
offspring, and one in which this tie was less significant. In both cases,
environmental effects seemed to have a small but significant impact on
the risk of alcohol abuse in the adoptees.
Now, although many researchers are convinced that this shows that
the tendency to alcoholism was most strongly influenced by their
biology, others are not so sure of this reasoning. For one thing, the study
did not take into account the effects of prenatal stress on developing
brains, which, as we saw in Chapter 3, would likely play a significant role
in whether and to what degree these children would be prone to alco-
holism. Babies who are adopted are likely to have been exposed to signif-
icant stress during gestation, but not all of them, and certainly not all to
the same degree. Many factors influence the decision to place a child for
adoption, but oftentimes the decision involves highly stressful circum-
stances. Other factors as well could have confounded the results, such as
the representativeness of the parents involved in adoption studies, the
selectiveness of placement (not just anybody can adopt a baby), prob-
lems with attachment to the new parents, and the child’s possible late
separation from the birth parents. In the case of late separation (eight
months is a long time in an infant’s life), the birth parents will already
have had significant time to influence the child’s stress, attachment,
and other factors involved in developing a predisposition to addiction.42
And the results of the Swedish studies have not been consistently repli-
cated. In fact, in another one of the most carefully designed adoption
studies, the 1998 Colorado Adoption Project, the authors found a zero
correlation between biological parents and their offspring on a mean
personality scale.43 While the combined results of these studies do not
warrant a conclusion that genetics has nothing to do with personality
 The Ecology of Addiction 75

traits, including vulnerability to addictive patterns, they do suggest that

the relative influences of environment and genetic contributions to a
disposition to addiction have not yet been clearly disentangled. And
recall that even in the Stockholm studies, the stronger genetic effect was
found in only one pattern of alcohol abuse.
The other kind of study often used to attempt to disentangle genetics
from environmental factors involves twins, both identical and fraternal.
Twin studies are presumed to be the best way to test for genetic similari-
ties. This is because both kinds of twins ought to have the same environ-
ment, but only identical twins have the same DNA, and so the genetic
factors ought to be isolable from the environmental ones. And research
does show that identical twins are about twice as likely to share addic-
tive patterns as fraternal ones. But the conclusion that this match must
be the result of DNA, Gabor Maté has argued at length, is just false.44 The
rate of concordance between identical twins as contrasted with fraternal
twins, he maintains, is equally consistent with environmental factors
being the relevant influence. First of all, the argument goes, fraternal
twins don’t share the same internal environment as identical twins do.
They are just as physiologically different as any other siblings, and so
their interactions with the world will not be biochemically any more
similar than any other siblings’ interactions. Their experiences of their
environment throughout gestation and development will for that reason
be different in ways that identical twins’ experiences of their environ-
ment will not be. Second, says Maté, because fraternal twins are as phys-
ically and temperamentally different as any other siblings are from each
other, parents will, however unconsciously, respond to them differently,
as will everyone else. This means that their social environments will be
just as distinct as are any siblings’ environments. By contrast, identical
twins are alike in these ways, which will prompt the same responses
from others in their environments. For this reason, says Maté, iden-
tical twins’ environments won’t really be that different, even if they
are raised separately. This is a strong claim, though, warranting some-
thing stronger than mere speculation as support. What does “really that
different” mean? If it means significantly different in the relevant ways,
then the argument is pure presumption. If it is extrapolation from the
sameness of DNA to the sameness of the children who share it, then it is
grossly oversimplifying, presuming the children to be more mechanical
than human.
In another line of reasoning, Maté argues, perhaps more convincingly,
that identical twins, unlike fraternal twins, do share the same uterine
environment for nine months, and so are exposed to the same epigenetic
76 Addiction

factors and the same kinds of experiences in the world before adoption.
So, he argues, even those identical twins separated at birth and raised
in different familial environments do not prove the genetic hypothesis.
Nurture has already had a chance to have its effect by the time of birth
and separation, so the genetic factor is not isolable even in this case.
What is more, all twins experience separation trauma when they leave
their mothers, when they leave each other, and when they leave what-
ever caregivers they may have in the time between birth and adoption.
So it would seem that both groups of twins would be equally set up for
vulnerability to addiction on that account (on this reasoning, though,
note that it would seem that all adoptive children are so set up). In the
case of twin studies, as in the case of the adoption studies, the implica-
tion seems to be not that genetics has a clear and strong influence on
the disposition to addiction, nor that it doesn’t; rather, the implication
is that addiction in human beings cannot be reduced to a single level
of analysis, either physiological or psychological. It is a higher-order
pattern that can only result from the complex and dynamic interac-
tion of an indefinite number of factors, including genetic inheritance,
physical environment, and psychological environment.

Other factors

A couple of further considerations must be addressed before we extend

our discussion to include the influence of culture on addiction. First,
remember that when we discussed Heyman’s criticism of the disease
model of addiction in Chapter 1, we noted that most people included
in research studies are those who sought clinical treatment. These indi-
viduals also suffered from other health conditions in addition to their
addictive problems, such as anxiety, HIV/AIDS, or ADHD. The influ-
ence of some of these conditions on addiction’s trajectory is well estab-
lished. Maté points out that ADHD “is a major predisposing factor for
addiction.”45 It shows up in a disproportionate number of substance
abusers of all types, and, according to Maté, “is no more inherited genet-
ically than addiction is.”46 The same arguments are relevant in both
cases. Generalized anxiety disorder as well is disproportionally repre-
sented among addicts. In one study, for example, which was designed
to circumvent the obvious fact that anyone undergoing treatment for
alcohol dependence would be experiencing anxiety, the comorbidity
rate for generalized anxiety disorder among alcohol-dependent patients
was nearly half. In this study, the disorder was shown to have existed
prior to the onset of alcohol problems 67% of the time.47 Another, much
 The Ecology of Addiction 77

larger study showed that having social anxiety disorder increased the
chances of someone’s having an alcohol disorder by a factor of four.48
Likewise, bipolar disorder is highly correlated with alcohol and other
drug use disorders, but in this case the relationships between the psycho-
logical and use disorders are very hard to disentangle. Researchers do
not seem to have uncovered a single causal order between them. With
respect to marijuana, for instance, it sometimes appears to increase
bipolar symptoms, and sometimes to decrease them.49 If this result
argues for anything, it is that bipolar symptoms may have different
causes in different people. Finally, in the case of major depression,
which is also highly correlated with alcohol problems, the causal arrow
seems to go in the opposite direction from that characteristic of anxiety
and ADHD disorders.50 Whereas researchers conjecture that alcohol is
used as a method of self-medicating ADHD and anxiety disorders, and
in particular social anxiety disorder, depression instead seems to be the
result of alcohol abuse. Much work has been done specifying these rela-
tionships for gender, race, economic status, and a variety of other vari-
ables, but for our purposes the main point is that addiction does not
arise in isolation. It arises in specific contexts, in relation to physical
and/or social environments at various levels of proximity, and it shows
up as both cause and effect.
Another thing to consider prior to an examination of cultural influ-
ences on addiction is that the social world in which we are embedded
is different at different times in our lives, regardless of gender, race, or
economic status. This fact is important to understanding the patterns
of addiction. When children are quite young, as we have seen, their
parents are experienced as virtual extensions of themselves. Everything
that their parents do or do not do affects the child’s own stress and
reactivity levels. When they become adolescents, their peers become
more influential elements of their environments. Even the popular press
has made it known how much they conform to the behavior of their
friends, even more than do adults. Scientific American’s 60-Minute Mind
podcast, for instance, reports on research that suggests that adolescents’
weight is correlated with that of their friends, and not just because they
choose friends who are like them in body type but also because others’
behavior influences their own, to the extent that they gain and lose
weight based on the behaviors of those around them.51 While generally
there is no reason to correlate something such as the influence of friends
on specific behaviors to something as serious as DMS-IV-TR-defined
dependence, since most people who try smoking or drinking or other
drugs will not become addicted, absent any independent evidence for
78 Addiction

that correlation, in this population there is reason to attribute a corre-

lation. The fact that adolescents are influenced by their peers to begin
smoking, drinking, or taking other drugs is relevant because early onset
of the use of alcohol and drugs of addiction has been shown to increase
the frequency of dependence in adult life by four to six times.52 Even
the age of onset of smoking, which seems a popular vice for adolescents
but not directly related to other drug dependence, has been found to be
a significant predictor of alcohol use and dependence.53 Rather than the
much-maligned marijuana, if there is a “gateway drug,” it would seem
to be tobacco.
We can with reason, then, seek contributing causes and correlations
to addiction from the molecular level to the organismic level to interac-
tive levels with parents and social groups. The one thing that we cannot
find is a single cause, or even a single state, that is called “addiction.”
What we find is a process, which mainstream researchers characterize
in terms of three stages, but which others characterize in terms of the
ongoing processes that may be limited to the level of individual choices,
or that may be traced to epigenetic effects on the unfolding of our DNA.
I suspect that this latter analysis won’t make sense unless we at least
postulate the existence of the DNA that unfolds, but that DNA is essen-
tially best understood as itself a process that comes into existence and
changes at many points over the span of an organism’s life. Each of
these complex patterns of ever-changing action is involved in what we
know as addiction, but none of them alone constitutes it.
5
The Culture of Addiction

The solution is the problem, and the problem is the

solution

Individuals are both created by and give rise to their cultures. Not only
does no one become an addict in a vacuum, but also, in addition to
one’s physical environment and immediate social interactions, human
addiction takes place within a larger culture. As sociologist James Barber
puts it, “[w]e learn to drink, smoke, and take drugs because others show
us not only how to do it but also how to enjoy it.”1 The relation of
addiction to culture is, like all the other levels of analysis that we have
considered, dynamic and complex, and different in every case. In many
of these cases, specifically within the past few hundred years, psychoac-
tive substances and addicted populations have been, and continue to be,
both the cause of and the cure for many of society’s problems. Without
addicted laborers, some of whom were paid in kind for producing the
very substance to which they were addicted, the global markets in
tobacco and caffeine products, such as coffee and tea, could not have
arisen, not to mention the smaller but significant opium, cannabis, and
coca markets.2 The use of these substances played a large role in keeping
laborers laboring, and markets growing. Today, given the DSM-V’s inclu-
sion of food addiction among its listed disorders, we might add the fast-
food market to the list. Low wage-earning fast-food workers often take
advantage of readily available cheap and fast food, saturated with fat
and salt, because it suits both their schedules and their incomes. The
discounts or free food that they often receive at such jobs suggest that
the corporations for which they work find the arrangement mutually
convenient.

79
80 Addiction

It is difficult to overstate the role that these substances played in

the development of world markets and political power. Chinese colo-
nizers, for instance, depended on the incessant opium smoking of their
“coolies” for their profits and power. Colonial leaders allowed monopo-
lies to be created and protected for the sale of opium, sometimes keeping
half or more of the workers’ wages as proceeds. China’s colony Singapore
received as much as half its revenue from opium in the 19th century.3
In Europe and the United States, the relevant products were alcohol
and tobacco. In Eastern Europe prior to mechanical agriculture, peas-
ants were notorious for being drunk for days on end, and the same was
true of poor Europeans who came to America to work. But even alcohol
consumption was no competition for tobacco. Beginning in the 17th
century, tobacco production occupied all the European colonizing coun-
tries, with the slaves who produced it receiving daily rations of the crop.
Every demographic engaged in some form of tobacco use, from diplo-
mats to tourists to laborers, and, most prominently of all, soldiers. By
1670, the English were using about a pound of tobacco per capita annu-
ally, while the Dutch were using about one and a half times that much.4
Tobacco was used in various forms throughout the 18th century, but by
the middle of the 19th century, smoking was the clearly favored manner
of consumption. First pipes and cigars, and then, by the early part of the
20th century, cigarettes became the preferred manner of indulgence. In
the late 1950s, Americans were buying some 15,000 cigarettes a second,
and by the mid-1990s, a third of the world’s population over the age of
fifteen was smoking cigarettes.5 But those numbers, staggering though
they may seem, are small in comparison to the quantities of caffeinated
products consumed, particularly coffee. According to historian David
Courtwright, “by the late twentieth century it [coffee] consistently
trailed only oil as the world’s most widely traded commodity.”6 It is no
wonder that coffee and cigarette breaks came to shape the very structure
of the workday in the middle of the 20th century for white- and pink-
collar workers in the West.
One account of why these substances became so ubiquitous, in addi-
tion to their unparalleled ability to create profit and tax revenue for
the wealthy and the powerful, through keeping the money earned by
workers in the hands of their employers, is that these substances also
served and continue to serve to control indigenous peoples and other
impoverished workers. For centuries, stimulants and pain- and grief-
soothing substances have kept people working long hours at grueling,
repetitive, mind-numbing jobs, through heat, hunger, and disease.
In the 17th century, when Europe was afflicted with every misery
 The Culture of Addiction 81

imaginable, substances such as tobacco, coffee, and tea, according to

Courtright, served a “dire utility” in “helping peasants and workers cope
with lives lived on the verge of the unlivable.”7 At the very least, it seems
that preoccupation with seeking and consuming drugs results in such
apathy that workers are unlikely to try to do anything to change their
circumstances. Like religion according to Karl Marx, these substances,
are the opiates of the people, keeping them distracted from their miser-
able situations.
In the 20th and 21st centuries, coffee breaks, happy hours, and drive-
through fast-food restaurants, as well as cocaine and, increasingly,
prescription drugs, serve to keep spirits up and people working. It is also
true, however, that some of the substances that have been tolerated and
even encouraged for centuries can all too easily render workers useless.
Years of cigarette breaks – we, as a society, have gradually learned –
turn into massive expenditures in healthcare down the road, and the
same was discovered about the three-martini lunch. With respect to the
weaker varieties and smaller quantities in which the palliative substances
were used by peasants and slaves, the price for allowing or even encour-
aging use was small. But as the dynamics of society changed, as well
as the means of production, so did attitudes toward the use of specific
substances. In an agricultural setting, no one seemed to mind if hemp
harvesters were ingesting cannabis all day long, or if serfs were swilling
stale beer. But as soon as spirits were distilled, trouble arose. This much
stronger variety of beverage resulted in complaints from government
officials and employers alike.8 Cheap gin in particular, which became
widely available in Europe in the early 18th century, was so obnoxious
to productivity that a contemporary author complained that “the lowest
class of people could afford to indulge themselves in one continued state
of intoxication, to the destruction of all morals, industry, and order.”9
Before the 17th century, distilled alcohol was considered a medicine,
sold only in apothecaries, and at a prohibitive price for commoners. But
by the early 18th century, distilling technology and increased produc-
tion made it possible for it to be sold even more cheaply than beer,
making heavy drinking a possibility for people of all economic ranks and
statuses. But that democratizing carried a price in terms of the destruc-
tion of the moral status quo (obedience to law and church), industry
(hard work), and order (compliance). Much like cannabis and psyche-
delics in the 1970s, the use of spirits in the 18th century was cited as the
direct cause of crime and disorderliness. Threatened and real disruptions
among working class individuals who failed to show the proper fear of
authority and shame for their actions created significant apprehension
82 Addiction

among respectable citizens and political leaders, particularly as workers

became increasingly concentrated in cities. With industrialization and
globalization expanding, the number of variables potentially threatening
the established order rose. Ultimately, when the substances responsible
for creating such huge profits and tax revenues resulted in disorder and
threats to the national economy, not only the U.S., but one country after
another opted to impose restrictions or even ban the very items that
had helped their economies to expand and flourish. At the same time,
the individuals who had developed habits of using those substances
came to be denounced as moral reprobates, and later, as addicts. When
the solution to the problem of how to provide labor for industrializa-
tion and products for the rise of the global economy began to take on
a life of its own, that solution itself became a problem, with the owner
of the problem no longer being identified as the economy or political
unit. Now the problem belonged to the individual, who emerged as the
“addict.”
This observation suggests two questions. First, to what extent and in
what ways is the concept of addiction a social construct? If it turns out
that a large part of what we call addiction is the use of substances and/
or engagement in activities that disturb the order and productivity of a
society, then the conception of it in terms of a brain disease seems to be
constructed, at least in part, for control. Those who act inconveniently
can be “treated.” Alternatively, if construing the use of certain substances
and activities as a disease creates an economic boon to society, then the
conception of it in this way seems to be fortuitously profitable. A new
disease that creates a new treatment industry can be very valuable to an
economy. Second, to what extent is addiction brought about by social
circumstances themselves – whether the phenomenon is then analyzed
in terms of changes in the brain or not? If industrialization and the
development of a consumerist, competitive world economy, for instance,
actually encourage the development of patterns of behavior that we call
addictive, then attempts to resolve individuals’ suffering with “treat-
ment” aimed at fixing them rather than addressing their circumstances
just reinforces the social circumstances that give rise to the problem.
Individuals are sent for treatment, taking the blame upon themselves
for their misery. Meanwhile, the socioeconomic structure that is at least
in part responsible for creating the construct of the “addict” continues
to be supported by a burgeoning medical industry that benefits from
that construction. No doubt these issues are deeply intertwined with
one another and with the physical phenomena associated with addic-
tion. The social construct of addiction is emergent from the economic,
 The Culture of Addiction 83

political, and cultural environment that gives rise to both the need and
the ability to escape from stressful conditions in the first place.

A cultural construct

The very notion of addiction only became popular as the medical and
insurance industries grew and prospered, and consumerism rose to the
greatest heights it had ever seen. Sociologist Gerda Reith argues that
“[t]owards the end of the nineteenth century, a convergence of inter-
ests between the industrial nation-state and the medical profession
coalesced into a (fragmentary) discourse that postulated a state of ‘addic-
tion’ as a ‘disease of the will,’ and created a new type of individual –
and ‘addict’ – as a distinct identity.”10 As American culture became ever
more industrialized, she says, “[t]he bourgeois emphasis on industrial
productivity and labour discipline elevated the properties of self-regu-
lation and control to personal as well as political virtues, and also gave
rise to an increasing intolerance of behavior regarded as potentially
disruptive.”11 In order for productivity to continually grow, it became
increasingly important for workers to self-regulate their consumption
of certain products. Whatever else they did, workers would have to be
reliably functional in increasingly complex social environments. The
implication of this seems to be that it is the potential for disruption
of socioeconomic flow, rather than the quantity of consumption itself,
that establishes a substance’s or activity’s character as addictive, or the
agent as an addict. In fact, increased quantity of consumption of all
types of goods has consistently been pressed, and has surged radically
over the past one hundred years. Identity itself has come to be created
through one’s patterns of consumption: who one is, is a fluid construct
rather than an essence, a matter of choices rather than of nature.12 An
identity based on choice, though, although it is apparently an identity
created through freedom, is nevertheless based on a freedom of a very
particular, and a very peculiar, sort.
In Daniel Bell’s language from forty years ago, we see in the “cultural
contradictions of capitalism” a “fundamental conflict between the
ascetic values of the protestant work ethic” on the one hand, and “the
hedonistic values of instant gratification that come with capitalist
consumerism” on the other.13 As has become commonly recognized,
Americans, like members of many affluent nations, are bombarded
regularly with advertisements encouraging indulgence in everything
from chocolate to vacations to automobiles and jewelry (“every kiss
begins with Kay”). Meanwhile, and sometimes within fifteen seconds,
84 Addiction

the message is sent that one ought to be prudent, to develop self-

control, through consuming yet more: services from the most
responsible investment firm, or Weight Watchers, or Special K. This
schizophrenic approach to consumerism is essential to consumer capi-
talism, and the message is clear: more is better; consumption is good.
Consumption of additional products, whether diet products, consumer
counseling, or medical treatment for addiction, is the answer to the
“disease of the will” of out-of-control consumption. Most notable of all
about this situation is that the responsibility for all of this consuming,
overconsuming, and counterconsuming rests squarely with the indi-
vidual. The system of hyperconsumption itself in which the concept of
“addict” arises is never examined.
Before alcoholism came to be understood as a disease, regular drunk-
enness was simply regarded as a behavior, undertaken in the name of
pleasure. But as this drunkenness came into conflict with social control
and developing forms of productivity, several groups began to peti-
tion to eliminate it. As wide support around the world for prohibition
illuminated, alcohol itself, not the user, was understood as being to
blame for its excessive use. After the policy of prohibition in the United
States became increasingly clearly unworkable, a conceptual revolu-
tion with respect to alcohol and its abuse was required to justify repeal
of the constitutional amendment that had implemented the policy.
The notion of an “allergy” to alcohol spread. As it happened, in the
same year that the 21st Amendment was passed repealing prohibi-
tion, Alcoholics Anonymous (AA) was founded by Bill Wilson, along
with his doctor, Robert Holbrook (“Dr. Bob”), who told him about a
new disease theory of alcoholism. According to this theory, certain
people are just born with a predisposition to alcoholism (later referred
to as “addictive personalities”). Framing addiction in terms of disease
allowed the medical industry to get into the business of treating it. As
the disease model blossomed, so did the number of “addicts” found to
be in need of professional treatment. One California study found that
between 1942 and 1976, the number of citizens in treatment increased
at least twentyfold (2000%).14 With the AMA’s official declaration in
1987 characterizing addiction as a disease, whose treatment “is a legiti-
mate part of medical practice,” third-party reimbursement (insurance
payments) became possible for the treatment of addiction, bringing yet
another segment of the economy into the game. Addiction treatment
became very big business. Between 1978 and 1984, the number of for-
profit residential addiction treatment centers increased by 350%, and
their caseloads increased by 400%.15 Today, the Substance Abuse and
 The Culture of Addiction 85

Mental Health Services Administration estimates that spending at the

over 11,000 addiction-treatment centers in the United States will reach
$35 billion in 2014. It has become a major public line-item expense.
Federal programs such as Medicaid and Medicare, as well as state and
local programs, funded about three-fourths of that expense as of 2003
and will continue to carry the heaviest burden, although the percentage
paid by private insurers is growing.16
The disease conception of addiction is so thoroughly entrenched in
American culture that it is difficult to find any psychiatric, medical,
educational, or even criminal justice policy that doesn’t embrace it as a
fundamental assumption. This is true despite the fact that the preferred
method of treatment in some 90%+ of treatment centers is based on
12-step spiritual models, rather than on medicine. The deeply entrenched
assumption of the disease model might be thought to result from the
simple fact that this approach results in the best treatment outcomes,
were it not for the fact that the model carries with it political power and
authority, which means control over certain people’s freedom by certain
privileged others. As substance use or any other addictive behavior
comes to threaten productivity, social order, or economic power, those
individuals who engage in that use or behavior are rendered appropriate
targets for diagnosis, “intervention,” and treatment. As author Elaine
Rapping argues, the view that not only does addiction as a biologi-
cally determined disease obviate any need to look elsewhere for other,
perhaps social sources of the problem, but it also provides a properly
concerned way to deal with people and behaviors that appear threat-
ening. Those individuals and behaviors that might disrupt the status
quo can be dealt with apparently compassionately and objectively by
being understood and treated in terms of biological dysfunction. The
facts that they are locked away, stigmatized, and otherwise disempow-
ered, however, cannot be missed. “The biologically determined expla-
nation,” she says, “comes and goes, predictably, as society comes to
find certain kinds of indulgence, favored by certain kinds of population
segments, anxiety provoking.”17 In considering the social development
of the “disease of the will” conception of addiction, we must not forget
to reflect on who among us is deemed addicted, and where they stand
in the socioeconomic machine.
Consider, for example, the attitudes expressed toward the various
“addictive” substances by our legal system. Illegal drug use and sales
accounted for two-thirds of the rise in the federally incarcerated popu-
lation and half of the rise in state-incarcerated populations between
1985 and 2000, according to Michelle Alexander in her much-acclaimed
86 Addiction

book, The New Jim Crow: Mass Incarceration in the Age of Colorblindness.
Arrests for marijuana possession, despite its relative innocuousness
(particularly in comparison to prescription drugs), accounted for nearly
80% of the growth in drug arrests in the 1990s.18 Alexander’s point here
is that it isn’t just anybody who is getting arrested. In the vast majority,
those who comprise these incarcerated populations are people of color.
A commonly cited statistic is that, while African American males consti-
tute about 6% of the general population, they constitute about 35% of
the prison population. And that is just one subgroup of the dispropor-
tionally incarcerated. These populations with high incarceration rates
exhibit less stable and fewer permanent relationships, a situation created
by the incarceration itself. This is not to mention associated phenomena
such as less available stable work and inferior jobs for those who have
been incarcerated, as well as increased exposure to violence and poor
nutrition. These circumstances result in living situations marked by high
levels of stress for everyone involved, which, as we saw in Chapter 3,
render not only adults but also children in such environments more
vulnerable to drug use and abuse.
Further exacerbating the problem is the prevalence of the drugs them-
selves and their attendant dangers in lower socioeconomic neighbor-
hoods. Although individuals in middle and upper socioeconomic classes
enjoy the use of drugs, they do not wish to have them widely avail-
able in their own neighborhoods. It has been argued for decades now
that drug use, drug sales, and addiction have affected poor and minority
communities more harshly than they have white and more affluent
communities, despite the fact that middle-class whites are significantly
more likely than blacks to use illegal drugs and alcohol.19 Reasons for
this include the same race and class discrimination that have resulted in
certain groups being blamed for other social ills, including welfare and
food stamp abuse, and child neglect and abuse, despite available statis-
tics to the contrary. In the case of addiction, we can agree with William
Kornblum that some of the reasons that poor and minority populations
are perceived to have worse addiction problems than others is that the
sale of drugs has typically been located in poorer, more densely popu-
lated areas. Why? For one thing, when individuals are crowded tightly
together, any one person’s activities are less likely to be noticed, When this
crowding reflects a difference in wealth, rather than simple geographic
limitations, people in such situations are also, due to their poverty, likely
to be less valued than their richer counterparts, and therefore less likely
to receive resources dedicated to improving health and safety. Another
reason that drug activity and addiction have affected poor areas more
 The Culture of Addiction 87

harshly than rich ones is the lack of opportunity for job training and
education for those already poor in resources and respect. As the United
States has transitioned into an information-based economy, changes in
production methods have often “deprived low-income minority indi-
viduals of better-paying, more secure industrial employment,” leaving
them with little hope and little to do.20 Drug distribution was one of
the few ways in which many people could provide for themselves and
their families, and the option of moving away from such “vice districts”
remained unavailable to most inhabitants. By the 1980s, the ghettos and
immigrant neighborhoods of New York City, Los Angeles, Washington,
DC, and Miami had become loci of the cocaine and crack trades, which
brought with them high levels of homicide and addiction. “The dispro-
portionate involvement of minority and recent immigrant groups in
the illegal drug industry,” Kornblum explains as inextricably linked to
“historical patterns of vice market concentration in stigmatized, segre-
gated communities.”21
It has been argued widely for at least forty years that police forces were
created and continue to exist for the purpose of controlling people of
lower classes.22 While law enforcement often turns a blind eye to infrac-
tions committed by members of the middle and especially the privileged
class, it responds to the socially unacceptable behavior of the poor and
disempowered by “cracking down,” which results in more incarcera-
tion and the perpetuation of the cycle that creates the need for illegal
drug use and distribution and other vice markets. Such tightening of
enforcement and increasing of penalties does nothing to alleviate the
variables that produce the value and even perceived need for drug use.
The stresses, trauma, and hopelessness of living in poverty and discrimi-
nation remain just as they were. In fact, “cracking down” makes all of
these things worse. According to Alexander, the massive incarceration
of largely people of color in connection with drug use operates together
with “a web of laws, regulations, and informal rules, all of which are
powerfully reinforced by social stigma”23 to confine certain people to
the margins of mainstream society and to deny them access to the main-
stream economy. Drug enforcement policy creates a subclass, which
further defines the concepts both of addiction and of whole swathes of
the population. This approach of isolating people of color (and people of
lower socioeconomic classes in general, we can extrapolate), Alexander
charges, operates as a “stunningly comprehensive and well-disguised
system of racialized social control.”24
It’s not just control of recognized marginalized groups that the
construct of addiction achieves, however. The social control extends
88 Addiction

much further, although in decidedly different ways in different parts

of the population. Whereas the original disease model, as conceived
by the founders of AA, assumed that the addict herself would have to
voluntarily seek help, perhaps after “hitting bottom,” the notions of
“tough love” and “denial” became popular through the later part of the
20th century, culminating in the practice of “intervention,” or forcible
commitment into treatment. The very idea of an addict in denial
suggests in a rather insidious, self-justifying, nontestable way, that the
addict himself is not capable of acting as an autonomous individual,
that he is unable to determine for himself whether or not he is addicted.
In a bizarre twist, then, a person can not only prove by his denial that
he is an addict but also in some sense can become one through the act
of objecting to the characterization. Addiction thus becomes a disease
that one can “develop” instantly at the attribution of someone else. If
an individual decides to attribute all of his problems to a substance or
behavior, rather than to social structures and stresses, physical or sexual
abuse, or anything else, or, more importantly, if someone else attributes
his problems to his “addiction,” then he becomes an addict. The ascrip-
tion of someone’s problems to addiction can change his whole life: how
everyone around him views him, how employable he is, how welcome
he is at various kinds of social and volunteer events, how trusted he is
around children, and even whether he is accepted as a citizen in his
community.
Who gets to decide who is an addict is thus a matter of no small
import. It is not analogous to having tests run to determine whether
someone has diabetes or heart disease. If a person uses an activity or
substance more than certain other individuals deem reasonable, regard-
less of whether the “addict” in question maintains a job, pays her bills,
or perhaps even reaches high levels of success in many areas of her life,
she can still find herself facing intervention for her addiction. This
means that any troublesome relative (or any person with a particularly
meddlesome family) can be coerced into treatment, on the grounds
that her denial itself is a primary symptom of her disease. This is most
problematic with the increasingly pervasive practice of hospitalizing
difficult youth, which becomes a legitimate way for parents to allow
them to become somebody else’s problem, by bringing to bear insti-
tutional control. Experts can take the place of parents in dealing with
children’s addictions, legitimizing parental abandonment and aliena-
tion, even though this approach has the attendant effect of further
dividing and disempowering families. And this is not true simply in the
case of drug addiction. Unwelcome behaviors ranging from gambling
 The Culture of Addiction 89

to video gaming to eating to sex to viewing porn can now land you in
treatment if you’re sufficiently rich. For the poor, the “treatment” is
often jail.
In the event that the argument from the ever-expanding types of
culturally specific addiction is not persuasive that addiction is at least in
part a social construct, consider another sort of case. That the astounding
increase in levels of addiction in the West is the result of social attitudes
as much as it is the result of expanding medical insights seems plain
from looking at the contrast between the American response to heavy
indulgence (in this case, in alcohol) and the South Korean response. In
South Korea, heavy drinking by men is “encouraged, even demanded,
in certain social contexts.”25 While social norms and mores discourage
drinking by women and solitary drinking by men, South Korean culture
supports regular drinking contests in bars after work, after which many
contenders have to be carried home. Men who indulge in this manner
are not considered addicted, and drinking in this manner is not consid-
ered a problem. As it happens, even with this high level of consumption,
due to the social structures that constrain the time and circumstances
of a man’s drinking, statistics show that the dependence-to-abuse ratio
is reversed in South Korea relative to the West. That is, although a larger
number of men abuse alcohol in South Korea than in the West, a smaller
percentage of them become physiologically dependent on it than do their
Western counterparts. This suggests that not only do cultures construct
the concept of addiction differently but, moreover, some would not use
the concept of addiction at all, or develop any of the practices or institu-
tions that accompany its recognition as an individual problem requiring
treatment. Different cultural conceptions of the place of excessive indul-
gence within the overall system of customs and practices determine in
large part where there even exists such a thing as addiction. Moreover,
those very social conceptions, norms, and traditions themselves seem to
have a significant influence on the degree to which the population of
users becomes dependent on substances.
Martin Levine and Richard Troiden argue that some addictions have
been completely culturally constructed.26 Consider, for example, the idea
of the sex addict. Levine and Troiden argue that the concepts of sexual
addiction and sexual compulsion are based in cultural beliefs regarding
extrarelational sex that became more openly widespread in the late
1970s and ’80s. Because those who came of sexual maturity in the sexual
liberation movement of the ’60s and ’70s were seen as a threat to social
cohesion, the sexual behaviors developed during that period and shortly
thereafter were construed as deviant by those adhering to traditional
90 Addiction

standards. Levine and Troiden say that, rather than being varieties of
medical conditions, “[s]exual addiction and compulsion refer to learned
patterns of behavior that are stigmatized by dominant institutions.”27
On their view, it is political and social agendas that created the possi-
bility for this kind of addiction to enter the ontology and linguistic
conventions as disorders in need of treatment. Whether this behavior
is portrayed as an addiction or a compulsion, or an impulse control
disorder (these are described slightly differently), Levine and Troiden
argue that the diagnosis rests on “culturally induced perceptions of what
constitutes sexual impulse control.”28 Broad differences characterize the
attitudes and practices of different cultures and different ages. In “sex-
positive” cultures, such as Mangaia, for instance, casual sex with many
different partners is normal. It is the religious emphasis on low sexual
desire and activity that would be seen as abnormal. “There is nothing
intrinsically pathological in the conduct that is presently labeled as
sexually compulsive or addictive,” assert Levine and Troiden. “[T]hese
behaviors have assumed pathological status only because powerful
groups ... define them as such.”29 Characterization of “excessive” sexual
behavior as a disease has its utility as well, though, as we have seen in
the popular press, in exculpating wandering partners of moral wrong.
When politicians and celebrities have found their careers jeopardized by
sexual infidelity, they have in recent years found it convenient to blame
their behavior on an addiction to sex.
The implications of portraying certain types of activities or substance
use in terms of an addictive disease, though, are double-sided. On the
one hand, characterizing people as addicts doubtless creates the poten-
tial for an autonomy-robbing power differential between addicted
people and nonaddicted ones. On the other hand, though, because of
this very diminution in autonomy, the attribution of addiction also
provides an excuse, an escape from responsibility. Being “diagnosed”
is used both as a way of demonizing some individuals, a way of sepa-
rating them from the “healthy” folk, and as a way of releasing them
from responsibility for certain behaviors. The flexibility of the term
serves to make every kind of problem potentially an “addiction,” which
allows the legal system to construe treatment as either or both punitive
and/or rehabilitative, depending on the case. As Gene Heyman points
out, this dual implication of characterizing addiction as a disease existed
before either the legislation governing addictive drugs or the science
behind the medical model existed: “from the start, addiction invited
both legal prohibitions and the impulse to cure it.”30 The very meaning
of admitting to or being accused of being an “addict” carries import
 The Culture of Addiction 91

that could be either a condemnation of an individual’s life, as when an

employer or partner uses it as the basis for dissolution of a relationship,
or exculpatory, as it has come to be in a growing number of legal cases.
Gambling addiction has made a double transition in the eyes of the law
over the past 200 years, according to I. Nelson Rose. Rose says that, while
gambling prior to the 19th century was judged a sin, not to be spoken
of, with its wins assumed to ensure eternal damnation, it gradually came
to be seen instead as a vice, the fault and responsibility of the gambler.31
This view, still the mainstream, implies that legal gambling debts, for
example, are unenforceable, since the purveyor of gambling, like the
purveyor of prostitution, is seen as exploiting the gambler’s vices, and
acts at his own risk. With “pathological gambling” becoming a recog-
nized disorder in the 3rd edition of the DSM, the view that gambling
is a choice totally within the control of the gambler began to fade. Like
sexual addiction, addiction to shoplifting, and alcohol and drug addic-
tion, the disease model has been used successfully by many defendants
in cases involving excessive gambling. Some attorneys even advertise on
their websites that they can assist clients by showing that the defend-
ant’s actions are the result of addiction. At the very least, they claim to
be able to undermine the charge of specific intent to undertake criminal
activity, thereby minimizing penalties. Of course, if this line of defense is
employed in order to receive a “not guilty by reason of insanity” verdict,
then the addict faces a dubious future within the labyrinth of mental
health institutions

Social inequities and other ecological factors

As any addiction researcher or therapist would agree, drugs and other

addictive behaviors serve a function in the addict’s life, at least in the
early phases of use; otherwise, the inclination to excessive imbibing
would never develop. As we have seen, various stimulants have kept
workers in a variety of developing economies working steadily to bring
about fortunes for the producers of the substances to which the workers
were addicted. Moreover, many returning soldiers and other post-trau-
matic stress disorder (PTSD) sufferers use drugs or alcohol to mask over-
whelming feelings, as do individuals with depression, bipolar disorder,
and anxiety disorders. Over and above that, we are obligated to look at
the stymying social inequities that have continually developed along-
side world markets over the past century, but particularly dramatically
in the past 15 years, and the changes that these inequities have brought
to the quality of life for huge masses of people. According to Credit
92 Addiction

Suisse Research Institute’s 2014 report, for instance, “[a]ggregate house-

hold wealth has more than doubled since the start of the millennium
from USC 117 trillion in 2000 to USC 263 trillion in mid-2014,” with
the number of millionaires rising 164% during that period.32 At the
same time, an Oxfam report calculated in early 2014 that the eighty-
five richest individuals on the planet owned as much of the world’s
resources as the poorest half of humanity combined. Since the begin-
ning of the worldwide financial crisis in 2008, the number of billionaires
worldwide has grown to 1,645, while homelessness around the globe
has increased steeply. From July-November 2007 to the same period
in 2008, for instance, the number of families entering New York City
shelters rose by 40%.33 In another powerful example, a survey by the
National Alliance to End Homelessness found that 10% of clients being
assisted between 2008 and 2009, at the height of the mortgage lending
crisis, were experiencing homelessness as a result of foreclosure.34 The
majority of these individuals were renters whose landlords could not
afford their mortgage payments, leaving the renters with no recourse
and no deposits to recover. While many of us think about the huge
differences between rich and poor as occurring between wealthy, devel-
oped countries and traditionally impoverished countries, the numbers
of impoverished and homeless people in the United States belies that
claim. “Around the world, inequality is making a mockery of the hopes
and ambitions of billions of the poorest people,” the Credit Suisse report
announces.35 This sort of disparity in income and security brings with it
a kind of despair that prevents people from finding sources of meaning
and value in many aspects of life.
Neuroscientist Carl Hart, a distinguished professor tenured in two
departments at Columbia University, member of the National Advisory
Council on Drug Abuse, and research scientist in the Division of
Substance Abuse at the New York State Psychiatric Institute, grew up
a poor boy in Miami who both used and dealt drugs. He argues that
drugs are not the problem. He says that for him, while growing up the
“problem was poverty, drug policy, lack of jobs – a wide range of things.
And drugs were just one sort of component” that wasn’t as important
as researchers have suggested.”36 In a 2011 review of numerous kinds
of neuroimaging and neuropsychological studies, Hart’s research group
showed that claims regarding the effects of methamphetamine on
cognitive performance and changes in the brain were flawed, not repli-
cated, and exaggerated. Not only are the media to blame for spreading
misperceptions about drug use and its dangers, Hart says, but so is the
scientific establishment, because scientists rarely speak up to correct
 The Culture of Addiction 93

misrepresentations by their peers. Why? Because the value for scientists

is to avoid being wrong. Making claims outside the orthodoxy might
expose them. But the price for adhering to orthodoxy in these cases
is high. According to Hart, punishments for possession in the United
States have been “inconsistent with the scientific evidence and ... exag-
gerated the harms associated with crack cocaine use. The monetary
and human costs of this misunderstanding are incalculable.”37 The
social milieu in which they are taken, rather than the drugs them-
selves, have the most dramatic impact on whether individuals become
addicted. For many of those whom we would call addicted, Hart’s lab
found, when worthwhile alternative life choices were available, drug
addiction was not a widespread issue. Bruce Alexander’s group, as we
saw previously, discovered a similar pattern with respect to the rats
in Rat Park – social environment played a significant role in whether
rats chose to self-administer drugs. In fact, as Heyman, asserts, “every
major epidemiological study conducted over the past 30 years” reports
the same thing – when viable alternatives for a valued life are avail-
able, they will be eventually be chosen over drugs.38 Such options
all too often, however, aren’t available. According to the US Bureau
of Justice Statistics, personal income from all sources for 83% of jail
inmates interviewed in 2004 was less than $2000/monthly, and less
than $1000 for 59%, although over half were employed full time in
the month prior to arrest. Add to this that over half of the jail inmates
interviewed had grown up either with a single parent or under the
care of a guardian, as well as that only 50% of them had earned a high
school diploma, and the picture emerges of a population with little
hope for viable alternatives for a good life. It is no surprise, given these
numbers, that 66% and 69% of inmates interviewed reported regular
alcohol or drug use, respectively. Meanwhile, the National Institute of
Justice and the National Center on Addiction and Substance Abuse at
Columbia both estimate that the actual number is closer to 80%.
Corroborating this wider view of the factors contributing to addic-
tion, one researcher on causes of drug addiction in Pakistan found that
social and cultural beliefs, in combination with socioeconomic condi-
tions, play an important part in the explanation of why some people
are more likely to become addicts than others.39 Over 23% of those
responding to the “World Opium Survey 1972” cited the attempt to
escape from personal or economic problems, difficult, laborious jobs,
or “sexual reasons” as their impetus for using drugs. While nearly 34%
of the addicted individuals surveyed claimed that they began taking
drugs as a cure for physical illness, disease, or injury, 74% of them were
94 Addiction

addicted to opium, which is never prescribed by physicians. The impli-

cation of this survey, according to Karamat Ali, is that “social disor-
ganization and deprivation of legitimate means for achieving socially
accepted goals” leads to addiction.40 The “sexual reasons” response is
interesting, given social facts in Pakistan: there, sex for any reason other
than procreation in marriage is frowned upon (and in many cases is
illegal or impossible, because of constant sex segregation). In this case,
drugs are often taken for the purpose of making sex last longer with
prostitutes, since interactions with these women are infrequent, as well
as to deal with the stresses of prohibited homosexuality, or simply to
overcome the anxiety and guilt associated with sex in order to enjoy
it. Again, social circumstances here prevent individuals from obtaining
generally desirable human goods. Crushing poverty has the same effect.
“Hard jobs with low nutrition, poor health condition [sic] and no recrea-
tion compel poor people to use drugs,” Ali concludes.41 Similarly, in
a study of impoverished Colombian adolescents, Daniel Lende found
that teens often used drugs to shift their attention from “worrisome,
stressful or painful things.”42 Drugs were cited as a way of alleviating
the stress associated with family, poverty, and prevalent armed violence.
Other researchers had previously found that intrapersonal distress was
related to drug use for boys and girls in Colombia to a greater degree
than it is in the United States, as were violence and drug availability.
This difference, the researchers speculated, could be because the drug
trade and violence are more endemic to Colombia than to the United
States.43 However, Gilbert Quintero and Sally Davis found in 2002 that
Hispanic and Native American teens smoked cigarettes for reasons
similar to those cited by Colombian youth, for example, to alleviate
mood issues arising from family life, school, and the stresses that attend
poverty and social inequality.44 This finding, Quintero and Davis argue,
should interest medical anthropologists, given the otherwise “highly
charged, health-focused atmosphere” in the United States at the turn
of the millennium. Although these Hispanic and Native American
youths cited other reasons for smoking typical among US teenagers in
general, such as image maintenance and the influence of peers, one of
the most pervasive reasons for smoking given by this group (including
33% Hispanic youth and 24% Native American youth) was “to relax,
calm down, and relieve stress in order to treat various emotional and
bodily states of being, including ‘nerves, anger, frustration, depression,
and ‘boredom.’”45 Once again, we see that lack of alternative means for
achieving high-quality human lives pervades the list of reasons provided
for opting for addictive substances.
 The Culture of Addiction 95

The other side of the money

The sort of passive endorsement that we find for locating relief in mind-
altering substances in many cultures sounds not so different from the
“happy hour” created in the 1960s in the United States that became
“binge weekends” for working adults who entered into competitive,
faceless positions in giant corporations. It seems that after-work and
weekend binge drinking and eating, officially loudly bemoaned, serve to
maintain social order, largely by promoting apathy in the face of aliena-
tion, income inequity, and unfulfilling work. When people are either
escaping through indulgence or are hung over and remorseful as a result
of it, serious attention and meaningful change is unlikely to be brought
to bear on the oppressive religious, social and/or economic inequities.
On this view, in which everyone is left on their own to navigate a path
of providing themselves with housing, food, transportation, health-
and childcare, in uncertain circumstances, it is easier to blame those
who cope with the stresses of everyday life by numbing themselves in
some way than it is to take a hard look at the structural and political
arrangements that create the need to self-soothe. In such an environ-
ment, it is much easier to “treat” those who falter in the productivity
cycle by putting them into treatment or jail than it is to take seriously
the circumstances that make life so difficult. As we have noted, appeal
to the disease model, to the power of the drug, and to the “addictive
personality” shifts attention away from any questions that might be
raised about social contributions to people’s misery and self-medication
and distraction, allowing instead everything from drugs to gambling to
video games to shopping to just about anything that one might do or
ingest, to become an object of certain “defective” people’s obsession.
This approach, however, has little to offer toward improving the lot of
the addicted. As noted by Paul Hayes, professor of Drug Policy at the
London School of Hygiene and Tropical Medicine, despite the cultural
narrative to the contrary, “the experience of the overwhelming majority
of addicts” is that “social isolation, economic exclusion, criminality and
fragile mental health preceded their drug use rather than being caused
by it,” and, he argues, until this is understood, we “are doomed to
misdirect our energy and resources toward blaming the outcasts and the
vulnerable for their plight rather than recasting our economic and social
structures to give them access to the sources of resilience that protect the
rest of us.”46
But there’s something even more sinister than institutionalized racism
and classism behind the shifting nature of addiction in the worldwide
96 Addiction

market. As is often the case in seeking causes of crimes and social ills,
it is illuminating to follow the money. In following the money, we find
that, for instance, keeping marijuana illegal has been a priority of certain
organizations that benefit from the financial success of certain prescrip-
tion drug companies. While the general tide of public opinion over the
past several years has turned in favor of relaxing marijuana laws, the
Community Anti-Drug Coalition of America (CADCA), for example, a
vocal opponent of the legalization of marijuana, and other groups at the
forefront of opposition to relaxing marijuana laws, tellingly “derive a
significant portion of their budget from opioid manufacturers and other
pharmaceutical companies.”47 According to a confidential financial
disclosure from the Partnership for Drug-Free Kids, the organization’s
largest donors include “Purdue Pharma, the manufacturer of OxyContin,
and Abbott Laboratories, maker of the opioid Vicodin. Perhaps worse,
Alkermes, a major supporter of the CADCA, makes an opioid, Zohydrol,
which is reportedly ten times as strong as Oxycontin.”48 When forty-two
drug-prevention groups protested approval of Zohydrol, neither CADCA
nor the Partnership for Drug-Free Kids joined the protest. So it seems
that the political urgency of keeping marijuana illegal may derive from
something other than concern for the health and well-being of the
populace.
A good place to look for the source of that urgency might be the
multibillion-dollar pharmaceutical industry. America constitutes only
5% of the world’s population, but consumes 50% of the world’s phar-
maceuticals, and 80% of the world’s narcotics. In 2000, 290 people per
day (106,000 per year) died as a result of their prescription drugs.49
According to the Centers for Disease Control and Prevention (CDC),
44 people die in America every day from prescription opioid overdose,
three times as many as die from heroin, meth, and cocaine combined.
Although this rate is rising steadily (the CDC reports a 117% increase
from 1999 to 2012), addiction to these drugs does not have the same
meaning in our culture as addiction to alcohol or other drugs does.
Against these perceptions, however, consider that in 2012, drug over-
dose was the leading cause of accidental death, and 53% of these
deaths were caused by pharmaceuticals. Of those deaths, 72% involved
prescription painkillers. These are not the drug overdoses that we see
in mainstream media, and drug overdose has not yet been publicly
discussed as a serious public health problem. At least there has been
no lessening in the prescribing and selling of these drugs.50 The most
plausible explanation for the continuing proliferation of these drugs,
and the addiction and deaths that come with them, is that they mean
 The Culture of Addiction 97

big money, and big money means power. In 2010, Novo Nordisk, Inc.,
for example, saw $2.67B in sales, while by 2009 Bristol-Myers Squibb’s
revenues had a reached $18.8B. But it is the astronomical rate of rise in
these companies’ revenues that is most striking: Eli Lily’s profits, for
instance, rose from $875M in 2003 to $23B in 2010. As a result of the
Medicare Prescription Drug Plan of 2003, the campaign that was led by
a group of legislators, each of whom received hundreds of thousands of
dollars in campaign dollars from pharmaceutical companies, “the phar-
maceutical industry realized an eight billion dollar increase in profit.”51
While it would be going too far to say that our government and the
pharmaceutical industry operate in a conspiratorial way to foster addic-
tion and then blame the addicts for it, it surely would be reasonable to
assert that when an industry has the capacity to influence major policy
decisions, the role of that industry in the social phenomenon of increas-
ingly endemic addiction cannot be ignored.

Meanings and addiction

In 2011, 6.9 million people were under corrective control in the United
States. As we have seen, as many as 80% of those incarcerated were
considered problem users or addicts of alcohol or other drugs. Not all
addictions, though, are equally likely to land a person in prison, or cause
him to be blamed or ostracized. Addiction to cigarettes is not signifi-
cantly correlated with incarceration, nor is video gaming addiction,
food addiction, or gambling addiction. For many of these “diagnosable”
addictions, there is not even much social stigma attached, particularly,
and tellingly, with respect to addiction to work. In many cases, it is the
social meanings of particular drugs and activities that determine whether
engagement with them is associated with blame, shame, and confron-
tations with the law. The primary drugs being used by the adolescents
in the Lend study in Colombia, for example, were marijuana, followed
by basuco, which is similar to crack, as well as cocaine, inhalants, and
street-supplied pills, in short, the drugs of the poor and the young.52 The
drug that to which the Pakistanis were overwhelmingly addicted was
opium, a drug about which Ali says that if you “[v]isit any shop, you will
see beggars, domestic servants, truck drivers and stray children queuing
to purchase this pernicious narcotic,” whereas better-off young people
tend instead to use LSD, marijuana, and morphia.53 In the United States,
marijuana and heroin are cheaper to access than cocaine and prescrip-
tion drugs. In general, the “addiction problem,” and the incarceration
that attends it, seems disproportionately associated with those drugs
98 Addiction

and activities indulged in by the young and the poor. To some degree, it
appears to be the meanings of these substances, as well as of the activi-
ties of gambling and certain kinds of sexual activity, that seem to drive
policy, rather than hard scientific evidence about their relative dangers.
In a 2013 study, obesity accounted for 18% of deaths among adults
between 40 and 85 in America, but since unhealthy weights have
become the norm, it goes virtually unmentioned in public policy, except
for requiring suppliers of unhealthy foods to inform consumers.54 No
public policy regulates the behavior of the consumers of food. At the
same time in the United States, where marijuana has been legalized
in several states, and decriminalized in others, or legalized for medical
use, official US policy nevertheless keeps it on Schedule 1, among the
most dangerous drugs available. But surely this discrepancy cannot be
accounted for by scientific research. In fact, the research argues the other
way, as we can see from the obesity case alone. Policy seems to be driven
by some other force. And there are consequences. Kornblum argues that
categorizing marijuana in this way “helped prepare the way for far more
troublesome drug epidemics in minority communities like Harlem.”55
His argument is that portraying drugs such as marijuana as on a par
with other Schedule 1 substances, since marijuana and some others of
these drugs seem to have few ill effects, leads to the impression that the
government’s cataloging system should be ignored. Other drugs deemed
sufficiently dangerous to be categorized as Schedule 1 drugs, many will
reason, might be just as safe to use. At the same time, categorizing large
numbers of substances as among the most dangerous brings about the
incarceration of large populations for possession of drugs that could
be legalized, decriminalized, taxed, and regulated. As Kornblum says,
“the public at large has supported prohibitions it knows are not effec-
tive because to do so gives people assurance of a moral order however
symbolic,” and however contributory to “the stigma born by racially
distinct people in America.”56 The problem here is that whether drugs or
activities are considered addictive, and therefore are outlawed, is often
much more influenced by social and political leanings and dogmas than
by research findings, or what sociologist Howard Becker once called
“politically inconvenient scientific knowledge.”
Now consider the purported addiction popularly discussed in the
United States in the 1980s and ’90s, but which seems to have lost
momentum recently in the addiction literature: the addiction to work.
This one seems not to fit the mold of other “addictions,” with respect to
social and political attitudes, at least not in highly competitive societies.
Certainly we don’t find workaholics at the forefront of the incarcerated
 The Culture of Addiction 99

population or of those in treatment centers. In fact, workaholism is

often claimed with an attitude of pride. What does this tell us about
this form of “addiction”? It is not the case that overwork does not cause
harm. Stress, distractedness, and lack of sleep wreak havoc on everything
from cardiac health to personal relationships to driving safety. But these
disruptions occur only at the individual level. More generally, “worka-
holism” contributes to the maintenance of the economy and social
order. Whether for these reasons or others, it has not found its way into
the DSM. Here we find a social construct modeled on addiction, but one
that carries an even less negative connotation than food addiction. So,
what seems perhaps most important in determining whether an activity
engaged in beyond typical levels is considered normal or pathological
has everything to do with the place that that activity has in upholding
or threatening certain kinds of order and social structure. It has every-
thing to do, that is, with the meanings that that activity carries within
a particular society.
Not only are meanings important with respect to social aspects
of addiction but they are also central to the experience of addiction
from the subjective side, as well. As long ago as 1938, sociologist Alfred
Lindesmith argued against the then-prevailing view that addicts were
madmen, rapists, and killers.57 Vigorously opposing the positivistic,
quantitative methodology that became popular in the social sciences
in his day, Lindesmith’s attention was concentrated on qualitative
research, comprising mostly open-ended, unstructured interviews with
heroin addicts. As opposed to psychoanalytic and medical models that
attempted to isolate the essence of addiction, Lindesmith was much
more concerned with examining the process of becoming addicted. In
this regard, he argued that “the symbolic meanings [that] drug users
communicated to one another regarding the effects were essential to the
transformation of a non-addicted heroin user into a heroin addict.”58
Lindesmith’s unique contribution here was that, in contrast to both the
behavioristic and the disease models coming into vogue at the time,
he outspokenly distinguished the phenomena of tolerance and physical
dependence from the phenomenon of addiction per se. In this sociolo-
gist’s view, neither the behaviorist nor the disease model could explain
the subjective experience central to correctly characterizing addiction.59
In pointing to the irreducible subjective experience involved in addic-
tion, Lindesmith was adducing an aspect of addiction that none of the
reductionistic physical theories had the tools to address. The response
to Lindesmith, however, as epistemology and philosophy of mind
developed, was to focus attention on the rejection of mental/physical
100 Addiction

dualism, and on developing one of two alternatives: either reductionism

of one sort or another, or what came in the American tradition of soci-
ology to be called a “praxeological approach.” On this latter view, with
respect to addiction in particular, addicts not only learn symbolically, or
linguistically, to attach meanings to drug use or addictive activities and
their accoutrements but also “to use drugs as resources in given fields of
practical action.”60 The focus in this case is on the context – specifically,
the context of practical action. On the process ontology that we have
adopted throughout this book, this central involvement of meanings in
the development of both the vulnerability to, and the addictive uses of,
substances and activities requires no new conceptual equipment and no
special account. Certainly context is important, but it is not, any more
than any other single thing is, “the answer” to explaining what addiction
is. Addiction, like all human activities and psychological experiences, is
the natural consequence of the progress of a highly complex, self-organ-
izing system organism that develops in and interacts with its physical
and social environments in particular ways. Addiction is a multilevel
emergent phenomenon that cannot be fully understood at any one of
those levels of analysis. In the next chapter we turn specifically to the
role that meaning plays in the assembly of the set of phenomena that
we call addiction.
6
Addiction and Meaning

Addictive processes emerge from hierarchies of interacting complex

adaptive processes both internal and external to an individual. These
processes include and emerge from cells and cell systems, and also from
psychological phenomena, as well as from higher-level emergent proc-
esses operating at both the physical and social levels. From the begin-
ning, the world outside the individual is dynamically involved in the
development of his or her physical and psychological traits and disposi-
tions. As we saw in Chapter 4, the influence of social conceptions on
one’s experience of diverse aspects of life, such as family, property, work,
discomfort, and gratification, are profound and have a significant impact
on whether, how, and to what extent individuals may become addicted.
Patterns of activity at this level interact with personal and subpersonal
patterns of action to create meaning. Meaning operates at the core
of addiction for the addict and her close social circle, as well as for
researchers, treatment professionals, and policy makers. When an indi-
vidual becomes addicted to some substance or activity, what that thing
means to her shifts fundamentally, as does her conception of herself
and the rest of the world. The meaning of that substance or activity to
her spouse, friends, children, or parents, although completely different
from what it is for the addicted person, is a driving force in their lives. To
understand how this works, we need a theory of meaning.
First, though, let us consider some common observations. Interactions
between addicts and their nonaddicted friends and family often leave
the impression that the two groups live in vastly different worlds.
Nonaddicts try to understand addicts’ actions in terms that make sense
of what seems to be obviously self-undermining and otherwise irrational
behavior. Addicts often feel that they aren’t understood, and, as a result,
that they are being judged or threatened or dismissed. It should come

101
102 Addiction

as no surprise, then, that people who interact with addicted individuals

often interpret the addicted person’s thinking in ways that fail utterly to
correspond with the addict’s own experiences. The two groups of people
use similar sentences, but seem to talk past one another. Everyone,
including the person struggling with addiction, agrees that the addic-
tive behavior is destructive and pointless. However, nonaddicts tend to
attribute the addict’s repeated relapses to a failure to care about others,
or about the addict himself. They may even attribute the behavior to the
addict’s trying to punish others or end relationships. These are consider-
ations that perhaps never occur to the person struggling with an addic-
tive pattern. Meanwhile, in one commonly cited model, the addicted
person himself may be struggling with a cycle of firm-minded inten-
tion to abstain, followed by return to use, which is in turn followed by
remorse and a return to firm-minded repudiation of use. He agrees with
all the reasons why he should stop his use, shows clear understanding of
the consequences of failing to do so, and wants to follow the path that
he and those who care about him envision. He sees a happy freedom
from the substance or activity that has plagued him, along with produc-
tivity and a positive future. Then suddenly something happens and the
world shifts. Everything in a moment seems different, and use seems
essential, even inevitable. But what has changed? Family and friends
are stunned, disappointed, angered, and mystified. They had believed
that everyone was on the same page. Was the addict lying the entire
time? The only phenomenon common to the two groups seems to be
the observed behavior itself. Their respective understandings of reasons,
causes, and explanations seem to exist in separate, perhaps internally
coherent, but unconnected systems.
We have two things to explain here: the systematic failure of commu-
nication between addicts and their friends and family, and the sudden
and concrete world shifts that can take place within an addict’s own
experience. The latter is a well-known phenomenon in recovery circles.
Moving in the direction from use to abstinence, this gestalt shift is
expressed in terms of various metaphors, such as “seeing the light”
or “experiencing a spiritual conversion.” It is worth noting that both
of the phenomena that we seek to explain are generalizable. Both the
systematic failure of communication and the gestalt shift characteristic
of transition out of addiction not only seem to concern addicts and the
nonaddicts with whom they interact but also enter into communication
breakdowns between any two groups with different worldviews in the
one case, as well as into the sudden shifts experienced within individuals
when they experience religious or scientific conversions. The theory of
 Addiction and Meaning 103

meaning offered here is thus general in nature. It is not intended to

apply only to addicts or to dealing with addiction – although it is the
only theory available that can account for certain phenomena central
to addiction and recovery. As we saw in the previous chapter, addiction
is at least in part a social construct. Without the meanings ascribed to
certain objects, feelings, and events in particular contexts, no substance
use or repetitive activity would ever amount to a psychological, much
less a social, problem. There would only be cause and effect. But humans
experience the world fundamentally as meaningful, and so it becomes
critical that we see how meanings arise and how apparently identical
objects, actions, and events can have such different meanings for
different people, and for the same person at different times.

Concepts

To begin, let us inquire into what drives the systematic misunderstand-

ings and failures to communicate that seem to occur between addicted
individuals and their friends and families. Nonaddicts believe that
what they see is simply what the world presents: someone they care
about is acting selfishly and irrationally. Supporting this conclusion
is the assumption that the way the nonaddict sees the world is the
way it is. This conclusion presupposes a sort of theory of meaning.
The theory tacitly assumed seems to be that meaning comes from the
world’s impressing itself on experiencers. Numerous philosophers,
from ancient times to the present, have defended this sort of view.
Historically, John Locke and David Hume, for example, believed that
the way we understand the world is through experience imprinting
itself on our minds, then being copied. Concepts, or “ideas,” as these
thinkers called them, are either the copies themselves of original expe-
riences, either internal or external, or they are derived from these
copies through such mental operations as abstraction of some parts
from the details, the rearranging of parts, and so forth. Once copied or
created from copied components, these concepts are taken to be repre-
sentative of the way the world is.
However, some thinkers have been taken with the notion that
concepts, at least the most important ones, must be “innate” or inborn
in the mind or soul. This is because, according to this group of philoso-
phers, which includes Plato, René Descartes, Immanuel Kant, and some
contemporary thinkers, it is impossible to acquire certain concepts
through sense experience. There are two reasons for thinking this. One
reason offered is that certain ideas are necessary prerequisites for making
104 Addiction

sense of our sense experience. If we have no concepts at all to start with,

these thinkers ask, then how would we ever recognize anything, or
see how things can be related? How can you tell that what someone
is pointing at is a dog (rather than the color of it, or the way it moves)
when that person is first teaching you the word, unless you already know
what a dog is? It is the age-old dilemma of learning, first posed by Plato:
how can anyone ever learn anything new? If he doesn’t know what it
is, he won’t recognize it when he sees it, and if he does, then he has no
need to look. If not the concept itself, later thinkers conclude, at least
the principles of individuation or something like that must be innate to
the mind. Another reason given for belief in innate ideas is that certain
kinds of concepts seemingly cannot be acquired through experience.
Historically, those have included modal concepts such as necessity and
impossibility. We learn from experience that things are in fact some way
or other, but we cannot learn through this method that things could be
no other way. Neither do we ever encounter the impossible, by defini-
tion. These kinds of concepts, the argument goes, must then be already
“in the mind,” regardless of whether we are ever conscious of them, and
regardless of whether they were learned in another life, bestowed by
God, or derived through evolution.
There are problems with both kinds of theories of meaning. On the
one hand, innate ideas would seemingly require some kind of appeal
either to the supernatural – to Plato’s realm of Forms, or to God’s crea-
tions of minds – or to evolution. The first option defies the naturalism
that the current theory embraces. But the second option will not work,
either, since it would mean that certain concepts, or at least certain
mental mechanisms responsible for concepts, are the result of genetic
determination. This seems incredibly unlikely, however, given that
concepts emerge from the disposition of sets of neurons to fire together,
which is in turn determined by constant adjustment of the strength of
the synapses that connect them (firing together, thus “wiring together,”
via LTP). While the mechanism of synaptic strength adjustment is
certainly determined by genes, DNA cannot be responsible for specific
concepts. Genes would have to be capable of setting individual synaptic
weight values for the approximately 100 trillion synapses that connect
our neurons, using their approximately 10 billion functional base pairs.
Since every brain is uniquely wired, unlike other body parts (one heart,
comprising two atria, two ventricles, one pulmonary valve, etc.), it is
impossible to see how genes could accomplish this.1 However, if we
understand ideas or concepts to be copies of the external world, we
have no reason to expect that the conceptual frameworks could differ
 Addiction and Meaning 105

as much as they apparently do among different people, and within the

same person over time.
A theory of meaning that better accounts for the two problems that
we are considering has its grounding in pragmatism, the psychology of
child development, and neuroscience more broadly. To make the case
for it, we begin again from the presumption that living organisms are
complex, dynamic systems that are constantly adapting to stay organ-
ized against the natural tendency toward increasing entropy. They are
constantly evolving moving patterns, doing things to keep themselves
alive in an environment. This means that certain things are going to
have direct implications for their survival, and those things will be rele-
vant to them. In other words, the fact of being a living organism by its
very nature involves the capacity for meaning making in some sense. As
human babies’ extremely complex brains are developing, their attention
is drawn to, for instance, their own internal discomforts – early on, gener-
ally signals from the gut. And they are just as aware of signals received
from caregivers. Meanings, on this view, are essentially involved with
action and purpose – on what one needs and wants to pick out from the
environment, which, as we have discussed, is constantly changing us
(feeding us, heating or cooling us, comforting us), and being changed
by us. At the neural level, we have seen that the ways in which babies’
brains develop are constrained by the environments in which they live.
Now we can add to that the fact that even before we are born, asso-
ciations between experiences are already being made, and the resulting
meanings are beginning to be constructed. Below we discuss the specifics
of how this meaning making operates, and how the meanings that we
construct play into addiction and recovery.
First, though, it is important to see two things: 1) that the view we
are exploring is not the received view of meaning, and 2) the implica-
tions that the more commonly accepted views have for the two prob-
lems we have outlined. In general, concepts are understood today by
the preponderance of contemporary linguists and philosophers not so
differently from the way that they were by classical thinkers. Certainly
current theories vary in many details, but the majority of them generally
regard concepts as mental representations that are to be understood as
something like copies of the external world, caused in us by inputs from
the world. Some lines of contemporary argumentation, such as that put
forth by philosopher Jerry Fodor, in addition to this structure, maintain
a tight link to nativists’ views, retaining a central position for innate-
ness in the theory of concepts.2 Fodor’s theory, which he characterizes
as “informational atomism,” includes two basic claims: first, that the
106 Addiction

content of our concepts “is constituted by some sort of nomic, (rule-

governed) mind-world relation,” in other words, that our concepts
represent the world in some systematic way, and second, that concepts
are simple and fundamental – the atoms of our mental representations.
In this system, primitive concepts are undefined. This seems to be
corroborated by experience: perceptual experiences, for example, such
as the taste of licorice, the smell of a rose, or the way that a cocaine
high feels, cannot be defined, although perhaps they can be described
in some way (based on other sense experiences, which are useless if the
person to whom we are doing the describing doesn’t have those primitive
concepts). The contents of these primitive concepts, according to infor-
mational atomism, are acquired through information encoded by our
various sensory receptors. Then these primitive concepts are put together
“by the application of a finite number of combinatorial principles” to
create representations of things that we encounter in the world.3 Just as
we use the rules of grammar to construct sentences, Fodor’s language of
thought theory says, so do we build mental representations of the world
out of fundamental concepts using a limited set of rules of combination.
We can create an unlimited number of thoughts (or sentences, on our
above analogy), using just these primitive concepts and combinatorial
principles, because, as Fodor says, “the application of these constructive
principles can iterate without bound.”4
Why is this important? It is important because some version of it is the
most widely accepted view of what meaning is, and one that explains
how most people assume that their conceptions and beliefs work. It
also reveals something telling regarding how individuals who think of
concepts in this way often view people who do not see things as they
do. If our concepts represent the world in the way that Fodor’s compu-
tational view suggests, via information transduced and relayed over and
over again from our sensory receptors to ever-higher levels of processing
in our central nervous system, and if the meanings of our concepts are
the things in the world that cause those concepts, then what you see is
what you get. The way that you see the world is the way that it is: your
concept of DOG is caused by dogs (caps are used here to distinguish
concepts from the use or mention of words).5 What your concept of
DOG means is dogs, the things that cause the concept. So, the concept
of ADDICT held by the addiction researchers in the various fields that
we have considered, as well as by therapists and families of addicts,
is caused by addicts. Unless someone is defective, she must mean the
same thing that every other normally operating person does when she
conceives of a substance as DANGEROUS, or when she conceives of an
 Addiction and Meaning 107

individual as an ADDICT. Fodor calls this feature of his view asymmetric

dependence of error on correctness.6 The way to understand error on this
view is as a malfunction in a normally reliable process. Since the addicted
individuals are by all accounts the defective members of a population,
whenever there is a disconnection between their concepts and those of
and nonaddicts, the addicts must be the ones who are wrong. They must
be wrong (or lying) when they say, “I love you. My behavior has nothing
to do with that.” While there are caveats here to consider with respect to
whether the meaning of concepts is natural or nonnatural, theory laden
or not, the important point is that if the atomic informational approach
is right, then people with normally operating senses and brains are in a
position to tell the people with defective systems how the world really
is. And that is a scary and unwelcome thought for people struggling
with addiction, although it does seem to be how the medical model
works. Truth and power accrue to those who would treat the defective
addict’s problem, while compliance and surrender to being “fixed” is
the addict’s lot.
Despite the widespread acceptance of this view of how the mind
generates meanings, there are good theoretical reasons for thinking
that it is wrong. For one thing, according to Walter J. Freeman, who
heads the Freeman Laboratory for Nonlinear Neurodynamics at the
University of California at Berkeley, it all rests on “a mistaken view of
how neurons work.”7 Just how they work is exquisitely complex, but
the main point to note here is that, rather than acting like the ones and
zeros of binary code, the electrical signals in neurons act in a number
of intricately complex ways that are best understood at the population
level rather than at the level of individual neurons. Meanings operate, as
we have said, in living, dynamic organisms, which are complex systems
of systems, even down to the particles that make up the living cells and
beyond. The neuronal level of activity attracted attention in the 1940s
as the computing machine was being conceived. As we know, neurons at
any instant are either firing or at rest. This conception of neurons led to
the analogy to binary code, and the world was off and running with the
metaphor of mind as computer. But the metaphor does not fit. Neuronal
activity is actually measured in a number of different ways at the same
time, at different parts of the neuron. For example, it is measured both
in terms of its pulse rate (at one end) and in terms of the intensity of
its wave amplitude (at the other). And every living neuron is always,
always active.8 With perhaps a hundred billion neurons undergoing
thousands of simultaneous interactions in thousandths of a second, the
effects of an individual neuron on the system are vanishingly slight.
108 Addiction

It is the interactions among groups of neurons rather than the actions

of individuals that are central. Moreover, it is ill conceived to under-
stand concepts or representations of the world as symbols that are stored
somewhere in the brain; instead, they are ever-changing, pulsing, activi-
ties. What is more, the affective systems in the brain cannot be left out
of the calculation. Although it has no place in the atomistic informa-
tional account, emotion has everything to do with how our concepts
are created and used. Neither an addict’s nor his spouse’s concept of the
drug or activity affecting their family seems anything like a symbolic
representation of something outside. It seems rather to be a viscerally
loaded constituent of his world.
For this reason and others, it is reasonable to conclude that symbolic
encoding of information from sense receptors does not amount to
meaning, however much that information is manipulated. Interpretation
is necessary before information can be said to represent anything; infor-
mation is only information to someone or something.9 Without positing
a homunculus (a “little man” in our brains) somewhere along the line
to interpret the information received, it seems that a system like the one
Fodor supposes would never generate meaning. It would just exchange
symbols for symbols. The obvious trick of proposing a “self” or “mind”
that could do the interpretation would just push the question back –
where and how does that “self” arise in the electrical storm of firing
neurons that is all that seems to be inside brains – the very same brain
that is supposed to be generating meanings? Another way of looking at
the question is this: why does a person’s idea of a baggie of heroin carry
so much import for her as well as for the authorities? It is surely not
because the retinas involved have absorbed certain photons, allowing
them to detect the edges, the sides, and the color of the baggie, and so
forth, transducing and sending that information forward for binding at
ever-higher levels of processing. As we will see later, an understanding
of what that baggie is requires that it be perceived in the first place in a
situation within a whole world in which it plays a role.
Finally, the language of thought approach provides no explanation
for why anyone should want to say that information detection and
transduction of signals results in anything particularly mental. The sort
of causation that atomic informationalism sees as the source of mental
representations happens in all kinds of systems, such as those involving
light switches and thermostats, to which no one would ever attribute
mentality. Even if information detection and transduction happen in a
brain, as Levine and Mark Bickhard note, as happens for instance when
neurons respond to various neurotransmitters, that doesn’t mean that
 Addiction and Meaning 109

there exists any mental content.10 Neurons clearly do detect certain

chemicals, and send signals in response, as we have seen. When a partic-
ular threshold of activation has been crossed in an individual dopamin-
ergic neuron, for instance, the neuron fires, releasing dopamine into
the synaptic gap. Information is detected and transduced, and a signal
is sent (in fact, lots of signals are sent), and it all happens in the brain.
But nothing in that process suggests anything of a specifically mental
character.

Naturalism and prototypes

On the view that we have been elaborating, meanings for biological enti-
ties are a function of experience, and experience is always a matter of
interactions between the particular internal and external environments
of organisms. In our pursuit of an understanding of meaning making
and its role in addiction, we are seeking an account that accords with
all that we have come to understand about how human organisms, and
in particular, addicted humans and those who care about them, under-
stand the objects, places, and words involved in the experience of an
addictive pattern. In seeking a theory of meaning that accounts for the
phenomena observed in addiction, it seems important to consider not
just conceptual issues but also the empirical data regarding how our
concepts are built and what that says about their structure and function.
First, since minds are not separate from the world, but are emergent
from it, our conception cannot be that meanings are copies in the mind
of things in the world. The term “copies” implies separation between the
representation and the represented – and two different media in which
those two things exist. That is just what does not exist on the present
account. Second, because of the whole-brain massively recurrent and
dynamic processing from which meanings emerge, they are necessarily
always emotion- and history infused and peculiar to each individual.
Moreover, meanings are not static things, but rather are constantly
evolving processes. The same object or place (or word) can come to have
different meanings to the same person over the course of a day or a
year, and does, as she transitions into or out of addiction. This happens
without the implication that anything correspondingly changes in the
world, or in her perceptual apparatus, although it is true on another
level that everything in the world, including individuals’ perceptual
apparatuses, is always changing. Such change needs an explanation.
In developing our understanding of how addicts conceive of the world,
and how those conceptions can shift, we would do well to keep an eye
110 Addiction

on the findings of the best science associated with these questions. In

addition to Freeman, numerous other neuroscientists have remarked on
the fact that the general public, and many philosophers and psycholo-
gists as well, misunderstand the nature of the mind’s representation of
the world. The first thing to note is that, as we have shown, we do
not “take in the world” by being passively imprinted with its forms.
Although what information we do get from the world may be close to
how it is, from our extremely limited perspective, as organisms with the
perceptual and processing setups that we have, we in no way encounter
the world “as it is.” Neuroscientist Antonio Damasio, for example, puts
it this way:

[w]hatever the fidelity may be, neural patterns and the corresponding
images are as much creations of the brain as they are products of the
external reality that prompts their creation. When you and I look
at an object outside ourselves, we form comparable images in our
respective brains. We know this well because you and I can describe
the object in very similar ways, down to fine details. But that does
not mean that the image we see is the copy of whatever the object
outside is like. Whatever it is like, in absolute terms, we do not know.
The image we see is based on changes which occurred in our organ-
isms – including the part of the organism called brain – when the
physical structure of the object interacts with the body. The signaling
devices located throughout our body – in the skin, in the muscles,
in the retina, and so on – help construct neural patterns which
map the organism’s interaction with the object. The neural patterns
are constructed according to the brain’s own conventions, and are
achieved transiently in the multiple sensory and motor regions of
the brain that are suitable to process signals coming from particular
body sites.11

So there is no sense in thinking that meaning, rather than lying in our

concept of a thing, how it feels and looks to us, and the import that it
has for us, emotionally and otherwise, resides instead in the objective
thing itself, because there is no access to the thing outside of us, period.
Every concept of every kind that finds its way into the virtual reality
that is our experience of the world is emotion laden, spun out of inter-
connected neural systems including various limbic structures activated
by and activating other parts of the brain’s perceptual and processing
apparatuses. Moreover, it is personal, depending as it does on the unique
connections previously established in a particular brain. This does not
 Addiction and Meaning 111

mean that the world of our experience is not caused by interactions

with the world; rather, it just means that our concepts, and the world
that they constitute, are not things external to us. As philosopher Paul
Churchland describes it, “the content of a concept is its highly peculiar
portrayal of some aspect of the world, a portrayal that is often quite inac-
curate, a portrayal that enjoys no automatic referential connection to
the external world.”12 From this perspective, the denotative element, or
reference, of any concept, rather than being the thing in the world that
causes our perceptions, is just a conventional abstraction from these
very personal, very perspectival portrayals that are developed over time
by individuals. This is not the concept’s meaning. The meaning of any
concept is rather the place that that concept’s content occupies rela-
tive to everything else in the individual’s world, as carved out by her
particular experience. This is not to say that there isn’t a world outside
us, or any such nonsensical thing; rather, it is merely to say that our
concepts aren’t merely the causal result of interacting with that world.
Our concepts are our own internal portrayals of those things, brought
about from internal as well as external elements. The smoker’s concept
of a cigarette, except in its most abstract outlines, is not the nonsmok-
er’s; the details of a particular smoker’s concept of “cigarette” are meted
out entirely in emotional and physical connections to cigarettes and
everything else in the world, derived from her specific history, body,
and environment.
As Damasio notes, we are similar enough biologically that the repre-
sentations that are built in individuals’ minds are close enough that we
“can accept without protest that we have formed the picture of some
particular thing.”13 But the fact that we can accept it does not make
it the case. Every idea and concept that we form is essentially tied to
our own unique experiences and our whole body’s neural and chemical
structure and function. This was recognized in a crude form in the 18th
century by British philosopher David Hume, who noted that even the
most abstract ideas, such as the idea of God, “which seem the most wide
of this origin [personal experience], are found, upon a nearer scrutiny,
to be derived from it.”14 That mental representations, or ideas, as Hume
calls them, are essentially private and experiential seems clear from
his examples concerning emotion: “A man of mild manners can form
no idea of inveterate revenge or cruelty; nor can a selfish heart easily
conceive the heights of friendship and generosity.” And of the experi-
ences of external objects he says the same: one who has never had the
opportunity to taste it, “has no notion of the relish of wine.”15 We could
add that if it has never been experienced, a person could have no clear
112 Addiction

concept of a “high.”’ Hume was a simple imprint theorist, however, who

could not have known about the active input and movement required
for perception, or the involvement of feedback loops from parts of the
brain shaped by previous experience, or by extension, the way in which
our brains derive our concepts only over long experience. He does seem
to recognize, though, that different individuals will have different repre-
sentations of the world, and, until some confrontation occurs, won’t
know that they do.
Prototypes, unlike Humean ideas, are built slowly over time, and so,
contrary to what the imprint theorists seem to have supposed, no one
instance of a sense experience can therefore be the cause of a concept.
As Churchland says, our semantic connections to the world are earned,
by “strenuous cognitive activity expended over years of learning.” This
process of continual learning results in a portrayal of a fairly stable set
of categories and their relations.”16 We experience sets of inputs that go
together, over and over again, and learn to recognize regular groupings
and to expect to find them. This means that the prototypes that are
our concepts inherently carry with them relations to everything else in
the world. We delineate individual things from the noisy background
of the world, more and more precisely as we gain more experience, and
so each concept has from the beginning an internal structure relating
it to everything else, and it is the whole world together that constitutes
the meaning of any and every thing. Our concepts themselves, on this
understanding, inherently provide the possibility of the complex syntax
that humans employ, of the limitless variety of things that we can say
and think. They do this by providing within their own structure, which
includes their relations to the rest of the world, implicit rules about the
set of inferential roles that they can and cannot play. From the concept
BROTHER, for example, because of its place within the whole semantic
system, we see that we cannot directly infer anything about A = πr2, the
area of a circle, although we can infer things from that concept about
maleness, familial relations, and so forth.
This variety of a holistic, prototype-based system of meanings can help
us understand how people so radically misunderstand the experience of
others. In fact, Churchland says in this regard that while for atomistic
information theorists “it is a minor mystery why anyone ever misun-
derstands anyone else,” on the holistic prototypical worldview, “it is a
minor marvel that anyone ever understands anyone else.”17 This latter
worldview has the ring of truth, when we think of how human interac-
tions actually operate and, in particular, when we think of how addicts’
interactions with “outsiders” differ from their interactions with other
 Addiction and Meaning 113

addicts. Although even individual addicts’ experiences are all slightly

different, and each person develops his own pattern with his substances
or addictive activities, when they want to be understood, addicts often
trust for understanding to others who have similar experiences, and, as a
result, conceptual maps similar to their own, rather than to nonaddicts,
who “just don’t understand.” A person with no experience of addic-
tive patterns simply does not have a place in her map of the world, for
example, for the urgency and compelling call associated with what she
just sees as overpriced beer being hawked at a stadium, nor does she
have a conceptual space for the map of a neighborhood that operates in
the addict’s mind, keyed to locations of liquor stores or pushers’ corners,
rather than to streets or subway stations or jogging paths.

Early development of concepts

The reason that the person with no experience of addiction completely

lacks the sense of the compelling value of things such as beer in a
stadium or cigarettes being puffed outside a restaurant door is because
everyone’s world results from her own particular constitution, activities,
and interactions. The construction starts, as we have said, with intrin-
sically emotionally imbued concepts, which are developed through
personal, emotion-laden experience, carved out from the world of
“noise” with which we all begin – we have originally plenty of brain
cells for processing inputs, but no organization with which to make
sense of them. For example, a newborn experiences mainly undiffer-
entiated noise, but the smells, sounds, and feelings in its own body
of pressures here and there, and alarm or pain exchanged for pleasure
and comfort, as well as the visual inputs that all come together when it
encounters its mother or caregiver, become recognizable as a group, or
a package, standing out from all the rest of the goings-on in the world.
The first concepts developed in this way, distinguished from the rest of
the world, are certainly not symbolic, but are nevertheless meaningful
and complex, and without doubt affect laden. The milk that the baby
tastes, with its accompanying feel in the mouth and its pleasurable
accompaniment of cessation of discomfort in the body, may not yet
be separated from the caregiver that provides it, but it will be at some
point, and particularly early if the baby is bottle fed, and by more than
one caregiver. The point is that every concept is hard earned, through
much experience, and the more the baby learns, the more the baby
is able to learn, since he has increasingly more points of reference for
distinguishing one thing from another.
114 Addiction

To make all this organizing and meaning making work, babies have
to be motivated to interact with the world, given the significant effort
and overcoming of fear that the task requires, and they are so moti-
vated – through the same reward system that is activated when drugs
of addiction are ingested. They begin to want to interact with the world
because they get positive reinforcement from doing so. “Right from the
beginning,” note psychiatrist Stanley Greenspan and philosopher Stuart
Shanker, in language very well suited to our dynamic complex systems
analysis, “caregivers and infants are engaged in rhythmic, co-regulated
patterns that enable the infant to begin attending to the outside world.”18
Positive and calming feedback provides rewarding experiences for the
child, who otherwise, as we saw in Chapter 3, becomes stressed by the
demands of a highly stimulating and unregulated environment. And
rewarding feedback, as has by now become our mantra, evokes repeti-
tion of the rewarding activity. Such feedback loops become internalized
in the development of concepts as expectations develop and operate in
the activities of perception and response.
Initially, infants experience not the world of things, activities, and
sensations that adults are accustomed to, but rather “a limited number
of global states, for example, calmness, excitement, and distress.”19
Eventually, through soothing interactions in ordinary cases – and
this will show how disruptive the stress we discussed in Chapter 3
can be – these global states become increasingly differentiated and
elaborated. According to Greenspan and Shanker, there is at first in
an infant’s experience just discomfort and distress, then comfort and
calm. Later, there is experience of a discomfort of a particular kind,
followed by comfort of a particular kind. The infant, if responded to
reliably, comes to recognize the caregiver as associated with relief and
comfort, as something good. She develops expectations and emotional
responses based on the caregiver’s responses and emotional state.
As we have seen, the very development of infants’ nervous systems
is shaped by the character of their interactions with a caregiver. The
patterns that form the child’s mind are constrained by the larger ones
that form her emotional environment. As a result, people who experi-
ence heightened stress or trauma in their family relations as children
live in a very different world from those who experience calm and
pleasant nurturing. And, of course, everyone’s sensory apparatuses and
emotional processing systems develop uniquely, with differing degrees
of sensitivity. This means that the tenor of experiences will be different
in different individuals. The same physical encounters carry different
meanings: “a hug feels tight and secure or tight and frightening; a surface
 Addiction and Meaning 115

feels cold and aversive or cold and pleasant; and a mobile looks colorful
and interesting or colorful and frightening.”20
The world that each of us inhabits is, then, fundamentally subjective
and emotional, as well as physical and full of potential; it is a function
of mobile, invested, interested, and emotionally experiencing organ-
isms, as well as of its own physical features. Concepts of the meaningful
things in our world are carved out of regular co-occurring sense experi-
ences and their accompanying emotional responses. In physical terms,
repeated encounters with individual objects result in similar neural firing
patterns. But these firing patterns do not include merely informational
inputs from perceptual receptors. “Wired together” with perceptual
information are signals coming from “upstream,” from the emotional
centers in the brain, and from patterns already established. So, the world
that begins by being experienced as undifferentiated global emotional
states comes, as a baby gains more experience, to be differentiated into
things and people and activities to which emotional responses are also
associated.21 The more a given set of inputs and responses fire together,
the more they are inclined to do so, and the more “this type of thing”
comes to be carved out from and related to all the other things included
in the child’s world. As more things come to be distinguished in the
world, one’s concepts become more precise. What is more, as we have
seen, the character of any individual’s responses to the things that he
comes to distinguish in the world is also influenced by others’ responses,
particularly the responses of caregivers in early life, but, as for example
with teenagers, the responses of peers as well. Meaning making, then,
turns out to be essentially social, as well as emotional and perceptual,
rather than syntactical and symbolic, although we can make and mean-
ingfully use symbols as well. The social and physical environments
thus become integrated into an individual’s world, and shape her atti-
tudes, beliefs, and behaviors with respect to any specific stimulus. The
important thing is that meanings are not merely the result of or for
the purpose of processing information; instead, they result from and
perform profoundly important roles in living and acting in a world with
others.

Prototypes and meanings in addiction

As people move into addictive patterns, they learn the special meanings
of their substance(s) or activity of choice in the same way that anybody
learns meanings: through the emotion-laden experiences that they
have with it. At least at first, the cycle of heightened pleasure, elevated
116 Addiction

beyond what any natural reward could bring, tells the addict that the
drug or activity is a good thing, as are its associated sounds, tastes, sights.
Remember that, since meanings are portrayals of the world, rather than
information received from the world, they will be limited and perspec-
tival, and in some instances starkly incorrect. The good that comes to
be included in the concept of the drug or activity reinforces the impor-
tance connected with it, and thus reinforces the seeking behavior that all
natural goods instigate in humans and other animals, but more so, since
this good is experienced as more powerful than any natural one. As we
have seen, at the physical level, activities and substances that result in a
greater than expected availability of dopamine in the relevant brain areas
are associated with the perception of large rewards, while other activi-
ties and substances, such as food, sex, or solving a puzzle, which result
in relatively less dopamine availability, are perceived to carry smaller
rewards. And these reward experiences and expectations contribute to the
formation of the concepts of their associated activities and substances.
The “special” substances and activities therefore come to have a different
meaning for those who experience them as especially satisfying relative to
other activities or substances. Those substances and activities that arouse
a greater reward response will be conceived as better than others, even if
one “knows” through previous learning, perhaps less viscerally powerful
learning experiences, that they are bad in other respects. Further, not only
do some substances and activities operate to create an overabundance
of reward experience-generating chemicals, but additionally, since indi-
viduals are unique, they will respond differently to each of the dopamine-
burst-creating chemicals and activities. This means that people who
become addicted will have preferences not only for “addictive” things but
also for specific things – they will develop substance or activity preferences.
Naturally, what that particular substance or activity then comes to mean to
the susceptible individual is fundamentally different in many ways from
what it means for others, including positive expectations, importance,
relation to other experiences, and relative value to other activities, as well
as its call for action in specific circumstances. Again, as we have said,
the larger social milieu in which one is exposed to rewarding substances,
activities, or experiences has significant influence on the meaning that
that thing comes to have for an individual or group. Remember the heavy
drinking bouts among Korean men that, due to the social context of their
occurrence, are not amenable to being understood as addictive behaviors,
however unhealthy they might be.
Furthermore, since our concepts hang together to form our individual
worlds, all meanings change (at least to some degree) together. A feature
 Addiction and Meaning 117

that atomic linguistic theorists find to be a weakness in the holistic

prototype understanding of concepts is that the latter suggests that any
changes anywhere involve changes everywhere. This is problematic,
atomic linguistic theorists think, because it implies that the world is not
stable, but is rather constantly shifting as our concepts are refined and
change. This seems to be a strength of the view, however, rather than a
fault, for the whole world does change as we grow from babies to toddlers
to children to adults. Can you imagine inhabiting the world of a seven-
year-old? The world also changes as one becomes addicted, as many who
have experienced that transformation will attest. Not only does the role
and significance of a particular substance or activity change in a person’s
meaning structure as he becomes addicted but so do the roles and relative
value of people who can procure it, the places where the addiction can be
indulged, and people and places who might thwart use. Ultimately, this
can mean that the value and relative place of all other things in the world
are affected as well. The concept of the addictive substance or activity in
some cases can take on such importance, although it doesn’t always, that
it can color the meanings of every other thing that formerly held pride
of place in the addict’s life. Musical instruments and baseball card collec-
tions become means to get money, whereas before they may have been
outlets for stress, means of self-expression, or beloved souvenirs. If addic-
tion becomes central in one’s life, certain places may become opportuni-
ties or obstacles, as can people, activities, and other objects, in addition
to whatever other layers of meaning they may carry. Since in a holistic
system all things are defined in relation to everything else, when one
thing moves or changes, others move or change with it, at least to some
extent. In some patterns of addiction the people, activities, and objects
that had previously held relatively more central places in a person’s
world can come to be marginalized and changed in import, perhaps even
coming to be conceived of as threats or obstacles.

Meaning flips, recovery, and triggers

When an addict has had it, when she is “sick and tired of being tired,”
“hits bottom,” or, as Gene Heyman argues is the case most of the time,
when she is motivated by professional, health, family, or financial
concerns, she will transition out of addiction.22 She will come to see her
addictive behavior differently. In fact, she will come to see everything
differently. This has been called in some frameworks a “spiritual awak-
ening,” and surely it must feel like it, because it is a revolution in one’s
conceptual framework, a complete gestalt shift. It would not even make
118 Addiction

sense to speak of an addict quitting her substance or activity as long as its

meaning remained intact. The very act of quitting use, even if as the result
of imprisonment or other involuntary circumstances, would change the
meaning of the object of addiction. In order to stop voluntarily, the
positive emotions, expectations, and importance of the substance or
activity would have to be changed. All of a sudden, although it may be
the result of a long process of experiencing negative physical and social
consequences, and emotional experiences associated with the addictive
behavior as well as other factors, things can just seem different. The
addict sees the substance or activity “in a new light.” Unsurprisingly,
this shift is often prompted by extreme emotional and physical suffering
associated with an indulgent episode, but this isn’t necessarily the case,
because a shift in meaning is what is essential, not the objective conse-
quences evoked by continued use. Some people will use throughout their
adult lives, and even to death, if they never come to see their preferred
substance or activity as a thing that can be abandoned. And some people
will simply give up use because some other source of meaning or value
grabs their attention. Either way, the conceptual shift that comes with
transition out of addiction is essentially emotional. The substance or
activity is drained of its appeal. Likely, it is imbued instead with negative
connotations. It can come to be conceived as merely uninteresting, or as
poisonous perhaps, or even as evil. Other things take prominence in the
addict’s world, with the contours of the whole shifting accordingly. And,
as with the shift into addiction, inputs from one’s social environment
both contribute to this shift and help sustain it.
The meanings that things have for us operate in important ways
outside of our conscious awareness. We may never know what our
concept of a given thing is until we turn our attention to an analysis of it.
Since the meanings that things may have for us may not be fully known
to us, we are perfectly capable of providing ourselves with reasoned
accounts of what we’re doing and what we believe and what we plan
to do, while those accounts may have little to do with what we actually
want, believe, or plan to do.23 Even after an individual with a history
of addiction has abstained from his preferred substance or activity for
a significant amount of time, resisting temptation under all kinds of
circumstances, and has consciously worked to reframe the activity or
substance of addiction in negative terms, even as “impossible,” the
world can shift back. As certain “triggers,” or associated meanings, in
an addict’s environment bring to the forefront feelings and responses
that may have been consciously put aside, the world can suddenly and
unconsciously revert to its previous structure. In a complete reversal of
 Addiction and Meaning 119

the original gestalt-type shift, the meanings that constitute the addict’s
world can return to the structure in which the substance or activity of
choice takes a central place and influences all associated concepts. This
may result in the individual’s having thoughts totally unconnected to
the substance or activity of addiction (such as “I hate my boss, my job
is overwhelming, I’m so exhausted ... ”), but which lead nevertheless to
the experience of world shift, in which return to use is rated as pref-
erable to abstinence. Anticipation of imminent relief, satisfaction, or
pleasure, as the behavioral economist tells us, predictably evokes this
response, and the more so, the more the anticipation is entertained, and
the more proximal it appears. These facts about our concepts and beliefs
operating unconsciously can be frightful for those struggling with addic-
tive patterns, since they imply that a person’s concept of her preferred
substance or activity might be associated with many triggers that she
has never thought of. Knowing this fact, however, seems to provide a
counterbalance to the power of unconscious effects, for it suggests that
anyone can work daily toward consistently increasing awareness of her
own associations, and thus her own vulnerabilities.

Some objections and responses

The view of meaning that has been presented in this chapter has been
expressed in light of its main opponent, the atomic linguistic theory.
Although it seems to stand up well in the face of familiar objections, not
all of them have been adequately answered. A couple of issues remain.
One we have already encountered: according to those who hold some-
thing like the atomistic informational view of meaning, prototypes
and meaning holism are doomed from the start because the meaning
of anything affects the meaning of everything. So, the argument goes,
anytime anybody learns anything new, or one meaning is changed in
any way, all meanings are thereby changed. This is seen as unaccept-
able on the grounds that no one would ever have a firm grip on his
own beliefs and desires, much less could two people ever understand
each other. I have expressed these results as features of the perspective,
rather than as bugs in it, for it is a fact in need of an account that our
concepts are constantly changing, subtly shifting, depending on the
context in which we consider them, and so are the beliefs and desires
that are constructed of them. Within constantly changing internal and
external contexts, our conceptual state space (the “space” within which
concepts can be carved out) is constantly morphing, although not to the
extent that our opponents might want to make us think. Our concepts
120 Addiction

of people, events, and objects remain recognizable through change, as

their relations to one another remain similar. When my concept of my
uncle Joe is significantly altered by new information, so is my concept
of my aunt and perhaps additionally even my concepts of dinner, Easter,
and tranquilizers. But that does not mean that the world is no longer
recognizable. The influence of changes of one concept on another dimin-
ishes as the “distance” between them grows. And what is more, when
concepts are understood properly, as emerging from minds that in turn
emerge from physical processes, it becomes obvious that we don’t hold
them, but reconstitute them as needed. This means that a little differ-
ence goes unnoticed. The concept that we form for a given occasion is
close enough to others that we have formed to function just fine. With
respect to the likelihood of communication failure on the holistic view,
we should observe that this preserves the phenomena: conversations
between addicted individuals and those who have never been addicted,
and even among a group of self-defined addicts, people with differing
preferences and patterns often seem to exhibit more miscommunication
than communication. If this is a flaw, it is one that accrues to our nature,
not to our theory.
There is another kind of worry to consider as well. The prototype-
centered version of meaning holism that we have outlined here may be
threatening to people who believe that in order for there to be science or
study of anything at all, there must be a single, unambiguous world to
which we all have access. Our theory seems to some minds suggest that
there is not one body of science, one world to study, one correct theory,
and so it may seem to shake our stability as knowers. This implication
does not make our theory wrong. Minds, whether human or those of
other animals, work to create meanings in much different ways than
philosophers and others have portrayed for millennia. Now we must
rethink how to account for our beliefs, knowledge, science, and other
types of study in light of what we are, rather than trying to think of how
we must be in light of dogmatic views about what knowledge, science,
and other studies say. This criticism seems to cut against philosophers’
assumptions more than it does against meaning holism.
Finally, there is a potential concern, not with respect to prototypes
themselves, or to meaning holism, but with respect to what the view we
have elaborated on says about addiction. The theory that has been put
forward in this chapter is a general theory of meaning, and so the fail-
ures to communicate that occur between addicts and nonaddicts are not
peculiar to these groups, but apply to any pair or group of individuals
with different conceptual frameworks. Moreover, the gestalt shifts that
 Addiction and Meaning 121

mark transitions out of addiction, and relapses prompted by “triggers,”

could equally apply to PTSD “flashbacks” or desperation brought on by
the discovery of a cheating spouse or by losing one’s job. The charge,
then, is that the proffered theory of meaning says nothing in particular
about addictive patterns. To that I say, these facts rather support the
theory’s truth than undermine its applicability. The fact that the level
of meanings as an emergent feature of addiction works to characterize
many diverse human experiences says 1) that the view has a good chance
of being correct in showing how the highly complex physical systems
that human beings are can be moved by very real nonphysical processes,
and 2) that addicts are not so very different from the rest of the popula-
tion. Addicts are people moved to action by the values inherent in the
world that is constructed by them, in interaction with their environ-
ments, both local and global. There is no good reason for saying that
addicts are addicts because of a disease, or a genetic mutation, although
they may well in some numbers have some genetic difference from the
nonaddicted population, and they may cause themselves diseases by
their addictive behavior. However, there is also no reason to say that
addicts resolve to harm themselves and others by obstinately electing to
engage in addictive behaviors after weighing their options in the same
terms that some others might use. In making their determinations to
act, those who suffer with addictions are reasoning within a different
conceptual space than are those who would criticize them or treat them.
What is more, because meanings are essentially dynamic and intercon-
nected, there is no reason to say that the situation cannot change.
7
Phenomenology and Its
Implications

As I sit down to write this chapter, one of my friends who struggled

with addiction has just died. He was, like many who considered them-
selves addicts, a man of many faces. In our conversations he was self-
deprecating and funny, but expressed a deep fear of rejection. Every
comment or suggestion was qualified with as many as a dozen itera-
tions of phrases such as “this is just my opinion,” “I don’t speak for
everyone,” “everyone is different, of course.” And yet when his obituary
was publicized, it revealed things that most of his friends didn’t know,
including that he was a highly educated, highly successful professional
in at least two or three very diverse fields. He had not used alcohol for
over a decade. Unlike the addicts that Gabor Maté profiles so sensitively
in his In the Realm of Hungry Ghosts, many of the people whom I have
met in the groups that I have visited are doctors, lawyers, professors,
chemists, judges, actors, and artists, respected in their public lives,
reserving their addiction for only those very dark corners of their private
lives. Most think that they have no friends, while they are surrounded
by supporters and admirers, and although many have underlying social
anxiety issues, they are often charming and influential among those
with whom they interact. All this is to say that when you think you have
a handle on addiction and addicts, you probably don’t.
Every addict’s story is different, from the inside and from the outside.
The account that we have been developing leads us to expect that to
be true, given that every addict has unique DNA, activated in a unique
environment, and unfolding under a unique developmental trajectory.
Any given theory of addiction may well explain some varieties of addic-
tive experience, or several, such as the susceptibility of trauma victims
to become drug or activity dependent, but that same theory might falter
at connecting that background to the economic or other circumstances

122
 Phenomenology and Its Implications 123

associated with whether that susceptibility is actualized. Choice theo-

ries might track preference reversals relative to proximity of opportu-
nity for use, but what do they have to say about the personal anguish
of sober moments, and the giddy heights of freedom, confidence, and
fearlessness of drugged exhilaration? Neurobiological theories may
well explain how some addicts come to respond to certain cues virtu-
ally automatically with reward-seeking behavior. But what does incen-
tive sensitization tell us about why people in different social contexts
respond differently when exposed to these cues? And how do any of
those explanations help us understand the role that addiction plays in
the shaping of one’s identity, or how it feels to have a craving, or to be
high “in just the right way,” or what we ought to do to help a person
change her own psychology?

Why care about phenomenology?

When Bill Wilson took his first drink, it “produced in him instant feel-
ings of completeness, invulnerability, and an ecstasy that approached
the religious.”1 Similarly, when philosopher Owen Flanagan was twelve
years old and had his first drink of hard cider, what he remembers is
an immediate, powerful feeling: “I felt release from being scared and
anxious. It was good. I did not know, I would not have known to say if
asked at the time, that I was a scared and anxious type.” But he knew
quite well that after imbibing the cider, “a certain eighth-grade boy
was released for a little time from a certain inchoate fear and anxiety.”2
These two experiences are paradigmatic of what we have come to expect
from addicts. These stories are quite different, though, from those who
choked on cigarettes for months, attempting to fit in with the crowd,
only having it slowly dawn on them perhaps years later that they had
difficulty quitting when they finally decided that they no longer wanted
to smoke. They are different as well from the stories of those who gamble
because it is exciting and fun, the same reasons that draw others to video
games – not reasons or feelings anything like those that moved Wilson
and Flanagan. And the Wilson/Flanagan type stories are different from
the experiences related by those who drank or gambled for many years
without any major consequences, only to have serious difficulties crop
up all of a sudden in midlife as a result of their indulgence.
Flanagan is surely correct when he says that we want to know whether
there are any commonalities among the experiences of addicts (he
focuses particularly on alcoholics). He is also right when he says that
we want to know “how the socio-cultural-political ecology normalizes,
124 Addiction

romanticizes, pathologizes (and so forth)” addictions and related

patterns of behavior.3 That is in fact part of what we have been trying
to do throughout this book. Flanagan also recognizes that the power
and influence (what he calls the “phenomenal authority”) that AA in
particular has enjoyed in determining the assumptions governing the
direction of discourse on the subject may be undeserved. In fact, it is
undeserved and it has worked to misguide analysis of addiction for
decades. AA’s phenomenal authority, as we have seen, is the result of
accidental historical facts, such as the way that the central text, the “Big
Book,” was put together, with its collection of stories of people hitting
“rock bottom,” having experiences of God, and so forth, not to mention
the way in which AA was formed out of a Christian perfectionist orien-
tation based in Wilson’s own family’s history. Because of these coinci-
dental facts, together with the way in which AA was advertised from
the beginning, as highly successful, and the fact that no ready alter-
natives presented themselves, and because of AA’s consequent embrace
by the medical and insurance industries, assumptions about what it
means to be an alcoholic or addict have been driven by characteristic
AA discourse, distorted and restricted though it may be. What is actu-
ally a wide variety of human experiences has been skewed, smoothed
into a recognizable pattern and reified into a diagnosable disease with
an inevitable progression. As a consequence, little attention has been
paid in the discourse on addiction to the drastic differences among real
individuals’ experiences. The phenomenal authority of AA has shaped
people’s thinking about their own stories, not least because the authori-
tative voice that has become so pervasive in self-help rooms as well as
in treatment facilities says that it is “what we have in common” that
matters. Focusing on what differentiates members is usually referred to
pejoratively as symptoms that are destined to propel people into failure
and despair. Members, as Flanagan rightly points out, are told outright
to find what they can “identify” with in the stories of others.
We will discuss some other implications of this kind of instruction
later, but for now it should help us recognize that most of the accounts
of addiction that we encounter in popular literature and in people’s
anecdotes are based on “folk-tale” experiences of addicts, ones that fit
within the formula driven by a particular cultural structure. How does
this happen? An empirical study led by Rebecca Hammer in which sixty-
three individuals in treatment centers gave personal narratives of their
addiction found that the stories told were “a combined product of indi-
vidual agency and socialization from treatment program ideologies.”4 As
argued in Chapters 4 and 5, meanings are generated from individuals’
 Phenomenology and Its Implications 125

physical and emotional experiences in a largely socially constructed

world. This means that lived experience is unique, but it is conditioned
by the social milieu in which those experiences unfold. If one begins
to write one’s narrative while in treatment, it will be significantly
influenced by the rhetoric used in the treatment center in which one
resides. Hammer’s group found this to be true at least of their inter-
viewees. Likewise, if that story is constructed from within the walls of
12-step rooms, it will be informed by paradigmatic AA narratives. Since
the 12-step approach dominates treatment, both in professional facili-
ties and in church basements, the assumptions of that orientation can
be expected to exert significant influence on addicts’ stories, and even
more so when the person has been immersed in such programs.
The power of the voice of 12-step programs has driven the develop-
ment of the numerous theories of addiction we have considered. Since
many stories gathered by clinicians and studied by researchers seem
similar in type, the similarities have been focused on at the expense
of the diversity. Further, those who have worked at the neurological
end of the explanatory continuum have gone looking for, and have
found, brain change correlations in addicted subjects. As discussed in
Chapter 1, however, it is not clear in which direction the causal arrow
goes with respect to these brain change analyses: do these changes cause
the addiction or follow from it? The theories that we have considered,
including the hedonistic theory, the avoidance of withdrawal, the sali-
ence sensitivity approach, the ego depletion theory, the trauma-based
developmental theories, and the psychodynamic theories, each reso-
nate with some addicts’ experiences, but fail to resonate with others.
When researchers ask the question of whether “real” addicts have this
or that characteristic, it is clear that they mean people who meet their
own criteria for addiction. For the purposes of doing focused research on
an aspect of the phenomenon, this is absolutely necessary. No science
proceeds without its assumptions.
Nevertheless, the diversity of addicts’ experiences is greater than is
the universality. Since the project of studying addiction is not merely a
theoretical exercise in trying to characterize it, or in attempting to deter-
mine the degree of responsibility that people would have if addicted,
but is rather a preliminary step to finding ways to prevent and escape
suffering, we need to reflect on the particular things that individual
addicts have had to say about their experiences. We need to take time to
focus on the details of individual experiences, rather than relying only
on abstracted prototypes of addiction or individuated aspects of the
phenomenon. As Hammer’s group put it, it is important that individual
126 Addiction

addicts’ voices “not be disenfranchised from the research done for

their supposed benefit.”5 What is it that makes one drug or activity the
indulgence of choice for one person, but not for another? How is it
that some people can have one drink as a youth, and be altered for life,
when others can sometimes have just a glass of wine, and at other times
behave as though obsessed? Why are some people apparently addicted
to everything that can be overdone, while others only experience addic-
tive attachment to one substance or activity – able to gamble just a little,
or use cocaine only at parties? We have seen how the social construct
of addiction has expanded so much that virtually any activity can be
deemed an addictive one, and we have discussed how the psycholog-
ical pattern of addiction can be characterized in terms of a hierarchy
of dynamic levels within complex dynamic systems. But we have not
yet considered addiction from the subjective side that emerges out of
all this complexity. To that we now turn, for it is in light of individuals’
descriptions of their real-world addictive experiences that we need to
evaluate our account and its potential for actually helping people lead
more satisfying lives.

Two systems and ego depletion

One of the more promising ways of thinking about addiction consid-

ered earlier was based in the dual systems understanding of our thought
processes, according to which we have on the one hand a fast, intui-
tive, undemanding and simplifying way of thinking, which operates by
default (System 1), and on the other hand a slower, more deliberate, kind
of thinking (System 2) that requires more mental resources. According
to this theory, when individuals become depleted of cognitive resources,
either through having exerted self-control chronically for some time or
through being stressed in some way, System 2’s control of their behav-
iors may be overwhelmed, resulting in a switch to the much less taxing
System 1 mode of thinking. In this mode, people accept bad arguments,
or just do whatever is most habitual or whatever is closest to hand. They
escape the difficulty presented to System 2 by switching out of that
effortful, deliberate kind of thinking into the more automated mode,
with the result that they decide that indulgence is the preferred action.
Many experiences described by addicts seem to accord with the ego
depletion theory. Take, for example, the group of subjects in the Hammer
study whose responses are loosely collected under the theme that the
authors call “punctuated equilibrium.” This was the most common
theme found among interviewees’ responses. The title is employed in
 Phenomenology and Its Implications 127

order to describe addiction “as a problem that oscillates along a static

equilibrium, flaring only with specific triggers.” Punctuated equilibrium
is the paradigmatic pattern of struggling addicts, the one that inspires
the characterization of addiction as “a chronic relapsing disease.” A man
whom the authors call Joe experienced his alcohol abuse as connected
to the amount of stress in his life, particularly in connection with his
employment status and his relationship with his wife:

I resigned one job due to the stress and then I would start another one
and that is the one I’m at now and I enjoy the job, but the increase in
work duties just kept piling up where the stress was built up again for
me ... You know, in this day and age, they try to put as much respon-
sibility as they can on people ... I mean management does, basically
to cut costs and that hurts the blue-collar people. I mean, and the
stress just got worse and that is why I started again ... My support has
always been my wife. She pointed out that if I didn’t quit, she would
leave ... I just quit, and, you know, just go for awhile and then the
tension would build up, the stress would build up again and I would
go back to it.6

This ego depletion theory seems to explain key elements of Joe’s expe-
rience in a way that the simpler reward-seeking, withdrawal-avoiding,
and mere habituation models that we have considered cannot. Joe’s
experience and the ego depletion analysis of it seem to accord with the
incentive salience phenomenon, according to which the pull that the
substance or activity of use seems to have emerges when stress rises,
even absent any anticipated pleasure. Joe just seemed to return to the
“solution” of alcohol use every time the pressure built up.
Lance Dodes, a Harvard psychiatrist who was a leader in the develop-
ment of the psychodynamic approach to treating addiction, describes
a similar response in one of his clients. This man was a business owner
who had a history both of alcoholism and of being the victim of embez-
zlement by his own son. “When he discovered that the son’s thefts
from the company were far greater than he had known, Dodes says, “he
ended many months of sobriety in a two-day alcoholic binge.”7 Very
often we see cases in which someone is capable of controlling his use of
his favored substance or activity for days, weeks, months or even years.
He can control it right up to the point at which the emotional issues,
physical exhaustion, financial issues, or some other major stressor is just
too much. Then he capitulates. It seems plausible to conclude that in
these situations the automatic thinking of System 1 takes over.
128 Addiction

People who have this sort of experience in addiction often make deals
with themselves, swear off for a time, and are successful for a time, but
how long that time is ranges widely. In some cases, decades go by with
the promise made good before something incites the switch. In other
cases, it is remarkably short. Caroline Knapp, for instance, tells in her
bestselling memoir, Drinking: A Love Story, of making such a promise to
herself and to her mother at one point, after her drinking had become
disturbing for both of them: “‘I’ll cut down. Two drinks a day. No more
than that. I promise.’ I’d meant it.” But by the end of that same day,
back in Boston, not feeling well and observing people relaxing in deck
chairs, sipping beer from plastic cups, she capitulated.8 When the phys-
ical raggedness that she was feeling due to a hangover combined with
images of people relaxing and enjoying beers, her promise went by the
board in favor of her default response: to drink.
Sometimes the return to use doesn’t seem to be related to anything,
though. So it seems that even in this most prototypical of addictive
patterns – the one most particularly amenable to the dual systems and
related theoretical approaches – many people’s experiences are not
captured. As actress and comedian Kristen Johnston put it, the return to
use sometimes “sneaks up on you and all of a sudden you’re boozing at
the bar, or whatever. And it doesn’t have to be because of you or pres-
sure or this-or-that. It can just be.”9 No system switch seems to have
happened here, no turn to an easier way of thinking seems to have
occurred because of stress, pressure, or any identifiable cognitive load.
Kristen just found herself drinking.

A day in the life

It seems from Kristen’s experience that the dual systems approach

cannot account for all the kinds of experiences that people have with
their addictions. In fact, it cannot begin to do so. In a critique of the dual
systems approach, Jeanette Kennett suggests that some people simply
have no concept of a good life that is available to them.10 These indi-
viduals never reach the point of being on their way to a life they envi-
sion, only to hit an obstacle and return to habitual patterns; instead,
they remain in the habitual patterns always. In order to explain this
situation, Kennett distinguishes between what she calls intentional self-
control, which is the kind of self-control that we exert in order to
perform individual actions of our choosing, and normative self-control,
which is necessary for directing one’s actions over time toward the kind
of life that one takes to be good. Addicts, like anyone else, must and
 Phenomenology and Its Implications 129

do exert intentional self-control, whether to purchase drugs, drive to a

casino, or solicit sex. It is the failure of normative self-control that char-
acterizes addiction, Kennett argues. This kind of failure could happen,
she suggests, for one of two reasons: an individual might be deprived of
a conception of the good life to begin with, either because of life circum-
stances or because of addictive indulgence itself, or one might have a
real conception of the good life but in such a way that it exercises no real
power over one’s choices. Rather than accepting a breakdown in System
2 (due to ego depletion or cognitive load) as the explanation for this
second reason for failure of normative self-control, Kennett thinks it is
“more likely that in these cases the person does not see the life he would
value having as available to him,” given his emotional experiences of
self. That is, for some reason he just can’t see the life that he would truly
wish to live as available to him.
The individuals whose stories are loosely connected by the theme that
Hammer’s group labels “What’s Normal?” seem to experience something
like the first reason that Kennett offers for the failure of normative self-
control. That is, they seem to be deprived of a conception of the good
life to begin with. A sad, difficult, disadvantaged life for these people
seems to be the unquestioned norm. Many of physician and author
Gabor Maté’s patients in Downtown Eastside, Vancouver, for example,
expressed little understanding of the potential for a better life. In one
case, a young woman named Celia had a difficult time trusting anyone –
for one thing, because she was sexually exploited from the time she was
five. Her abuser for eight years was her stepfather, who regularly spat
on her, among the many other indignities that he inflicted. She was
pregnant at the time that Maté first saw her. She had been involuntarily
committed to a psychiatric ward, had a long medical history of bone
fractures, bruises, and black eyes, as well as abscesses, dental infections,
recurrent fungal infestations of the mouth, and other manifestations of
HIV infection. After the baby was born, Celia left the hospital, unable to
resist the allure of cocaine.11 Although the baby was born dependent on
opiates, and so faced an uncertain future of its own, it at least was placed
in a foster home, with some hope for a better life. Celia hadn’t ever had
that chance. For Celia, like for many of Maté’s patients, it was as if “an
invisible barbed-wire barrier surrounds the area extending a few blocks
from Main and Hastings in all directions. There is a world beyond, but
to them it’s largely inaccessible.”12
Some people, though, seem to experience a much less diminished
conception of a good life, and nevertheless see the addictive pattern as
the norm. Allison Moore, for instance, a young vice cop who became
130 Addiction

addicted to methamphetamine, expressed the normality of addiction in

her family life without the kind of hopelessness characterized by Celia’s
situation. Moore says in her memoir that

[m]y family has a long history of addiction, mostly to alcohol. My

mother, two uncles, and both maternal grandparents were alco-
holics ... my uncles were at the height of their alcoholism, my cousin
was a heroin addict, and my mom, after enjoying fifteen years of
sobriety during my childhood, had relapsed into alcoholism during
her divorce ... The rampant alcoholism was hardly a big secret; it was
just something everyone laughed and joked about. No one in my
family treated it seriously. No one thought it was a big deal.13

In this case, the very normality of addiction within the family seems to
have played a role in Moore’s falling into her own addictive pattern. Not
every situation, however, in which the presence and use of substances is
taken as normal seems to have much to do with Kennett’s suggestions
for why people fail to exert normative control over their lives. Knapp,
for instance, who grew up in a world starkly contrasting with Celia’s and
Moore’s, says that in her life drink was “just always there.” The daughter
of a psychoanalyst and an artist, a graduate of Brown University, and a
successful writer, this woman was surely not deprived of a concept of
the good life. Nevertheless, in one way, her experience is similar to those
just described. She found the availability of alcohol and daily drinking
the norm: “In my parents’ house the Scotch and the gin sat in a liquor
cabinet, to the left of the fireplace in the living room, and it just emerged,
every evening at cocktail hour. I never saw it run out and I never saw it
replenished either: it was just there.” This experience sounds much like
one of Hammer’s interviewees, Jill, who said, “I really thought everyone
had a cocktail at five. And when I think back, I think, well, [so and so]’s
parents never did that ... but all of my parents’ friends did.”14 Although
these stories do not seem to be illuminated by either a dual systems
analysis or by the self-described addicts’ lacking a concept of the good
life, they are similar in revealing what an impact the presumption of use
can have on the development of addictive practices.
But even without this presumed normality of substance use, some
who do see a very good life as available to them nevertheless become
addicts. Consider the future that Johnston saw for herself:

Despite that my life at this point was sort of a bummer (for an upper-
middle-class, Midwestern kid with plenty to eat, lots of fun vacations, a
 Phenomenology and Its Implications 131

beautiful home, and parents who loved her, that is), I knew something
none of my classmates did. Deep inside, I knew someday I’d win.15

As with Knapp, given her privileged family and all the attendant expec-
tations, one can hardly draw from Johnston’s description of her experi-
ence that her inability to exert normative control over her life was a
function either of her not having a conception of the good life or of her
not being able to see such a life as available to her. And, from the other
side, even after successful treatment, Moore did not appear to be able
to see herself in a meaningful life: “Once, I had had the opportunity to
have a wonderful, normal life, and now I never would. It was over. I was
done. I would carry on being detached and cold, pretending that none
of these things had happened.”16 And yet, Moore did go on to a life
of sobriety and continued success. Just like the other stories, hers tells
us that the theories we have examined are sometimes unnecessary and
sometimes insufficient for, and sometimes irrelevant to, providing satis-
factory explanations of the huge variety of manners and circumstances
in which addiction actually occurs in individual lives.

Like a light switch

Another theme that Hammer’s group found that tied together a few of
their subjects’ narratives is what the authors call “Pedal to the Metal.”
This type of narrative has as its focus the striking experience that we
saw in Bill W.’s story, and in fact in most of the stories from the book
Alcoholics Anonymous. In these stories, the addictive draw of a substance
was apparent from the first encounter. We see this pattern illustrated
vividly in the memoir of Allison Moore, when she first was exposed
to methamphetamine. After being handed some confiscated meth for
processing, and after confiscating a small line for herself that kept her
up for more than three days, Moore was hooked:

I had told myself when I did that line that I would only try it once. I
would never do it again. But when I started to come down I couldn’t
face being plunged into the icy cold water of my real life. I couldn’t
bear to have those feelings return. I did another line, bigger than the
first. It made me feel calm, confident, excited about my future. Meth
was the answer to all my problems.17

Although Hammer’s group found that this theme was the least common
of all those expressed by their interviewees, Moore’s experience seems
132 Addiction

closest to what is often offered up as the prototype of addiction. At least

it is the pattern that is most often described with respect to heroin and
meth, perhaps to deter the public from ever using it the first time. As
opposed to the punctuated equilibrium pattern, this version of addictive
behavior seems to be characterized by little control from the start, and
attended by physiological withdrawal symptoms when use is discon-
tinued. One of Hammer’s interviewees, named Bill, became a smoker in
a single day. He said in his interview that

there was a carton of cigarettes on top of the refrigerator and I decided

to try it and the next thing you knew, I was stealing all of her parents’
cigarettes ... I heard that you can’t smoke like a pack the first time you
smoke a cigarette, you know. But I smoked three packs the first night!
That is how much I loved it.18

None of the theories that we have discussed can explain such experi-
ences. There can be no issue of a brain “hijacked” by drugs here, no
question of withdrawal or of interpersonal bargaining. Although it could
be the case that there was trauma early in Bill’s life, it doesn’t seem to be
that he experienced any relief from his first use of tobacco; rather, it is
expressed as a purely pleasurable experience. Perhaps, then, the by-now
largely discounted hedonic theory captures Bill’s experience better than
do any of the others. After that initial use, he kept up his smoking, with
a vengeance, and he “could smoke six or eight” packs of cigarettes if he
were to stay up all night. But pleasure doesn’t seem to be the key factor
in all people who feel immediately addicted to a substance or activity.
Many people who experience addiction in this particular way feel that
it is more a matter of pure urge far more than a matter of any partic-
ular pleasure. These individuals, most of whom admittedly have gone
through a treatment program using this model, seem to understand
themselves in terms of the disease model, specified either as genetically
programmed or as psychologically predisposed to addiction. Hammer’s
group interviewed a woman named Nora who explained her experience
in these terms:

I was an addict before I ever even had that first drink. And that first
drink just sucked me in. I don’t feel like I would have had the same
unmanageability if I had never drank [sic], but I believe that I was an
addict and an alcoholic waiting to happen ... I always wanted more
of everything. Anything if it was like a food that I liked or whatever
I want more than one ... I think it is part of my personality, but there
 Phenomenology and Its Implications 133

was not a lot of progression for me. I was hooked on alcohol the
minute I drank.

For those who experience addiction in this immediately powerful and

all-absorbing way, use of one substance or activity can often only be
managed by substituting a different one. Individuals who experience
this sort of addictive process seem to be those who benefit most from
participation in the external control of 12-step programs, even to the
extent of using them as their substitution addiction, because the pros-
pect of having no addiction at all seems inconceivable. Moore also
experiences herself, after treatment for her meth addiction, as having an
“addictive personality,” as being doomed to addiction:

If I had stopped to think about it at the time – if I had stopped to think

about anything – I would have seen that I had always been an addict.
Throughout my life, my addiction had never been a substance. I was
addicted to more. More work, more control, more exercise, more sex.
I’m one of those people who has a bottom-less bottom. Whatever it
is, bring it on. I will go until I die. Original emphasis19

It is difficult to tell whether these people would have described them-

selves as diseased, either genetically or psychologically, had they not
been through 12-step-based treatment. In any case it is interesting that
the description of themselves as having always been addicts is made
in retrospect. Like medieval occult qualities, such as “soporific,” used
to explain the sleep-inducing qualities of certain substances, “addictive
personality” is an epithet without explanatory reach. Nevertheless, the
words are chosen by the women themselves to describe their experi-
ences, and so the characterization cannot be dismissed.
In these cases it might be helpful to look to a genetic contribution
as part of the explanation of the experiences portrayed. Even so, as we
have discussed, no more than 50% of the tendency toward addiction
is attributable to this contribution, and so other things must be oper-
ating as well. And those other things don’t seem to be accounted for
by hedonic, withdrawal, or dual systems analyses. Again, we seem to
get a partial explanation of the phenomena through one or more of
the proposed theories. We can’t discount that these women experienced
trauma earlier in their lives, in addition to other things that might have
contributed to their plight. The lesson again, though, is that no theory
illuminates the entire range of these experiences, while every theory
shines some light on some parts of some of the stories.
134 Addiction

The snowball effect

In certain cases a person can use a drug or engage in an activity for

years without any discernible negative consequences, and then at
some point, things begin to spin out of control. Hammer et al. found
this pattern in about a third of their respondents. Isaac, for instance,
a forty-seven-year-old man, said that becoming addicted was a long
process for him:

It took me a long time to become an alcoholic. I had to work really,

really hard at it ... I have been around people who drink, like all of
my working life, and I can drink and not drink. It was never a ... there
was never any kind of associative, addictive behavior. I mean I could
drink on weekends and then not drink all week. I knew where there
would be consequences to drinking and not do it. I would never plan
or necessarily look forward to it. And, I mean that was 25 years. I
mean, and then all of a sudden it just run tough. At that point, you
are making conscious choices to drink rather than do something
else.20

Individuals describing experiences like Issac’s, of drinking or smoking

or doing some other activity for years, only to find it careening out of
control quickly after all that time, Hammer’s group found, and quite
understandably, tended to be more intellectual in their talk about addic-
tion. They comprised a generally older group, and they had more expe-
rience with their addictions than did others. This group tended to be
more philosophical about what counts as addiction, which also seems
reasonable, since behaviors imperceptibly different from long-standing
customs seemed for them to come suddenly to have different meanings
and different repercussions than they had had previously. For Mary, a
news manager in her forties, the change was from being on the job 24–7
to having no job at all. “I was so shocked that I ended up the way I
ended up and I went downhill so quickly” (Hammer, p. 728). Like many
who experience this kind of sudden change with substances or activities,
Mary was totally blindsided by her addiction.
These experiences don’t seem to be accounted for by any of the theo-
ries that we have so far encountered. If these self-described addicts’
problems were due to changes in the reward system in the brain, one
would expect those changes to have been effected in fewer than the
twenty to forty years that it seems to have taken. But these experiences
aren’t any better explained by hedonic, withdrawal, or dual systems
 Phenomenology and Its Implications 135

theories. Certainly neither of the first two explains this pattern. Nor,
however, does this kind of situation describe someone who employs
System 2 to control something until the system is overwhelmed and
the quick and habitual sort of thinking takes over. Moreover, genetic
inheritance and trauma seem to have little to say about this kind of
sudden change in substance use patterns. Perhaps age itself changes
the way in which people react to the effects of certain substances
(there may be cases of gambling or shopping that follow this pattern,
as well). But if age is the issue, then the question arises why in the
prototypical story, as in Knapp’s experience, the progress of addic-
tion has “the feel of a swan dive, a long slow curving arc,”21 while for
people who fit into this group the experience is more like falling off
a cliff.

Isolation and love stories

One relatively common phenomenon related in the stories of addicts

is the feeling of total isolation. Whether self-imposed or because of a
reserved nature or shyness or something else, we often find that those
who exhibit addictive behavior do so in light of an inability or unwill-
ingness to ask for help or depend on others. For instance, even after
spending extended periods of time in the hospital due to a series of
potentially fatal health problems resulting from her addictive behavior,
Kristen Johnston realized that in order to change her life she would have
to change her relationship to herself. Of the time that she was hospital-
ized, she says,

I would rather lie alone, hour after hour, day after day, week after
week, for almost two months, than to have to tell anyone I needed
them. You see, if I needed them, that would mean I was weak, which
would mean I was flawed. And that would be unacceptable. A fate far
worse than death Original emphasis.22

Likewise, Allison Moore, the vice officer whose police culture didn’t
allow one to “just go and talk about your problems,” kept her troubles
to herself. She says, “I had spent my whole life keeping my own secrets,
believing that if I didn’t tell anyone my story, it couldn’t possibly be
happening to me.”23 Addicts who speak in support groups often talk
about isolation as a major problem, even after they have transitioned
out of active use, because it is such a temptation to take on the world
alone. The reasons that people give for isolating themselves, though,
136 Addiction

vary. Sometimes the issue is an overblown sense of one’s own power

and responsibility, but sometimes the emphasis seems to be on an “out
of sight, out of mind” motivation. If the problem is never shared, the
person reasons, its reality can be denied.
In some cases, the secrecy, isolation, and fundamental shame that
attend addictive vulnerability and addictive behavior are so great that
the addiction itself comes to be experienced as a friend. Many, including
the man in a recent Chantix commercial, characterize the very thing
that they are attempting to eliminate from their lives as their best friend.
Knapp subtitled her book A Love Story. She says that her story is about
“saying good-bye to something that you can’t fathom living without.”
In the end, she says her relationship with alcohol “was the single most
important relationship in my life.”24 Things can even reach a point at
which the power and poignancy of the relationship between an addict
and her substance or activity cannot be overstated. Kristen Johnston
experienced her addiction in that way:

When He’s got His evil talons in you, you don’t care. You will lie
to protect Him, no matter what happens. He’s your most devoted
better half, your longtime lover. He’s adoring and reliable and He’s
never let you down. It’s certainly not His fault that He’s killing
you. Like a battered wife, you take Him back even though He just
knocked out your two front teeth. You lie to your weeping mother
even though He’s convinced you to steal the painkillers she actually
needs after a knee-replacement surgery. You will die protecting Him,
no matter what. Because no one will ever, ever love you as much as
He does.25

This is a part of the phenomenon that none of the received theories

touches. Even the psychodynamic theory, which, instead of focusing on
genetic or neurophysiological analyses, operates purely at the psycho-
logical level, has nothing to say about this kind of personal experience.
Is there an account to be given of why some people would come to
see themselves as having this kind of powerful relationship that can
be categorized as a behavior pattern, a rational choice, or a disease?
While it is true that the incentive salience approach can give us a brain-
based account of the importance that an activity or substance can
come to have in someone’s life, it can tell us little about why certain
people come to experience this kind of personal struggle as an entity,
even a love. That is a function of meanings, for which we have devel-
oped a sketch of a theory. A full analysis at this level, however, is still
needed.
 Phenomenology and Its Implications 137

Medicating pain

Of all the approaches to understanding and treating addiction, the

dynamical psychological approach most appreciates the unique experi-
ences of individual addicts. Pain is personal, and relief can be sought and
experienced in an almost infinite variety of ways. On this approach, it
is neither the reward nor the avoidance of withdrawal, nor failures of
either System 1 or conceptions of the good life that drives consistent, and
sometimes constant, indulgence in addictive behavior. In this case, it is
not a loss of self-control that accounts for use, but rather of the only kind
of control that a person might have. Those who take the self-medication
view of addiction focus on the suffering that addicts undergo more than
do any other theorists. Indeed, researchers who take this approach tend to
be clinicians, rather than lab researchers or theorists. Maté, for instance, a
defender of the self-medication view, in addition to being a researcher and
author, has for decades been treating street addicts.
Those who ascribe to the self-medicating hypothesis believe, and
have research outcomes to show, that individuals tend to use specific
substances to self-medicate particular kinds of psychological suffering.
For instance, several researchers found that many of those who have
experienced trauma self-medicate with opiates. They use these pain-
killers to kill their own pain, and to manage the rage and aggression
that results from it.26 However, stimulants and cocaine have been used
to self-medicate depression, and, paradoxically, in “high energy” indi-
viduals with greater than normal need for excitement and euphoria, to
elicit an ongoing experience of the energizing effects that they crave.27
Finally, sedating drugs, including alcohol, have been found to be used by
individuals who have difficulty acknowledging emotions, feel psycho-
logically defensive and anxious, and tend to overrepress anger.28
Surely Moore’s use of meth seems amenable to this type of analysis.
She was working hard, overwhelmed, and worn out by the constant
demands of the environment in which she was working, and she tried to
handle everything alone: “It was an unspoken rule in most departments
that you don’t just go and talk about your problems. Instead, you fix
them by going out drinking with your buddies. I was drowning in my
depression, exhausted from lack of sleep, but I didn’t ask for help.”29 She
was exhausted and depressed, and the stimulant meth seemed to her
at first trial to be the answer to all her problems. Likewise, the famous
opium eater Thomas De Quincey found that in opium

was the secret of happiness, about which philosophers had disputed

for so many ages, at once discovered; happiness might now be bought
138 Addiction

for a penny, and carried in the waistcoat-pocket; portable ecstasies

might be had corked up in a pint-bottle; and peace of mind could be
sent down by the mail.30

And surely no one denies that use of alcohol can relax strongly repressed
emotions; indeed, the disinhibiting effect is what makes it such a central
feature at parties and other social events. One alcohol abuser, though,
put it in intellectual terms, of the sense of “rightness” and confidence
that accompanies use:

The thing that the non-addict needs to know is that there is a zone, for
the addict, equivalent to the zone of athletes, writers, artists ... where
you are ok. You don’t feel threatened by all the problems that you
know face you, and will face you later, with greater strength. You
can enjoy doing anything or nothing. You feel perfect. The fact that
there is a place like that never leaves an addict, like the feeling of
certainty, like the feeling of perfectly excited adrenaline for thrill-
seekers (funny that they’re called that, and not thrill addicts, even
though their yearning for adrenaline can kill them just as easily as
our yearning for the feeling that we want).31

In this case, the relief described as coming from alcohol use is experi-
enced as a truth, amounting to a certainty, in the face of all facts to the
contrary, that life will be ok. Again we have a case that seems amenable
to analysis by the self-medication approach. The kind of alleviation of
anxiety and production of confidence, as we have seen all too often on
the news, can have tremendously negative effects, from drunk-driving
accidents to dancing like a fool at the office party. This certainty, or
feeling of “rightness,” even in things purely intellectual, seems to be as
powerful as that brought about through seeing the proof of a theorem.
It is patently obvious that the feeling of certainty that what one is doing
is good and right is no indicator that it actually is good or right. In
fact, when the source of the feeling is a substance or behavior from
which one has often received short-term pleasure followed by long-term
pain, it is ironic that the impression of certainty can be a characteristic
experience.
The same kind of confident feeling of certainty can be brought about
by cocaine, however, and for Moore was brought about by meth. What is
more, many anxious people will not medicate themselves with alcohol,
no matter how uncomfortable they feel, because the threat of loss of
control presents an even greater source of anxiety. Further, even if it is
 Phenomenology and Its Implications 139

true that those who are prone to anxiety and emotion repression turn to
sedatives, we would need to ask why among that population some prefer
alcohol to the exclusion of any other sedating substance, while others
experience the converse, and some get the same measure of relief from
any number of substances. It seems that in light of the research, the
claims of the self-medicating thesis may be defensible in broad, general
terms, and indeed, some components of it are intuitively reasonable, but
given the range of experiences that individuals report with respect to
the substances they favor, the story must be far more complicated. Kyle
Keegan, for example, in his memoir, Chasing the High, thinks of himself
as an addict, plain and simple. He speaks of one dark evening on which
he had failed to secure the heroin he wanted: “instead of getting the fix I
had hoped for, I was offered a match-head of cocaine. Against my better
judgment, I accepted it and made my way to my roof. You see, though
I knew that cocaine without heroin would only make me feel sicker, I
was an addict, and therefore unable to turn down any drug.”32 The senti-
ment “I would take anything you put in front of me” is often echoed
in 12-step rooms. Like Nick, for example, one of the first patients we
encounter in The Realm of the Hungry Ghosts, it is common to hear that
“[t]he reason I do drugs is so I don’t feel the fucking feelings I feel when
I don’t do drugs. When I don’t feel the drugs in me I get depressed.”33
But Nick was both a heroin and a meth addict. If the self-medicating
hypothesis were accurate in its specifics, Nick ought to be seeking only
the meth. Perhaps, though, Nick was treating himself for both rage
and depression. He mentioned that his father had drilled into him as
he was growing up that he was useless, so he certainly had reason for
experiencing both. Likewise, Celia, whose baby was taken from her, was
addicted to both cocaine and heroin. In fact, many of Maté’s patients
would use anything they could get their hands on.
It is difficult to see, then, how this diverse collection of individuals can
be grouped, other than through the fact that they all suffered significant
pain and, due to living in Vancouver’s worst drug slum, all had ample
reason to want to feel differently. But that means that, like the other
theories we have considered, the self-medicating hypothesis on its own
cannot do much explanatory work. Not all those even in Downtown
Eastside were heroin users, despite their pain, although most in that
area were. Most were traumatized, neglected, and sometimes abandoned
as children, which is surely at least part of the explanation for their
urge to self-medicate, and for their strong responses when they did so.
But trauma has been associated with every kind of drug use, not just
that of heroin or alcohol. Further, many of these patients, according
140 Addiction

to Maté, had undiagnosed and/or untreated psychological problems.

But even within this restricted population, not all were addicted to the
same thing. What’s more, some of the people in the Vancouver Hotel,
although clearly suffering psychologically, were not addicted at all.

The transition out

There is a paradigmatic story about most elements of addiction,

including the transition out of it. While we have numerous examples as
well – particularly with respect to those patients whom Maté encounters
in Vancouver – of those who never escape the addictive cycle, research
show us that the majority do. In 12-step informed narratives, the story
often follows the shape of the swan dive, as described by Knapp. The
trajectory is of increased use over time, with increasingly bad conse-
quences: broken relationships, illnesses, financial and legal difficulties,
debauchery, and sometimes violence, to the point of some dramatic “rock
bottom.” Moore tells that kind of story, in which, after being rescued
from being held captive at a meth dealer’s house, her mother takes her
to a treatment facility. Flanagan says that at the end of his drinking days,
he was driving to the gas station every morning to secure enough beer
to get him through classes, after which he could obliterate himself with
vodka. The esteemed philosopher was “a wretched, worsening train
wreck of a person – a whirling dervish, contaminating, possibly ruining
the lives of my loved ones.”34 And then he turned to treatment. For
Knapp, the downward spiral hit bottom when she fell while carrying
two children who could have died from the fall, although even then it
took a couple of months and a career-ending blackout before she drove
herself to a rehab facility.
This is the kind of story that we hear again and again, and that the
treatment industry and self-help groups tout. But this is not the only
kind of transition out of addiction that happens. Sometimes, people just
decide to stop. In fact, according to a significant body of research, that
is actually the norm, as we saw in Chapter 1. In the case of Edie, for
instance, a cocaine user and dealer, it was her husband’s bizarre behavior
and sexual disability, but particularly the strain that his behavior put
on his relationship with their children that caused her to put a stop to
her drug use.35 For Henry, the unpleasant aftereffect of stuffy sinuses
attending his cocaine use together with his worry that his law career
might be at risk was enough. “As cocaine conflicted with people and
plans in which he was invested, Henry just stopped.”36 And Patty had
a much more difficult time quitting cigarettes than she did cocaine,
 Phenomenology and Its Implications 141

drinking brandy to help her to sleep (but not becoming addicted to it)
through the cigarette cessation, but not requiring anything to stop the
cocaine use.37
There are experiences at every possible place on the continuum of
difficulty in transitioning out of addiction, from the lightning bolt-
type of event that began Wilson’s move away from alcohol to those like
Henry’s, in which use just seemed to interfere with other things that
he wanted to do. In any case, it seems that the diversity of experiences
of transition out of addiction shows that we have no adequate theory
of it.

Conclusions

The very different experiences described by not just the self-identified

addicts mentioned in this chapter but also by the vast population who
for one reason or another include themselves under that umbrella, render
inevitable the conclusion that we do not as of yet have a workable theory
of addiction. Nor may we need one. For what we have seen is that no
single theory of addiction has the ability to explain all facets of the
phenomenon. Not even a single type of theory will be able to explain all
addictive experiences. Some of the accounts we have seen seem to call for
an explanation of the kind of background that sets up vulnerability to
addiction; some seem to give an explanation of how addiction progresses
with respect to behaviors, attitudes, and self-images; and some seem to
describe what the reward, or the pull, of addiction is like. An explanation,
of whatever kind, only makes sense against a particular contrast set. An
explanation can be judged as better or worse only relative to other theo-
ries attempting to answer the same question. The theories on offer in the
addiction literature seem to presuppose that there is only one question
to be answered, one phenomenon to be explained. Neuroscientific theo-
ries seem to think that they are getting at what is “really real” in addic-
tion. Responsibility/control theories focus on the question of whether
“real addicts” are responsible for their actions, and, by extension, what
the essence constituting addiction is. Others, such as the self-medication
theorists, investigate the suffering of the addict and suggest that cases
of addiction are actually cases of other disorders masked by attempts to
alleviate their symptoms. In this case, the theory makes the question of
addiction one that reduces to other psychological questions.
The fact is, there is no essence of addiction. If these phenomenolog-
ical explorations have shown us anything, it is that. Different theories
of addiction answer different questions, and speak to different issues
142 Addiction

associated with the phenomenon of addiction. That is not problematic.

In fact, it is just what is to be expected if the complex dynamics analysis
approach is right. The problems associated with the addictive syndrome
exist at a variety of levels, each of which has its own constraints and
descriptions, and its own responses to the question of what can be
done to improve an individual’s situation. Moreover, much of what
counts as problematic in addiction is subjective. When many people
consider themselves satisfied with their transition out of addiction,
and yet continue to smoke or to need their coffee, it seems clear that
what is a problem is what counts as a problem for the individual. Many
12-step groups disapprove of the use of any “mind-altering chemicals,”
and they insist that no one who continues to use them is truly “sober”
(or really “in recovery”). Others find that the use of such chemicals as
Suboxone or THC to control pain in opiate addicts, or the use of antide-
pressants or stimulants to treat psychological problems that may coexist
with or underlie the addiction, are essential tools for establishing and
maintaining “sobriety” or “recovery.” In the next chapter, we consider
the wide variety of approaches that might be used to transition out
of an undesirable addictive pattern and into a more satisfying and
valuable life.
8
Possibilities for Change

Addicts appear both to themselves and to others to be stuck in a partic-

ular pattern of action, and it must be admitted that getting out of such
a pattern is difficult. On many accounts, none of the well-known treat-
ments has a higher than “spontaneous remission” rate of transitioning
people out of addiction. That said, many people do make that change,
and new approaches to helping them are being tested every year.
Although some treatment programs self-report high rates of success in
helping individuals achieve desired behavior and improved quality of
life, and they even claim that it will work every time “for those who work
the program,” no such unconditional success has been demonstrated.
In fact, such claims are virtually meaningless, since they are essentially
untestable. Since any failure to sustain sobriety can be attributed to a
failure by the addict to “work” some aspect of the program, according to
the pervasive 12-step method of treatment, the claim that the program
succeeds in the vast number of cases in which the individual “works the
program” is self-affirming.1
In contrast to the optimism of 12-step proponents, the National
Institute on Drug Abuse’s (NIDA) finds that around 60% of those
treated for addiction experience relapse (these numbers are optimistic
compared to other studies). Whether and for how long a course of
treatment for addiction succeeds, according to NIDA, is determined by
numerous factors, such as the substance or activity involved, the length
of treatment participation, the motivation level of the addicted person,
and the amount of external support that is available to and accessed
by the addicted person.2 Given our analysis of addiction as an emer-
gent phenomenon arising from complex, self-organizing, and mutu-
ally interdependent causal systems operating on a variety of scales, this
variety of factors, as well as many others, would be expected to influence

143
144 Addiction

whether an individual can transition out of addiction. Addiction cannot

be reduced to any single pattern of neurotransmitter interaction, or
changes in brain structure or function. Nor can the “getting stuck,” even
lethally, in a thinking and behavior pattern, as happens in some cases, be
understood outside of the normal distribution curve that describes the
range of behavior in any aspect of a human population. Since no two
people are the same physiologically, psychologically, or socially, to think
that a one-size-fits-all program could be the answer to the suffering of all
addicts is shortsighted, as is the attribution of relapse to a “failure” on
the part of the addict.
None of this is to say, however, that addiction involves no identifi-
able general patterns, nor is it to suggest that there are no ways to make
inroads toward improving any one individual’s chances of achieving
lasting change. In fact, the implication is the opposite: there are many and
varied ways to disrupt the patterns that characterize addiction, and they
arise at as many levels as does the phenomenon itself. While prevention is
always easier than change of an established pattern, both approaches can
succeed, and both must be available. Although once an individual feels
stuck in what we call an additive pattern – and she will have to struggle
to some extent to get out of it (but even this happens on a very broad
continuum) – it may seem that she is helpless. However, any syndrome
that involves memory and habituation can be interfered with and redi-
rected, since the effective units of organization in the addictive pattern
are all dynamic. Interventions at the synaptic, neural, neural systems,
psychological, and local and global social levels can all be used to bring
about disruption of addictive patterns of thinking and behaving.

Manipulating neurotransmitters

As we have seen, an individual’s specific experiences alter the proba-

bility of the activation of specific neural networks. The more a particular
group of neurons has fired together, the higher the probability is that,
given the activation of a subset of its member neurons, a similar group
will be activated again. Above, we characterized the probability that
a given neural network will be activated in terms of attractor wells. A
group of neurons that has fired together in the past will be more likely
to fire together again when a subset of them is stimulated. Likewise, at
a higher level in the hierarchy we would speak of mental association,
wherein the more often a particular situation has been connected with
use or engagement in an addict’s preferred activity, the more likely she is
to “feel like using” or repeating the activity when she encounters those
 Possibilities for Change 145

familiar cues. And again, at the level of habitual behavior, the more
often one has followed a particular pattern of action, once that action is
activated, the greater the probability that that pattern of action will be
followed through to completion. But each of these is only a probabilistic
tendency, and the probability of each can be diminished.
For those who reject the medical model of addiction, the habitual
element looms large. From this perspective, addiction can be addressed
in the same way as any other undesirable habit: by doing something else
in place of the addictive activity. Going to meetings with like-minded
others at the time of day when thoughts stray to use has helped innu-
merable individuals. This is often at the end of the day. After the stresses
of a normal day of work, whether at school, at the office, at home, or on
a building site, many people are looking for relief. Addicts have uncon-
sciously developed a default setting that their brains will automatically
resort to for this purpose, and the sensitized pattern will be set off all the
more automatically, the more often they have used their preferred addic-
tive activity for coping. What’s more, the more their physiological and
psychological state has become used to relief from the day’s difficulties,
the greater the likelihood that the deep attractor well of their habituated
response will send them into that default pattern. Finding something
else that provides a significant reward, whether social support, medita-
tion, or a massage, to substitute for the addictive behavior can diminish
the likelihood of pursuing the undesired behavior.3
But addiction involves more than mere habituation. Most habits that
we engage in do not involve an increased sensitivity to the salience of
a particular thing. People generally tie their shoes automatically once
they have the strings in hand, directed by unconscious habit, with the
associated set of neural firing patterns involved later in that process
being set off by those occurring earlier in the process. This happens,
at the neural level, by the operation of a well-established attractor. But
the habituation involved in tying one’s shoe does not result in an urge
to tie one’s shoes every time one sees someone else doing so, nor does
tying one’s shoe once result in the urge to do it again and again, in
the same way that an addict’s imbibing a single dose of her substance
or engaging in a single instance of her activity of choice often results
in a “binge,” or at least in a strong desire for further use or continua-
tion of the activity. The addictive case is much more like the obsessive-
compulsive disorder case, a cyclical disorder in which a strong attractor
is developed to certain thoughts or emotions, which bring about
anxiety that leads to an urgent need to engage in particular behaviors.
Capitulation to that need only satisfies it for a brief while. When the
146 Addiction

thoughts or emotions inevitably return, so does the overwhelming need

to engage in the behavior. Addiction has the added feature, however,
that heightened neurological sensitivity to both the cues and the effects
associated with the preferred substance or activity sometimes persists
years beyond instances of previous use.
Given this increased biochemical sensitivity, perhaps it is important
to add to any attempts at habit shifts the option of changing the neural
activation patterns directly. It is possible, at the neural level, to inter-
rupt the circuits that seem to subserve the hallmark craving and seeking
associated with addiction. Opiate addicts are already receiving benefits
from Soboxone (buprenorphine and naloxone), a drug that occupies
opiate receptor sites. The result is that ingestion of opiates does not
result in the expected feelings. Campral (acamprosate) has been found
to be somewhat effective in promoting abstinence from alcohol.4 In two
different studies, Naltrexone has shown promise for treating alcohol
abuse. First, in 1992 Naltrexone was shown to be effective in reducing
opioid and alcoholic relapse frequency and reducing heavy drinking by
blocking stimulation of opioid receptors.5 Additionally, a 2006 National
Institute on Alcohol Abuse (NIAA) study showed that, in combination
with medical management, Naltrexone was the most highly effective
of nine different approaches for treating alcohol problems.6 It is widely
used in Europe, and has been approved for use in the United States since
1996, with a physician’s prescription. Chantix (varenicline tartrate) has
been shown to be more effective at supporting long-term abstinence
from smoking than bupropion hydrochloride (Wellbutrin SR or Zyban
SR), which is also used as an antismoking aid. Both these and other
pharmacoptherapeutic approaches have demonstrated some effective-
ness in interrupting the neural pathways involved in the cycle of addic-
tion to nicotine. Even anxiolytics (antianxiety drugs) such as clonodine,
diasepam, meprobomate, and others have been shown to have some
effectiveness as an aid in smoking cessation.7 Nicotine replacement,
provided through an array of delivery systems, has also been shown
somewhat effective in these efforts. Most recently, research into oxytocin
administration has proven very promising, at least in animal models.
This naturally occurring molecule, when present in sufficient amounts
in the brain, seems to block the specific receptor cites responsible for
alcohol’s ability to induce intoxication.8 Preclinical and clinical studies,
moreover, have shown that oxytocin might also minimize alcohol
consumption, craving, and even withdrawal symptoms, which are
more dangerous with respect to alcohol than any other substance. How
any of these substances will work for any given individual can only be
 Possibilities for Change 147

determined by trial, because, as we have seen, every organism is unique.

Nevertheless, the pharmaceutical approach is one tool in the box.
One problem with this approach, however, is that many of the treat-
ments available even now are not employed, because publicly funded
treatment facilities, and even private ones associated with 12-step
programs, discourage use of “any mind-altering chemicals,” including
those that exhibit excellent experimental results with respect to coun-
tering addictive responses. Soboxone, for instance, the safer and more
abuse-resistant successor to methadone as a treatment for opioid addic-
tions, has been used by thousands of addicts, often for many years, with
no relapses and no addictive behaviors observed in association with its
use. According to Mary Jeanne Kreek, pioneering researcher in the use
of methadone, the standard treatment, used in approximately 90% of
treatment facilities, continues to be abstinence, residential detention,
and immersion in 12-step practices, despite the fact that abstinence-
based treatment works in fewer than 10% of opiate addicts. 9 Dogma
and prejudice in this case effectively block the use of the most effec-
tive treatment available. To be fair, there is an argument that, when
used only in the short term, Soboxone fares no better than abstinence-
based treatment, and weaning former addicts off Soboxone is more diffi-
cult than weaning them from heroin. That argument raises a question:
since Soboxone seems to be capable of being administered for years
on end without ill effects to the body, why would anyone insist on
using Soboxone only as a short-term treatment, while lifelong insulin
use is expected for diabetics? In both of these cases, the drug can be
very dangerous to those who do not need it, but for those who do, it is
analogous to taking a daily vitamin, in terms of addictive effects, liver
damage, or other types of toxicity.
With any psychopharmacological approach, though, the devil is in
the side effects. As the low murmur of quickly stated warnings on the
commercials show, most of the drugs touted by researchers for their
ability to aid in diminishing cravings and addictive behaviors have their
own effects on the bodies and mental states of those taking them. It
would be impossible to show that any drug can do all and only what we
want it to do in the body, and, in fact, with respect to most drugs that act
on the brain, the mechanism of action is unknown. Drugs are substances
that, introduced into vastly complex systems served by our circulatory
systems, have effects wherever they are carried (throughout our whole
bodies, and affecting the psyches that emerge from them), and what
those effects might be we can only know after treating humans with
them. Even then, we cannot extrapolate from the effects that substances
148 Addiction

have had on some percentage of people included in trials to the effects

they will have on a particular person. This is not to say that some of
these drugs, or ones that might be developed in the future, might not
be extremely helpful for assisting some addicts with one level of their
problem. Soboxone is a good case in point. However, treatment at the
level of neurotransmitters and their receptors can never be the whole
answer. Claims such as those made in the National Center on Addiction
and Substance Abuse’s 2012 report, that “addiction is a disease” and
that physicians must “diagnose, treat, and manage addiction just as
they do all other diseases,” are just as wise and biased as are treatment
approaches that refuse to include pharmacology at all in the treatment
of addiction.10 Every drug has side effects, and each one can fail to be
effective. In the case of Soboxone, although it is safer than methadone,
it is still possible for those who do not have a high tolerance for opiates
to use it to purposefully become intoxicated, and it is possible to over-
dose and die from it. For other pharmacological treatments of every-
thing from smoking cessation to alcoholism, the story is the same.

Altering neurological systems

Even when there is not the problem of drug infusion throughout the body,
therapies targeting neurocircuitry alone cannot be the whole answer to
providing relief from addiction. In one extreme study involving four
very hard-core alcoholics, for instance, electrode implants were placed
directly into the basal ganglia for the explicit purpose of interrupting
the seeking, motivational circuit, and nothing else in the body. In this
case, as long as the electricity was flowing into the specific areas into
which the electrodes had been implanted, these four men’s cravings
disappeared, but as soon as the electricity was turned off, the cravings
returned to their previous levels, and so there was no extrapolation of
the experiment’s results in the lab to real-world conditions.11 The fact
is, though, that interrupting neural circuits simply will never be suffi-
cient alone to stop addictive patterns in highly complex organisms like
us. Even when Chinese surgeons ablated (burned away with electricity)
the cells in the “pleasure centers,” or nucleus accumbens areas in some
1,000 opiate-addicted patients, reminiscent of the 1950s practice of
frontal lobotomy in America, only 47% of the patients remained free
of opiates five years later, with 53% relapsing, a consequence no better
than chance.12 Unsurprisingly, large numbers of the Chinese patients
experienced side effects, including memory loss, loss of motivation, and
changes in personality.
 Possibilities for Change 149

If directly interrupting the brain’s craving response is in fact to be

of use in treating addiction, it would be better to try less catastrophi-
cally destructive ways than ablation of the nucleus accumbens. Versions
of transcranial magnetic stimulation have exhibited some promise in
this regard. In transcranial magnetic stimulation (TMS), a noninvasive
treatment, electrical coils are drawn across the outside of the cranium.
Repetitive TMS, and more recently and most promising, deep TMS – in
which the electrical current reaches further than the 2cm inside the
cranium than the previous types of TMS did, penetrating the emotional
centers beyond the cortex – have been discovered to be effective in
curbing cravings and lowering consumption of both tobacco and
alcohol. The probability that particular sensory cues will result in the
repetition of addictive behavior has been discovered to be diminished
through this process by what is thought to be increasing the function-
ality of the prefrontal cortex. Increased activity in this area is thought to
result in greater inhibitive ability. Even if these procedures are helpful,
however, and should be investigated enthusiastically, failing to recog-
nize that neural systems are dynamic systems integrated within an
organic hierarchy of such systems is bound to result in falling short in
the treatment of addiction.
What is more, strengthening the functionality of that “executive”
part of the brain can be done without drugs or surgery at all. Conscious
activities, such as training in various sorts of mindfulness practices, have
become very popular in both addiction treatment and many other types
of psychotherapy. While there are many types of mindfulness exercises,
and many kinds of meditation practices, let us consider as an example an
approach that involves both. Mindfulness meditation has been shown
to be effective in increasing the ability to avoid ego depletion, or the
exhaustion of executive control. Research indicates that this happens
by affecting different types of brain processing, or, on another level of
description, of mental processing. For instance, one study performed at
the Waisman Laboratory for Brain Imaging and Behavior, using Tibetan
Buddhist monks, showed that meditation in which attention is focused
on a particular object, as for instance the breath or a mantra, enhances
the ability to sustain attention even when one is not meditating.13 The
explanation for this is offered in terms of the “entrainment of neuronal
oscillations to sensory input rhythms.” In other words, the rhythmic
breathing or reciting of a mantra entrains the rhythms of neural firing
patterns. In accord with our complex dynamics analysis, in this case
“top-down” processing, or focusing mental energy, is shown to change
“lower-level” processing, in terms of brain structure and function. Since
150 Addiction

attention, as we have seen, is a finite resource, it costs to use it. It is

important, then, for those who want to change a particular behavior
pattern that they have attention available for that purpose. Focus medi-
tation has been shown to increase that resource, apparently by changing
the way in which the brain operates. Corroborating this hypothesis,
another group of researchers showed in a 2010 experiment that long-
term meditators have significantly greater cerebral blood flow in the
prefrontal cortex and the midbrain, among other locations.14 And yet
another study produced evidence that intensive meditation practice
makes attending to one object of focus easier (again reducing brain-re-
source allocation), so that greater resources remain available for dealing
with other issues.15 As discussed earlier, the ego depletion view of addic-
tive relapse suggests that people who try to control urges in one area for a
sustained period of time are more susceptible to giving in to temptation
elsewhere, to give up on difficult cognitive tasks sooner, and to display
less physical and intellectual fortitude. Attention and self-control are
expensive, resource-demanding activities, but these studies show that
both of these important resources can be strengthened – a claim that is
demonstrable at both the physical and mental levels.
Not only can humans train the brain through meditation but working
memory exercises as well have been shown to be correlated with dimin-
ished drinking activity in heavy drinkers. In one study, a group of
psychologists trained individuals whose behavior constituted hazardous
drinking, according to the Alcohol Use Disorders Identification Test, in
simple working memory exercises. For twenty-five sessions over at least
twenty-five days, these volunteers participated in working memory exer-
cises. Over the period of the study, not only did their working memories
improve but their drinking also diminished by as many as ten drinks per
week on average, and stayed at that level when tested a month later. The
effects of this training seemed to be greatest in those who also scored
high on an impulsiveness scale with respect to drinking behavior – in
other words, those who were not managing to inhibit urges. While
this is just one study, given its tendency to corroborate the findings of
the meditation researchers, it seems that, since the prefrontal cortex is
generally recognized to be responsible for decision-making, planning
complex behavior, and impulse control, anything that one might do to
increase prefrontal activity could be a useful asset in addressing addictive
patterns of thinking and behavior at the physical level. Since psycho-
logical experiences and behaviors emerge from this level, strengthening
its influence would seem to be a simple and cheap way to assist those
who wish to transition out of addiction to do so. Given the expense
 Possibilities for Change 151

and difficulty of administration that often attend other approaches to

assisting addicts, it would seem that these methods would be ideal for
widespread dissemination. Free yoga and meditation classes are already
available in public parks, churches, and other places where middle-class
individuals gather. Why not make these opportunities readily available
in halfway houses and homeless shelters as well? Without doubt, success
in this direction would require social acceptance of these opportuni-
ties in the communities into which they were introduced. That is to be
expected, and must be addressed. Understanding the rhythms and values
that emerge at higher levels of organization in the systems that we are
considering is essential to creating effective change at lower levels.

Natural systemic approaches

Even something as broadly systemic as exercise, whether aerobic or

resistance based, can increase an individual’s chances of transitioning
out of addiction. For one thing, exercise increases dopamine levels in
just the areas of the brain that are depleted of that neurotransmitter in
withdrawal. Not only that, but consistent exercise increases dopamine
storage in the brain, and stimulates the production of enzymes that
create dopamine receptors, which, as we have seen, are diminished with
the chronic overproduction that substances and activities associated
with addictions cause. As if that weren’t promise enough, consistent
exercise increases neurogenesis, the creation of new neurons, a process
that is halted in the addictive cycle. Brain derived neurotropic factor
(BDNF), a substance that helps existing neurons thrive and encourages
the growth and differentiation of new neurons, is also stimulated by
vigorous exercise.16 The brain is plastic, and it is precisely that plasticity
that allows for the changes that result in addictions, but it is that same
plasticity that allows for people to transition out of addiction and regain
feelings of control and well-being.
Appreciating the organic, integrated nature of our body/brains both
with respect to individuals and with respect to the larger environment
can provide additional tools for those seeking to transition out of addic-
tive behavior. Not only can actively working our bodies enhance our
overall health, and our ability to withstand the evocative cues that will
inevitably incline addicts toward their default behavior but so can merely
taking in experiences of nature. The power of our organic and essentially
embedded nature is highlighted in research that indicates the positive
influence that simply being around nature can have on our well-being.
One very large study (of 345,000 people), for instance, reported that
152 Addiction

those who live within one kilometer of a park or wooded area suffer
lower rates of depression and anxiety than those who face only concrete
every day. In areas with mostly concrete surroundings (10% green
space), about 2.6% of the population experienced anxiety disorders, and
3.2% dealt with depression, whereas only 1.8% of those living in areas
with abundant green space (90%) experienced anxiety, and 2.4% expe-
rienced depression.17 While these differences are small, and the specific
causes of the results unknown, numerous studies performed since then
support the findings, and anything that makes a difference in occur-
rence rates of these conditions is worth investigating further. Looking
for a single factor to explain the effect is probably wrongheaded. Human
organisms are more likely to flourish in the natural environments of
which we are a part, and that is for a complex set of reasons. The good
news is that even for those living in dense urban areas, there are ways to
take advantage of the positive effects that exposure to nature is shown
to have. Even if we don’t live amid trees and greenery, we can always
take a walk through a park, even if it requires some effort to get there,
and thereby enhance our exposure to both a healthful environment
and to exercise. Commenting on this research, Dr. Kathryn Kotrla of the
Texas A&M College of Medicine agreed with the approach of this book
that such research “highlights very clearly that our Western notion of
body-mind duality is entirely false. The study shows that we are a whole
organism, and when we get healthy that means our body and our mind
get healthy.”18 Where we start is not the issue; many places will do as
well as others. The point is that addiction is a human problem, but one
for which there are many potential opportunities for intervention, and
so much reason for hope.

Healing the trauma

As we saw in Chapter 3, the experience of trauma significantly increases

the likelihood of an individual’s becoming addicted. According
to the authors of the long-running ACES, who have studied over
17,000 subjects, “addiction overwhelmingly implies prior adverse life
experiences.”19 Among patients in substance abuse treatment, it is esti-
mated that 33%–59% of women and 12%–34% of men suffer PTSD.20
The standard of treatment for this disorder in the recent past has
been cognitive behavior therapy (CBT), in which patients are taught
to isolate and evaluate stressful thoughts. Next most popular is expo-
sure therapy, in which patients discuss the traumatizing events repeat-
edly in a safe environment until those events lose their emotional
 Possibilities for Change 153

power. Another, similar therapy involves eye movement desensitization

and reprocessing therapy (EMDR). In this final method, distractions are
employed to minimize emotional response while patients talk about
a traumatizing event, so that they can reassociate the memory with
diminished emotional reactivity. The idea is to capitalize on the fact
that memories are changed each time we experience them. If attention
is focused on vision while a patient brings up a traumatic memory, then
the affective response that typically attends that memory should be less-
ened. Often these therapies are provided in conjunction with antide-
pressants or anxiety medications, to help patients reprocess memories
with lowered affective association. The advice generally given in treating
traumatized addicts, though, has been to address the addictive behavior
first, and only then, after some period (often a year) of abstinence has
been achieved, should the PTSD be tackled. This approach has been less
than optimal, however, because as discussed in Chapter 3, PTSD symp-
toms themselves, such as hypervigilance and hyperreactivity are highly
predictive of addiction and relapse.
For this reason, some researchers have turned their focus to the func-
tioning of the autonomic nervous system. Lisa Najavits, for example,
observed in a 2013 interview that

[w]hen we were invited to China, Japan, India, and Africa to deal with
trauma there, I started to realize how much in Western psychology
we value thinking by figuring things out and how much other
cultures primarily emphasize self-regulation. For me and many of my
colleagues, going to those places has helped us discover ways of regu-
lating autonomic arousal by techniques like breathing, Qui gong,
drumming, or yoga. I have been surprised that something that is so
obvious to me is not central in our pursuit of effective treatments:
learning to regulate your autonomic arousal system is maybe the
single most important prerequisite to dealing with PTSD. Physiological
arousal needs to be calmed down before you can even access your
executive functioning and the rational part of the brain.21

Likewise, Saj Razvi and colleagues at the Love and Trauma Center in
Denver, Colorado, focus on treating trauma at the level of the autonomic
nervous system (ANS). In trauma, the sympathetic nervous system, the
activation portion of the ANS, is overcharged because, unlike in normal
emergencies, there is nothing that the organism can do to resolve the
situation (we can understand this particularly with respect to the kind
of complex, ongoing traumas that often affect people from childhood).
154 Addiction

In its turn, the deactivation portion of the ANS, the parasympathetic

nervous system, responds in an equally powerful way. As a result, with-
drawal, dissociation, lethargy, and other shut-down types of reactions
occur. Normally, when stressful experiences are just moderate, the
ANS system can return to its set point. When the stressful experience
amounts to trauma, however, and particularly in trauma that persists
for years, there is no opportunity for the ANS to return to a relaxed
state. Getting there would require going back through the high-level
activation, which is painful, frightening, and threatening. Therefore,
according to this model, people retain the stress from the trauma and
cope with it by moving around, attempting to physically distract them-
selves, or by mentally distracting themselves by reading, watching
television, trying to reframe in their minds what happened to them, or
becoming engaged in any number of other activities. The therapy in this
case operates by helping clients stop the natural impulse to abandon the
process of moving back through the high level of activation in order to
complete the stress response cycle and return to the natural resting level
of calm, alert integration with oneself and one’s body. By first building
resources for clients to rely on when they are most agitated, including
both intrapersonal grounding skills and a reliable interpersonal attach-
ment between the client and the therapist, the client can face the some-
what daunting task of recalibrating the ANS system, and integrate the
story of her trauma into her self-story in a productive way.
To maximize the speed and efficacy of this approach, called contain-
ment therapy, researchers have been studying what happens when
MDMA is added into therapy sessions. Supported by the Multidisciplinary
Association for Psychedelic Studies (MAPS), four Phase II studies are
currently ongoing in Israel, Canada, South Carolina, and Colorado.
Because of its effects on certain neurotransmitters and hormones,
MDMA has the effect of creating experiences of attachment and trust
toward oneself, others, and the world, of feelings of being valued and
loved, while producing a sense of intimacy with one’s own experience.
What might have taken several months to achieve without the MDMA
can be achieved in a single drug-accompanied session along with three
integrative sessions, and the studies completed so far have shown that
the results are lasting. In the South Carolina trial, patients using Zoloft
scored six points lower on the Clinicial-Administered PTSD Scale (CAPS)
scale (the generally used measure of intensity of PTSD) than did users
of a placebo; patients undergoing MDMA-assisted therapy by contrast
experienced a CAPS score drop of 30–70+ points. What is more, 83% of
the participants no longer met the criteria for PTSD even 3.8 years after
 Possibilities for Change 155

treatment. Additionally, CAPS scores dropped an average of ten addi-

tional points between a two-month follow-up and the 3.8 year follow-up
exams, indicating that healing begun in the MDMA session continued
to operate even after treatment had ended.
MAPS supports research into the use of other psychedelic drugs as
well, for healing trauma, mitigating anxiety, and treating addiction.
Phase II trials using psilocybin that recently concluded at both Johns
Hopkins University and New York University (NYU) achieved signifi-
cant success in alleviating anxiety about death in cancer patients. One
would imagine that these results would extrapolate to others with deep-
seated generalized anxiety, which, as we have seen, is strongly associated
with the onset of addictive behavior. Another Johns Hopkins group has
recently found that smokers using psilocybin as part of a smoking cessa-
tion treatment program fared substantially better at quitting compared
to those undergoing other behavioral and/or pharmacological therapies
in similar studies.22 Whereas the typical number of individuals who
manage to remain free of cigarettes six months after treatment with
other protocols generally is less than 35%, and often far less than that,
these researchers found that 80% of those in the psilocybin-assisted
program remained abstinent after six months. The distinctive thing
about hallucinogenic treatments is that, rather than attempting to
depress the sting of negative feelings by dulling them repeatedly, but
temporarily, treatments with hallucinogens seem instead to bring about
in just two or three sessions a fundamental shift that remains in effect
long after the treatment is over. Moreover, patients experienced very
positive side effects from these treatments. For example, 87% of the
patients in the Johns Hopkins studies rated at least one of their psilo-
cybin sessions among the ten most meaningful experiences of their
lives, and 73% counted at least one of their psilocybin sessions among
the five most spiritually significant experiences of their lives. The vast
majority also said that their personal well-being increased “very much”
as a result of their experience, and this lasted for a significant period
after treatment. The outcomes that illustrate most vividly the difference
between this kind of treatment and others, though, include that 73%
of participants in the Johns Hopkins study reported that the psilocybin
increased their belief in their ability to stop smoking, while 68% indi-
cated that they had experienced shifts in life priorities and values in
such a way that smoking just wasn’t as important anymore. Due to the
quite positive results in their early studies, both Johns Hopkins and NYU
are now preparing to move into much larger (400-participant) Phase III
studies.
156 Addiction

The connection to 12-step programs

The switch to a representation of self and world that values sobriety and
self-control over use and indulgence is a true revolution in the thinking
of the addict. As we saw in Chapter 5, it often comes like a gestalt shift
in the way in which one’s world is experienced, or, in another way of
putting it, a total shift in one’s conceptual state space. The experience of
this kind of shift seems in some ways totally inexplicable, and certainly
not subject to conscious control. Meanings systematically switch
together at once, some say “in a moment of clarity.” As in any revolu-
tion, this switch cannot be made to happen from within the system;
rather, such a shift requires stimulation from outside. Perhaps it is for
this reason that 12-step programs place such emphasis on “admitting
that our lives had become unmanageable,” and on “a decision to turn
our lives over to the care of God as we understood him,” because such
an overarching, revolutionary change to many seems to happen without
their input, as if by a miracle. This kind of revolutionary change is at the
very least mysterious, from our ordinary everyday perspective. But on
the present theory, it is the essence of natural. It is simply the result of
a far from equilibrium system’s being affected by a key input, as when a
pile of sand collapses at the addition of just one grain more. Rather than
being a function of magic or of the intervention of a supernatural God,
an overall addictive pattern is changed by changes made in the patterns
that create and sustain it. It may well be that one has been changed
through powers greater than oneself, but they are all natural powers of
one’s own body interacting with its physical and social environment.
As discussed above, research is showing that such a shift can be brought
about with significant reliability by hallucinogenic or magnetic treat-
ment, or by other indirect methods. But work on emotional reactivity,
impulse control, and managing responses to one’s motivation-reward
system within a social context can also be done by yet other means than
those so far mentioned.
An individual who identifies as an addict can improve her odds of
experiencing a revolution in her conceptual framework and thinking
and emotional patterns by taking an introspective approach, and
doing exactly the opposite of trying to seize control of her impulses.
In part, this is a familiar story to those who are aware of the 12-step
program’s “spiritual awakening” experience, which is promised to result
from going through the prescribed steps. Although the kind of funda-
mental shift that I am referring to may sometimes occur after taking
such steps, those particular steps are neither necessary nor sufficient for
 Possibilities for Change 157

achieving it. They are not necessary, because other kinds of self-reflec-
tive and socially supportive dynamics have been demonstrated to help
to evoke such a shift. Many people (although no research has been done
to determine the precise numbers) have experienced a shift in thinking
and feeling, and become happy abstainers through LifeRing Secular
Recovery, for example, and Smart Recovery – programs without steps
or a higher power. And working the steps is not sufficient for achieving
revolutionary change. Many who have wholeheartedly attempted to
work through such systems of steps have failed to achieve such a funda-
mental change in feeling and worldview. The more conservative thing
to say is that people who engage in self-revelatory and responsibility-
taking measures, along with taking perhaps many other conscious steps
involving such things as turning attention away from oneself, practicing
conscious gratitude, and helping others, have a higher statistical proba-
bility of entering into and sustaining periods of abstinence and freedom
from addictive symptoms, including cue-based cravings, and so forth.
Given the level of complexity involved in this kind of worldview
change, it won’t happen all at once, even if the gestalt-type switch that
begins a sober career is of a revolutionary character. The new worldview
is held tenuously at first, because holding it necessitates that one resist
“flipping” back to the other pattern, which has gained stability and
strength through untold numbers of repetitions. But the new perspec-
tive can be firmed up over time, with reinforcement and strengthening
coming in a variety of ways from a variety of sources. Rehabituating
one’s thinking, through giving and hearing testimony, speech acts
repeated over and over again about the actuality of change, is one of
the ways in which the newly established gestalt can be strengthened in
an individual. One of the most important things that 12-step programs
can do is help people believe that they can change. Repetitive story-
telling of how life was during the period in which use was paramount,
what happened, and how life is free from the cycle of abuse now can
rehabituate one’s thought patterns to ones that are more conducive to
a happy and peaceful life. Of course, this can happen in many different
types of support and other types of groups. There is nothing proprietary
about those who endorse 12-steps with regard to this function. Likewise,
interacting with people who model the behaviors and attitudes that one
seeks to emulate reinforces one’s own strength, much as parents do for
emotional children, by entraining the weaker, less confident person’s
patterns with those of the stronger, more habituated by success. In this
way, alternative automatic responses can be developed to counter diffi-
cult situations.
158 Addiction

The essential thing is that the addict comes to believe that ceasing
her addictive behavior is possible. Whether addicted or not, people are
moved by their beliefs. In fact, one way that philosophers sometimes
define belief is in terms of that upon which one is willing to act. We
may say that we believe all kinds of things, but if we aren’t willing to
act (“Of course, I trust you!”), that is a clear sign that we don’t actually
believe. This suggests that one way in which a person might become
motivated to abstain from a drug or other addictive activity is to become
firmly convinced that if she does indulge, she will certainly end up in
jail, or in a mental institution, or dead. This is oft-repeated rhetoric in
12-step rooms. Perhaps those who use it believe it. But if prison or insti-
tutionalization is not imminent for a person who nevertheless wants to
stop using a substance or engaging in an activity, those kinds of threats
will not be believed, and will have no power to help her, and they may
even hurt, by driving her away from what might be a very helpful belief,
that she would be better off if she were to stop. This brings up another
caveat regarding 12-step approaches to treating addiction: there is a clear
danger for those who attend meetings of these groups and try to take the
steps but do not manage to get out of the cycle of addictive behaviors.
The danger rests on the fact that “the program” is based on the self-
affirming mantra that it “works for those who work it.” In other words,
continuing in an addictive pattern subsequent to participating in such a
program means personal failure. And this is a failure that singles one out
as particularly hopeless, for, as the Big Book says, “Rarely have we seen
one fail who has thoroughly followed our path.” These programs and
the 90%+ of rehabilitation treatment programs that are based on them,
as has been mentioned, put the responsibility for transitioning out of
addiction squarely on the shoulders of the addict. If she fails to achieve
the goal that the vocal members around her have managed, there is a
clear danger that she will become even more mired in a negative cycle of
self-blame, addictive behavior, remorse, and hopelessness.

Deep psychology

As we have seen, the beliefs that affect motivation need not be true
and, more importantly, they need not even be conscious. The fact that
many, or even most, of our beliefs are not necessarily (or even prob-
ably) conscious has serious implications for addicts. For one thing, as we
know, nearly every addict has memories, accessible or forgotten, of the
substance of their addiction bringing about undeniable pleasure, peace,
satisfaction, or some mix of pleasurable sensations. Without such an
 Possibilities for Change 159

effect, it is hardly likely that anyone would continually return to the

use of something that ultimately brings with it serious negative conse-
quences (and if there are no negative consequences, then it is question-
able whether addiction is involved). Some enterprising addicts have even
gone to the effort of writing down their feelings while using, in order to
try to get an objective understanding of why they would continue to be
so compelled by something that they know in their sober moments to
be so damaging.23 What we find in these writings is sobering (the pun
is only partially intended). There is in the words of these addicts the
expression of genuine, heartfelt pleasure, relief, or satisfaction linked
with the substance of their choice. Those associations have been linked
in the writers’ brains, for better or for worse, and they will drive behavior
if left unattended. This is true regardless of “triggers” of which an addict
might be consciously aware, although sights, sounds, and smells asso-
ciated with these perhaps totally unconscious memories are certainly
important, as they will, if not countered, automatically activate the
anticipation cycle central to addiction.
So, how can addicts deal with unconscious processes? Fortunately,
there are ways, some of them encoded in the formulaic language of
12-step programs, and there are others having to do with rendering the
unconscious conscious. For instance, if the belief in a higher power is a
live option for her, an addict who believes can have a powerful ally in
managing the thoughts that lead to addictive behavior. She can “let go
and let God.” Rather than entertaining the provocative thoughts that
might incite them to action, addicts can focus attention on the higher
power, which necessarily shifts their thinking away from the thoughts of
use, since attention cannot truly be multifocused – perhaps long enough
for the sensitivity to those thoughts to pass. If one truly believes that one
has help, one does – just as a weight lifter often manages to lift a heavy
weight with the assistance of a spotter, even if the spotter only lightly
touches the weight. For those who cannot believe in such a power, there
are other options for reinforcing belief in their ability to change. As we
have seen, some hallucinations may have that effect. In more natural
ways, individuals can perhaps be convinced of their own brain’s power
to overcome itself, by reading scientific literature (or even books like this
one!) regarding the brain’s marvelous plasticity, the power to circum-
scribe the activities of the unconscious, the power of belief, or accounts
of meditative monks’ achievements, and so on. Skeptics can come by a
variety of ways to be “excited by nature” to develop beliefs that can aid
in their recovery. They just need something that is demonstrable, theo-
retically sensible, and replicable.
160 Addiction

More universally effective than these options is the “social method”

of developing beliefs – the practice of telling and hearing narratives that
play upon both the power of “making sense” that we crave, and the
power of the actual in bringing about belief in the possible. The testimo-
nies heard in AA, LifeRing, or other self- and mutual-help groups, serve
the purpose of instilling belief, for they provide undeniable evidence that
relief from the suffering of addiction does happen. No matter how hope-
less any newcomer might think his own case, when he hears repeatedly
the stories of people who had been as badly off or worse than he, and
yet became and stayed sober, he cannot but be buoyed in his belief that
his own transition out of addiction is possible. But this process of story-
telling carries an additional benefit – of rebuilding one’s own life through
narrative. As one talks through one’s own story of misery and confusion
with others, and is heard, one begins to make sense of one’s trauma and
begins to feel human again. Philosopher Susan Brison asks with regard
to surviving a life-changing trauma, “How does one go on with a shat-
tered self, with no guarantee of recovery, believing that one will always
stay tortured and never feel at home in the world?” The answer: “one
remakes oneself by finding meaning in a life of caring for and being
sustained by others.”24 Because those who have been addicted, like those
who have suffered other kinds of trauma, have often had their experi-
ence of everything, including their own identities, changed, the value of
reasserting themselves in the presence and with the assistance of others
cannot be overstated. Our memories are constructed over time, and they
change with time. In fact, they change each time we re-member them,
shining not with the emotional valance and significance that they origi-
nally had, but rather taking on the meaning valence appropriate at the
time of reconstitution.25 Through the sense-making process of telling
and retelling one’s life story, unbearable memories that may define a
given individual as one in whom transition out of addiction is impos-
sible, can become memories of events that were not person defining,
but instead memories of events that were necessary to bring one to the
present point of sobriety. In this way, not only do others’ life stories help
one entering into the transition out of addiction believe that she can do
it, but also her own story, the more she tells it and the more success she
sees in it, will become one that fosters the project of sobriety.
Of even further value of sharing narratives orally in groups is the
value of being heard. As we explored in the chapter on meaning,
discussions between addicts and their loved ones or treatment profes-
sionals are often exercises in noncommunication. And as we saw in the
chapter on the social sources of addiction, the alienated, the dislocated,
 Possibilities for Change 161

the disenfranchised often experience dehumanization as well. Being

“treated” for such an already difficult situation could exacerbate the
problem, were it not for the fact that treatment usually entails being
surrounded by others with similar problems and similar experiences.
Telling and retelling one’s story to others similarly situated enhances
the experience of being heard, an essential human need. Whether in a
program with steps or not, many experts agree that the social element
of support groups, whether for addiction, cancer survival, divorce, or
anything else, is a most effective factor in getting through difficult parts
of life. While the social world may contribute any number of causes to
the development and maintenance of addictions and other human ills,
interaction with particular other human beings seems to be one of the
most powerful tools available for dealing with them. Feeling included and
genuinely touched by other human beings is just as important for those
disentangling themselves from a cycle of misery and shame as it is for
babies trying to figure out the world for the first time. Communication
is difficult to achieve, but for those who have suffered the experience
of being “out of sync” with the rest of the world, it can be the key to
rediscovering, or discovering for the first time, how to live a meaningful
human life.

Reframing the social context

A sense of self-worth is essential to any program of self-improvement,

and in the case of addicts, that sense is often more than a little ragged.
This is why the “tough love” approach advocated so vocally in previous
decades by Al-Anon26 and other programs is so wrongheaded. In order
to transition out of addiction, particularly one that has taken a great toll
on the addict’s health, relationships, and/or professional life, the addict
must be reintegrated into the social systems from which she emerged and
of which she is a natural part. Even the toughest prison inmates have
shown the importance of such reintegration in overcoming personal
challenges. Sarah Huggins Scarbrough, a recent PhD from Virginia
Commonwealth University, showed the value of continuing support for
addressing addictive issues, violence mitigation, and recidivism. In her
three-and-a-half-year-long study, participants in a violent wing of the
Richmond City Jail showed that making a meaningful life can often
begin with taking responsibility for one’s actions and absolving oneself
of essential guilt. Using a peer-to-peer AA/NA-based treatment program,
along with significant postrelease services, the participants who were
studied had an 18% lower recidivism rate than did other inmates without
162 Addiction

such integration services. What is more, “[e]ven for those participants

who did recidivate, there was a significant increase in the amount of
time between release and re-incarceration.” The key to the success of
this program is twofold. First, it is a peer-to-peer program, which means
that the experiences shared by participants are heard by others who
have been in similar situations. Rather than being counseled by yet
more professionals who could not understand their feelings of aliena-
tion, resentment, anger, and “otherness,” these participants are met
by others who have been in similar situations. They can speak there of
things that cannot be understood elsewhere, and be part of a group with
a shared understanding, absolving them of alienating guilt. Addressing
other elements of their experience, the program studied by Scarbrough
includes, like all Anonymous programs, a spiritual/faith-based element
and, in addition, behavior modification practices aimed at helping
people deal with things such as “idle time, loneliness, abandonment,
dealing with fear, and/or not being comfortable with asking for help.”
The second key to the success of this program is its after-release compo-
nent, which includes transportation assistance; assistance in obtaining
important documents, such as birth certificates, social security cards, and
identification cards; and access to housing and employment services, all
elements necessary to successfully transitioning into a stable place in
society.27 With 6.9 million people incarcerated in 2011 (2.3 million in
the United States alone), and 80% of those addicted to alcohol or some
other drug, Scarbrough’s study deserves serious attention.
Another way to avoid the negative, self-reinforcing consequences of
incarcerating human beings for their addictive behaviors is to refuse to
incarcerate them to begin with, as has become the practice in Portugal,
the Czech Republic, and the Netherlands. In 2000, Portugal decriminal-
ized all drugs in a new approach to the “war on drugs.” As part of Law
30/2000, the usual substances are still illegal, but penalties for possessing
personal amounts of them are much the same as a parking violation.
Those caught with what amounts to ten days’ worth or less of any of the
normally criminalized drugs are required to interview with a “dissuasion
commission” office, which are lay panels located in unremarkable office
buildings, rather than in police stations. The recommendation in 2012
for 67% of those interviewed by these commissions was a “provisional
suspension,” which means that no consequences followed.28 Fourteen
percent of recommendations were for interviewees to undergo drug
treatment. These recommendations do not come without support. The
dissuasion commission’s task is to “evaluate the personal circumstances
of the individual” and refer them to an array of appropriate services,
 Possibilities for Change 163

of which there is a nationwide network.29 Significantly, the assistance

provided by Portugal includes employment subsidies, which make it
possible for individuals to provide dignified lives for themselves. The
result has been striking. In the mid-1990s, 100,000 of Portugal’s ten
million citizens were considered “severely drug addicted,” with a dispro-
portionally high number of them also HIV infected.30 Since 2001, there
have been significant reductions in new diagnoses of HIV and AIDS, and
the number of those who repeatedly use “hard” and intravenous drugs
has decreased by an impressive 50%.
Other approaches to undercutting the public health problems and
dehumanization of addicts have been tried elsewhere, including super-
vised drug consumption rooms, heroin-assistance treatment (pure
heroin, injected by medical professionals, for the deeply dependent
opiate user), drug courts, and supply-side regulation of cannabis. While
drug courts, unsurprisingly on the present analysis, have provided
no evidence of effectiveness, heroin-assisted treatment does seem to
improve retention in treatment of deeply entrenched opiate users, and
drug consumption rooms have improved health outcomes for drug
users and public nuisance problems associated with certain kinds of
drug use.31 The latter face legal battles, however, since they operate in
jurisdictions in which the drugs are illegal. The most famous of these,
Insite, in Vancouver, British Columbia, was closed in June 2014, with
the immediate result that streets and alleys became littered with needles
and other injection accoutrements. Importantly, though, the organiza-
tion that established Insite, the Vancouver Area Network of Drug Users
(VANDU), has continued to fight to reform public policy, to establish
dignified housing and health care for drug users, and to fight against
police brutality and inhumanity. It is in bringing these drug users back
into the community that VANDU has had the greatest impact and given
them the greatest chance to lead meaningful lives.

Tools in the kit

In any emotional/psychological phenomenon that humans experi-

ence, the questions concern complex dynamic systems interacting at
many levels, and unique individuals with unique lifetimes of experi-
ences. Attempting to use linear causal analysis to understand why some
people succeed in living the lives they want, while others continue to
be disappointed, is bound to result in frustration and demoralization
for those who fail. A more promising tactic is to approach overcoming
unwanted addictions in terms of increasing one’s statistical probabilities
164 Addiction

of avoiding falling into a well-established attractor well. Likewise, it

seems more helpful to frame addiction as a temporal problem rather
than as an essential one – a disease to which one is doomed for life.
While some number of addictions will resolve on their own (around
5%–8%), the most helpful attitude for the majority of the population is
to focus on increasing probabilities in one’s favor. Although we cannot
alter our DNA or remove the traumas of childhood, predictors of addic-
tion such as anxiety and hypersensitivity can be addressed through
medications, meditation, and talk therapy. Trauma can be addressed
through a variety of approaches, such as EMDR, cognitive-behavioral
therapy, and somatic therapies. The habitual element of addiction can
be addressed by changing any single habit, for success in this arena
breeds success. If someone begins to exercise regularly, for example, she
will have better success in managing her eating, and will create further
resources for control in the future. If she determines to attend a mutual
self-help group or join friends for coffee at around the time that she
would normally begin to drink or smoke cannabis, she will have better
success at managing those behaviors. If she begins a course of reflective
thinking or therapy to better understand her reactivity to stressful situ-
ations, she will be better prepared to deal with them. And if she reaches
out to other people and manages to find support, she will increase her
personal resources for self-comfort, just as an infant does by regularly
appealing to a reliable, comforting caregiver who helps her stabilize
and strengthen her own ability to self-soothe. At what may be the most
important level of human experience, if a person begins to speak and be
heard as a dignified voice within a human community, the resources of
that entire community may be brought to bear to stabilize and render
meaningful her life.
9
Conclusion

First question: are there “real addicts”?

Whether used as a tool for control and profit, a weapon for accusation, or
an excuse for inexcusable behavior, the appeal to addiction seems to be
ubiquitous. And yet, as we have seen, it can be applied to virtually anyone
given a particular context. Even in the most paradigmatic cases, it depends
upon a network of genetic, environmental, developmental, psychological,
and sociological factors. The concept “addiction” should be understood
not as a defined and settled phenomenon, the scope of which is delimited
by necessary and sufficient conditions, but instead as a prototype, a locus
within our conceptual state space. Close to that prototype are examples
like the individual who lives in an abandoned building, occupying all her
time and devoting all her resources to shooting up heroin. Further away,
but still within the scope of the concept, is the individual who drinks
coffee most days of the week, and is grumpy when he does not, or who
hasn’t had a drink in months, but continues to think of it daily. Surely
some generalizations can be made across cases; otherwise, there would be
no agreement that in most cases addiction is unwanted, and there would
be no support groups for escaping it. But we do notice that the support
groups are legion in variety, suggesting that many individuals who think
of themselves as addicted do not recognize their experiences as being
similar to those who are addicted to different substances or activities than
they are. Shoppers or gamblers may completely fail to understand how
alcohol or opiate addicts can use such dangerous chemicals, and the latter
two types of individuals may have no interest whatsoever in allures of
the casino or the shopping mall. It is simply not possible to get the kind
of definition that philosophers (and many others) want, and it is wrong-
headed to try.

165
166 Addiction

As Walter Sinnott-Armstrong says, if we are to answer the question of

whether addicts are responsible for their actions, “we need to specify what
is common to all real addicts that reduces or removes responsibility.”1
And that, he agrees, is just what we will not be able to do. What does
“real addicts” mean? Does it refer to those who lack control with respect
to use of some substance or tendency to some activity? We have seen the
range of problems with attending what “lack of control” can mean. How
far does lack of control have to go before an individual can be counted
as an addict, and what degree of lack of control are we talking about? As
we have said, almost anybody who could be characterized as an addict
has control in some ways and not in others, in some contexts and not in
others, and in varying degrees. This is true, though, of nearly everyone
with respect to something at some period in his or her life. In 2015, for
instance, a Pew Foundation study found that 73% of teenagers surveyed
reported having smartphones, with about a third of African American
and Hispanic teens declaring that they are online “almost constantly.”2
To high school teachers and instructors in introductory level college
classes, it appears that these teens are addicted to their phones. Even
when they agree to turn them off, and are penalized for using them,
these teens do not seem to be able to resist reaching for their phones.
Have we created/discovered a new addiction? Or should a new category
be created for such behaviors?
A simple, one-shot answer will not capture the phenomenon of addic-
tion. It is as unique in each individual who counts himself addicted as
is his psyche, and at each of the levels of analysis that we might wish to
make of it, and at any given time. What’s more, which level of specificity
counts as a basis for explaining other parts of the addicted person’s emer-
gent behavior largely depends on the kind of question we are asking. It is a
pragmatic question. On the view argued for here, there do not exist enti-
ties that are ultimately the basis of the entire system; rather, it is the inter-
actions that are primary. This, as we have seen, includes the individual’s
DNA as well as the environment in which replication and self-organiza-
tion of cells takes place, including the gestating mother’s stress, nutrition,
and exercise levels, and the larger environment with which the mother
is interacting, as well as the larger later environment within which the
individual develops, which she helps create. Whether a person becomes
an addict as a youth or an adult, even if she is born drug dependent, will
also then depend upon whether she suffers from attachment irregulari-
ties during postpartum development, and if so, when and how. It will
depend further upon whether she is exposed to trauma at an early age,
and if so, how that trauma is experienced within her personal world,
 Conclusion 167

and within the context of what cultural cues she has been sensitized to.
And all of this plays against the background of the world of meanings
into which she emerges as a self-conscious, reflective being with specific
sensitivities and expectations. The responsiveness of her caregivers, the
games her mother plays with her or the jokes she plays on her, the role
of cigarettes, alcohol, gambling, and other substances of abuse in her
environment, as well as age and brain development at the age of first
exposure to relevant substances or activities, all contribute to the likeli-
hood of her falling into addictive patterns, as does the safety of the entire
family within their cultural environment. This constellation of factors
together with a multitude of others influence an individual’s attitudes,
sensitivities, self-esteem, conception of the future and, in combination
with a multitude of other continually interacting elements, constitute
the complex dynamic that is the individual operating within her world.
The project of attempting to define “real addicts” in terms of one dogma
or another seems unhelpful, if not simply self-serving.

Second question: is there “addictive thinking?”

The factors listed above we have described as operating mostly outside

of consciousness, and in complex ways that defy any straightforward
causal analysis. That is why we can never know in advance who will
become addicted, or to what, or what that addiction will mean within
the context of that life. Just as little can we predict what might bring
about the revolutionary shift that marks the transition out of an addic-
tive pattern. Equally difficult is anticipating returns to use after some
period of abstinence, as those events are changes in the same complex
systems from which the addictive pattern emerged in the first place.
As one alcoholic put it when people asked him the standard questions
about his relapse – what had happened, what he had been feeling prior
to the relapse, where he had been, and so forth – he replied, “I haven’t
found the black box yet.” In-flight recording boxes often fail to solve
mysteries surrounding even such mechanistic events as airplane crashes.
It is hardly likely, then, that a person relapsing into an addictive pattern
will be able to point to the cause of that return to use. We can say in
terms of neural activity that a person’s total state on the verge of crisis
falls into an old and deep attractor well. That answers the “what” kind
of question. We seek the answer, however, to the “why” question. What
we find at the psychological level is a set of circumstances and an at
least partially confabulated story. What is most likely to be given as a
response to such questions, even by the most honest and reflective of
168 Addiction

addicts, is similar to what most of us will respond when asked to reflect

on why we did something: we give a “typical” story, one that fits with
the physical, social, and moral expectations of those around us. People
give the explanations that they would expect themselves to give. These
explanations provide a postevent sense-making narrative, based on some
handily remembered facts, not an insight into what actually motivated
people in a particular case. This is a common phenomenon, illustrated
with studies involving everything from people’s positions on conser-
vation issues to individuals’ elaborations of their choices of jam and
tea, to descriptions of why particular faces were seen as more attractive
relative to others.3 In some of these studies, people often provided full
explanations for why they preferred one or another of some proffered
option, when in fact the one about which they explained their reasons
for preferring wasn’t even the one they had originally chosen.
The kinds of filling in, justifying, and apparently giving a false
reason, like many of the other quirks that we’ve found to plague (and
assist) human thinking, does not apply to addicts alone. These patterns
of thought operate within and as a result of the evolution of human
minds within our environment. It’s not really fair, then, for families and
friends of addicts, or fellow addicts, or even addicted people themselves,
to demand after a slip, “Why did you do it?” There is no one story to
be told. The story that we experience of our lives, as addicts or not, is
ambiguous, because it is sketchy; we are privy to only a tiny amount of
the processing that actually goes on within the organism that we are,
and all of that processing is always constrained by and constrains the
processing going on in the environment of which we are also a part. It
is no wonder that there is significant space remaining for “filling in” or
“interpretation.” Philosopher Daniel Dennett says in this regard that
there is no penultimate draft of our story (or of the self that is the subject
of so much of our story).4 On one occasion, or before one audience,
who attracts our attention to a previously expressed aspect of our typical
behavior, we might give one explanation, and on another occasion, in a
different context, we might offer quite different reasons for our choices.
And no one of them is definitive.
This is just one example of what is often labeled “addictive thinking,”
which is actually a case of universal human cognitive biases being
employed in particular contexts, either connected with regular abuse of
a substance or activity or with the desire to indulge when it is to one’s
detriment, or with use against someone else’s desire to the contrary.
Here’s another one: denial. A main theme in 12-step based treatment
is that the addict is in denial of his addiction. In fact, denial seems to
 Conclusion 169

be appealed to regularly in literature associated with this approach as

the very essence of addiction: “addiction is a disease of denial” is a
familiar slogan. What exactly does this mean? Typically, it means that
the addict, while recognizing that certain unhappy consequences have
followed from his continued use or abuse, refuses to attribute those
consequences to his substance or activity of choice, but rather attributes
those consequences to something else. He finds other, particular events
or circumstances to explain the negative consequences that he has expe-
rienced, rather than chalk them up to the drug or activity. She may
deny that there is a problem with the use in general, even if she says
publicly that she recognizes there is a problem. This appears to simply
be a case of conservatism bias, wherein people, whether addicted or
not, demur from revising their beliefs even when presented with new
evidence to the contrary. It blinded NASA with respect to problems with
the Challenger launch. Conservatism bias is a pervasive bias, found in
all dogmatists, and characterizes attitudes of both optimism and pessi-
mism, but it seems to take on special meaning in the case of addiction.
In this circumstance, the common conservatism bias becomes a recog-
nized symptom of a disease.
Another way to think of the denial that is supposed to be a hallmark
of addiction is in terms of cognitive dissonance. We are uncomfortable
when our attitudes, beliefs, or behaviors are dissonant with one another.
We will believe whatever it takes to make a consistent story, keeping the
components that have the highest value for us and adjusting others.
When people experience dissonance between their beliefs and their
behaviors, or between sets of beliefs, or between beliefs and values, they
try to lessen the dissonance by changing one or more of the attitudes,
behaviors, or beliefs – or by securing new evidence that supports the
favored beliefs. This is simple enough to do, applying another well-
documented trick of our brains, confirmation bias, which results in our
finding cases that fit the system of beliefs that we most wish to preserve.
In short, we see the evidence that supports our preferred view, while
ignoring evidence contrary to it. Employing this naturally occurring
bias, we dismiss, or reduce the importance of, the beliefs or attitudes
that conflict with a favored or habitual behavior. This bias is so well
recognized that experimental science has made it standard practice to
ferret out where it might be operating, and put obstacles in the way of
its operation. This is the impetus behind experimental protocols such as
double-blind studies. But in the context of suspected addictive patterns,
it becomes recognized as “addictive thinking.”
170 Addiction

Also often characterized as “addictive thinking” is the “better than

average effect,” a bias that allows most people to take themselves to be
better than average at everything from driving cars to making moral deci-
sions to resisting seeing themselves as better than average. This effect is
quite obvious with respect to parents’ characterization of their children,
and is not generally seen in a bad light in this context. Likewise, this
phenomenon is hardly ever mentioned as a defect when it is observed
in the student applying for medical school against stiff competition.
Much less is it seen as defective in the soldier who stands with his group
against a much larger force. In this case, believing that one is better
than average is what makes it possible to summon the courage necessary
in such situations. In fact, Ryan McKay and Dennett have even argued
that this particular misbelief, or positive illusion is, if any misbelief is,
actually adaptive in evolutionary terms.5 In the case of those who have
been labeled as addicts, however, individuals who exhibit this bias are
judged to “have a case of terminal uniqueness,” an attitude that must
be rectified if the individual is to overcome his addiction. Two ironies
regarding this labeling are worth mentioning. The first is tragic: those
who are struggling to overcome addiction but become convinced that
they are not better than, or different from, the average and additionally
believe that only those with special qualities can actually change may
give up on their efforts to live better lives. The second irony associated
with calling out the “better than average bias” as addictive thinking is
that those who point the finger are engaging in another cognitive bias:
essentialism. Under the essentialism bias, alcoholism (or drug addic-
tion) is an essential property of certain people, and there is no way to
ever escape that characterization once it has been applied. As this view
says, “once an alcoholic, always an alcoholic.” For many involved in
12-step programs, the essentialism bias is a safety feature. If it were ever
recognized that many people just stop being addicted, there would be
no need for the dependence on “the program” that is accepted by devo-
tees, a situation that would present too great a threat for many who
thrive on community strength. In any case, with respect to the cognitive
biases themselves, they are widely recognized by researchers in people
of all sorts; they are not indicative of any particularly addictive types of
thinking.
Attentional bias seems to be the culprit in another kind of “addic-
tive thinking”: addictive patterns of thinking, as is generally recognized,
result in heightened attention being paid to those emotions, objects,
and events that connect to the locus of their most frequently recurring
thoughts. Again, this effect is recognized in psychological literature as a
 Conclusion 171

cognitive bias and not as an addictive mental pattern, for it is merely one
of the characteristics of human thought. This particular bias has been
vividly shown in hundreds of studies, including the famous “Invisible
Gorilla” demonstration, to characterize a fundamental feature of the
way human attention operates. When we are focused on one thing,
for example, players in white shirts passing a basketball, we can fail to
notice the most obvious of things also on the scene, such as a person in
a gorilla suit walking right through the scene, stopping to beat its chest
before walking off. Once again, though, when someone has been labeled
an addict, both the term used to express the bias (now “triggers”) and
the strength of its effect (to bring about virtually automatic behaviors)
are understood differently. Those who have stopped their unwanted
behavior while attending self-help meetings, particularly 12-step meet-
ings, with their particular structured type of sharing (recounting “what
it was like, what happened, what it’s like now”), exhibit a different kind
of attentional bias. Particularly in the “pink cloud” that many say char-
acterizes their first few months of sobriety, but also in the stories of those
who have been abstinent for numbers of years, the negative attendants
of their addictive behavior, as well as the positive events and feelings
accompanying abstinence, loom large. Of course, if the suffering was
great, and directly associated with the addictive behavior, then the relief
attending cessation would in fact be great. But those very same events
might well have been seen as “not that bad,” say, prior to an interven-
tion or hospitalization. Which characterization works is a function of
whether an individual’s focus is on the prospect of using again or on
the goal of abstinence. Countless details will escape her awareness in
either situation, but which details escape and which are attended to
have everything to do with what is uppermost in her mind.
This sort of directed attention operates in combination with hindsight
bias, conservatism bias, and the urge to resolve cognitive dissonance,
in all of us. Whether or not one has ever had an experience one would
label “addictive,” human cognition is biased toward telling a story that is
consistent over time, both with respect to expectations and in hindsight.
Neither any of these kinds of biased thinking nor any of the dozens of
others discovered to operate in ordinary healthy human beings is in any
way distinctive of addiction in particular, despite the collective wisdom
of certain circles to the contrary. The designation “addictive thinking”
is more groundless than the label “addict,” and yet these terms in
common parlance are unquestionably taken to embody something real.
This very language promotes particular ways of addressing a continuum
of human problems that are both dismissive of the differences among
172 Addiction

those who have these problems and the similarities between those who
are called addicts and those who are not. Far more helpful for dealing
with real problems in the real world is to understand the diversity to
which complex systems give rise and to deal with the individuals and
the social systems creating them and arising from them in terms of what
they really are.

The complexity of motivation

The conclusion to be drawn from all this discussion of complexity, levels

of analysis, social constructs, and universal psychological biases cannot
be that there is no such thing as addiction. No one can doubt that many
people ruin their health, their relationships, and their professional lives
through the use of substances and activities. And it would be foolish to
deny that many of these individuals sometimes seem to have no control
over their behavior, or at least feel like they have no ability to control it,
or have no motivation to control it. In any case, the task is not to play
with definitions. In many areas of science and social life, groups of people
make decisions and policies, and research careers go forward without the
field’s ever coming to consensus about definitions. The task in our case is
to discover why it is so difficult to resolve a certain family of human prob-
lems. Such resolution can occur, even within complex systems in which
the parts are always changing, adapting to the behavior of other parts,
creating new constraints within and for the ever-changing and adapting
new whole. For one thing, we can assume that none of the higher levels
of analysis can contradict lower levels: organisms cannot defy the laws of
physics in the operation of cells, any more than the social systems that
constrain the development of healthy or traumatized children can defy
the laws, whatever they are, that describe the operations of individual
psychology. Although systems “on the edge of chaos” like the weather
and the human psyche are not predictable for more than a short time into
the future, that fact does not imply that they are not deterministic. Causal
principles still operate. For another thing, we know that characteristic of
all complex adaptive systems is the existence of certain lever points, at
which small changes in inputs produce significant and directed changes
throughout the whole system.6 This means that seemingly paradoxical
revolutionary changes, such as a brain “stuck” in an addictive pattern
transitioning itself out of that pattern, are not only possible but also in
some cases and in some sense can be easy.
Addictive patterns seem particularly unstable in the sense that they
arise and can only be sustained by continued indulgence. What is more,
 Conclusion 173

as they progress, and motivations to continue become crowded by moti-

vations to change, they become even less stable. Particularly for those
who have established other patterns in the past (we can think of this
equally well in terms of neural firing patterns and their attractor wells,
or of habits, or of psychological patterns), any number of things might
prove to be the lever point that might make the whole addictive pattern
collapse. For instance, a DUI experience might be the trigger, or a fall
that results in broken bones. One person I met suffered an acute case of
pancreatitis that resulted in a five-day medically induced coma. From
then on, the desire to drink was nonexistent. From the positive side,
something like a new job opportunity, a child, or a new love might prove
the critical input. Even a change in habit, apparently in no way associ-
ated with the addiction, such as beginning a routine of evening walks or
making the bed every morning, can trigger positive changes that then
serve as lever points somewhere else until the person experiencing these
little changes makes large life changes, ultimately including cessation of
the addictive pattern. Simple abstinence itself can create a tipping point
in some cases. This may be the reason why the few people who make
a permanent change following a residential treatment program do so.
“Breathing space” alone may make the difference. What is it about these
events that can overcome years of overeating, or smoking, or general
indolence? Within the context of a particular complex dynamic system,
they serve as the grain of sand that hits just as the pile is in a critical
state, resulting in a slide. For a different person, or for the same person
on another day, or for the same person with an even slightly different
biochemistry, that event may not have precipitated a change. Chapter 7
outlined a number of points wherein changes in input at one level of
the system can cause disproportionately large changes in the whole. The
question is one of probabilities.
This brings up another concept that is woven through addiction
recovery discourse and operates as a point of contention among various
groups: hitting bottom. The paradigm of an addictive career, as told in
12-step rooms, memoirs, and the AA’s Big Book, is that a person begins
to use or do something that is pleasurable, it becomes too much, bad
things happen, and then the person finally “hits bottom” and recovery
begins. Without this hitting bottom, forward progress cannot begin.
The explanation often given when a person relapses into her addictive
pattern of behaviors is that she had not yet hit bottom. Some groups,
such as Rational Recovery and LifeRing Secular Recovery, however,
maintain that hitting bottom is not necessary, that people merely need
to get to a perspective from which they can see that they need to change
174 Addiction

something. Twelve-step endorsers will usually reply that people like this
are among the lucky few who only need to hit a “high bottom” in order
to be motivated to change. These are probably two ways of saying the
same thing. The important observation is that at some stage something
will happen, and nobody can know in advance what that thing will
be, which will operate as a lever point, triggering huge changes in the
person’s whole way of seeing things. That doesn’t mean that a different
life occurs instantaneously, but it does mean that a critical juncture has
been surpassed and that large portions of what had been a stable pattern
collapse, creating a move into a different one.
The jurisprudence system seems to think that negative reinforce-
ment can motivate people to stop at least certain addictive behaviors.
Gambling or shopping in ways that involve unagreed-upon losses of
others’ money, taking certain drugs, or at least possessing them, and
drinking after a DUI are met with still harsher penalties and sometimes
incarceration. In recent years, university campuses have experienced
rising numbers of their student populations wearing ankle monitors in
order to stop the latter. The problem with this attempt at controlling
people’s behavior is that it depends upon an economic, rather than a
psychological, understanding of motivation. And the presumptions of
that particular model of human behavior have proven so faulty that
even the field of economics has largely discarded them, while the field of
behavioral economics, which focuses on how humans actually behave,
given our implicit biases, has burgeoned. Rewards have been shown to
be more effective than punishments as motivations, as any dog owner
who has been to a training class knows. But even rewards are not always
effective, and sometimes can undermine the goal. Although we have
seen that in some cases drug users can effectively alter their behavior for
financial rewards, in the long run rewards may rob them of their sense
of autonomy and their confidence in their ability to act for intrinsic
reasons.7
In any case, it seems that the factors that enter into an addicted indi-
vidual’s ability to change are legion. Short of defining “hitting bottom”
as whatever it is that happens just prior to an individual’s transitioning
out of an addictive behavior pattern, it seems that crashing to earth
in some traumatic way is neither necessary nor sufficient to achieve
change. On the one hand, many people make a change, as we have
said, on the basis of a simple dissatisfaction with the overall feel of their
lives, while on the other, thousands and even millions of people have
experienced horrific consequences in connection with their use and
have persisted nonetheless. In complex adaptive systems that have the
 Conclusion 175

ability to create (and perhaps the inability to refrain from creating) a

narrative around big life changes, sometimes framing those changes in
terms of traumatic crashes might be helpful, and if so, then it should be
fostered. The 12-step model and its linguistic conventions do help many
people. But for some of those seeking a change, being exposed to the
prototypical “bottoming out” as a necessary part of the process might
be enough to frighten them away from accepting the value of making a
change at all.

Probability is key

Because addiction is a phenomenon that emerges from a complex

dynamic system, as we have said, those who wish to effect change in their
lives have to play the odds. If there is no “silver bullet,” and if instead
addiction is understood as a relatively unstable pattern approaching a
critical state, no one can predict what will be the tipping point for the
addict. As the guiding thinking behind the LifeRing Secular Recovery
program suggests, a person’s best bet for creating permanent change is
to create a “tool box” with as many resources in it as possible. Rather
than offering a set program, this support group advocates that individ-
uals create their own paths to change by reflecting on themselves, what
has motivated or stressed them in the past, and finding new ways to
support positive life changes. In one’s “tool box” might be drugs such
as Suboxone, Naltrexone, or Campril, meditation, massage, yoga, nutri-
tion improvement, journaling, talk therapy, psychiatric treatment for
underlying anxiety, depression, bipolar, or other disorders, or any of the
other variety of things that we considered in Chapter 7, as well many
other approaches not considered there. If prescribed steps, or Reiki, or
praying to Thor seems to help, then any of them can be included in
the tool box, because belief, too, is a causal factor in complex dynamic
systems, in which “top-down” causation is as real as the “bottom-up”
type. For those who are more scientifically minded, only evidence-
supported approaches will work. For the more mystical minded, though,
amulets and crystals are not out of the question. The point is to stack the
odds in favor of a particular attractor well, a slide of the sand pile to the
desired side. “Stack the odds in favor of slippage toward sobriety,” some
formerly addicted people often advise. In addition, encouragement to
try, and try again, without shame or guilt is important, because one
never knows which attempt will be successful, until one of them is, and
even if a person falls back into addictive patterns at some point, every
quality day lived counts.
176 Addiction

An indirect approach might prove the most valuable of all for

bringing about life changes. This may in fact be the point of the “spir-
itual awakening” of the 12-step model. Many 12-step group members
will tell newcomers to work not on the drinking or the drugs, but on
other aspects of their lives, such as resentments, character defects, and
correcting wrongs that they might have done. Do this, they say, and the
addiction will take care of itself. The book central to LifeRing Secular
Recovery, if there is one, Empowering Your Sober Self, employs an indi-
rect approach as well, focusing on strengthening the aspects of the
“sober self” that has always been functional and good, so that it over-
powers the “addicted self” that has more recently arisen. For complex
systems, in which causation is nonlinear, the intuitions behind these
approaches make good sense. Focusing on health, family, and enjoy-
able work and play activities, as well as on underlying psychological
distress and potential goals (not to mention all of us working together
to change the social circumstances that foster addiction) might well be
more helpful in overcoming addiction than dwelling on the addiction
itself. Attention to these other points will certainly be more useful than
isolating the suffering person with an “intervention” in which she is
held directly and individually responsible for the “disease” that she is
accused of having.
If we think and act in different ways, we can effect changes in the
oscillation patterns of groups of neurons, and in the ways that various
parts of the brain link up. If causation were to operate in the simplistic
way that most of us persist in expecting, this would seem to be peculiar
to say the very least. But given the reality of mutual and complex causal
interactions in systems like us, nothing magical is required to explain
the fact that focusing our minds in certain ways, in yoga or meditation,
for instance, or experiencing strong emotions, as happens when we fall
in love or take on a new and valued project, can and does change the
ways that our brains operate. This shouldn’t be surprising, even in the
long term, since the mind whose focus changes the brain emerges from
the same brain that is changed. The brain itself changes the brain in
meditation, in developing new projects, and in moving past addictive
patterns. Situating our study of addiction in a context that takes seri-
ously the complexities of human beings and the societies that we create
and live in provides many more opportunities for discovering effective
ways to prevent or intervene in addictive cycles. Some may say that this
approach only makes studying addiction unwieldy, creating more prob-
lems than it solves. But in some cases it is better to address real problems
 Conclusion 177

with all their difficulties than it is to create models of them that are
easier to manage, but that don’t translate into real-world answers. In
our case, given our generation’s endemic addictive problems, perhaps
it is worth the trouble to take on the harder problems that address our
actual lived situation.
Notes

1 Introduction – Dismantling the Catch Phrase

1. American Psychiatric Association Committee on Nomenclature and Statistics,
Diagnostic and Statistical Manual of Mental Disorders 4th ed. (Washington, DC:
American Psychiatric Association, 1994).
2. Gene M. Heyman, “Addiction and Choice: Theory and New Data,” Frontiers in
Psychiatry (May 6, 2013) doi: 10.3389/fpsyt.2013.00031. Here Heyman cites A.
I. Leshner, “Science-based Views of Drug Addiction and Its Treatment,” Journal
of the American Medical Association (282), pp. 131413–16; A. T. McLellan,
D. C. Lewis, C. P. O’Brien, and H. D. Kleber, “Drug Dependence: A Chronic
Medical Illness: Implications for Treatment, Insurance, and Outcomes
Evaluation, Journal of the American Medical Association (284), pp. 1689–1695;
and N. D. Voldow and T. K. Li, “Drug Addiction: The Neurobiology of Behavior
Gone Awry,” National Review of Neuroscience (5), pp. 963–970.
3. Approximately 500,000 people held in US prisons or jails have been convicted
of a drug offense, according to the Justice Policy Institute’s “Substance Abuse
Treatment and Public Safety,” (Washington, DC: January 2008), p. 1.
4. For various statements of this view, see Stephen Stitch, From Folk Psychology
to Cognitive Science: The Case against Belief (Cambridge, MA: MIT Press, 1983);
Patricia Churchland, Neurophilosophy: Toward a Unified Science of the Mind-Brain
(Cambridge, MA: MIT Press, 1986); Paul Churchland, The Engine of Reason,
The Seat of the Soul: A Philosophical Journey into the Brain (Cambridge MA: MIT
Press, 1995); and Daniel Dennett, Consciousness Explained (New York: Little,
Brown, 1991), among other works by these authors and others.
5. Terrence Deacon, Incomplete Nature: How Mind Emerged from Matter (New York:
W. W. Norton, 2012, p. 179.

2 Some Philosophical Questions (and a New Theory)

1. American Psychiatric Association Committee on Nomenclature and Statistics,
Diagnostic and Statistical Manual of Mental Disorders (Washington, DC:
American Psychiatric Association, 1994). Although the revised 4th edition
(IV-TR) is currently the most cited, some references will be herein made to the
5th edition.
2. World Health Organization, The ICD-10 Classification of Mental and Behavioral
Disorders: Diagnostic Criteria for Research (Geneva: World Health Organization,
1993).
3. See, for example, Time, April 30, 1990, http://content.time.com/time/maga-
zine/article/0,9171,969965,00.html
4. K. S. Kendler, I. M. Karkowski, M. C. Neale, and C. A. Prescott, “Illicit
Psychoactive Substance Use, Heavy Use, Abuse, and Dependence in a U. S.
Population-Based Sample of Male Twins,” Archives of General Psychiatry

178
 Notes 179

57 (2000): 261–269; K. S. Kendler and C. A Presscott, “Cannabis Use, Abuse,

and Dependence in a Population-Based Sample of Female Twins,” American
Journal of Psychiatry 155 (1998): 1016–1022; C. R. Cloninger, “Neurogenetic
Adaptative Mechanisms in Alcoholism,” Science 236 (1987): 410–416.
5. Until the summer of 2014, that is, when the DSM-V was published, with
much attendant controversy.
6. One might try to say that people are addicted, for instance, when they have
“addictive personalities”; or when they feel that they can’t control them-
selves, although they are at the same time just the selves that they can’t
control; or when they suffer from a “spiritual sickness.”
7. I. Marks, “Behavioral (non-chemical) Addictions,” British Journal of Addictions
85 (1990): 1389–1394.
8. Constance Holden, “Gambling as Addiction,” Science 21 307, no. 5708 (2005):
349, doi:10.1126/science.307.5708.349d; A. Blaszcznynski et al. “Withdrawal
and Tolerance Phenomenon in Problem Gambling,” International Gambling
Studies 8, no. 2 (2008): 179–192; H. Rachlin, “Why Do People Gamble and
Keep Gambling Despite Heavy Losses?” Psychological Science 1, no. 15 (1990):
294–297.
9. A. N. Gearhardt et al., “Neural Correlates of Food Addiction,” Archives of
General Psychiatry 68 (2011): 808–816.
10. Matilda Hellman et al., “Is There Such a Thing as Online Video Game
Addiction? Across-Disciplinary Review,” Addiction Research and Theory Early
Online: 1–11 doi:10.3109/16066359.2012.693222.
11. APA (February 2010) News Release “DSM-5 Proposed Revisions Include New
Category of Addiction and Related Disorders. New Category of Behavioral
Addictions Also Proposed” (Release No. 10–08)
12. DSM IV, 176.
13. Gene Heyman, Addiction: A Disorder of Choice (Cambridge, MA: Harvard
University Press, 2009).
14. Heyman, 112.
15. Heyman, 83.
16. Heyman cites the study by L. N. Robins, J. E. Helzer, and D. H. Davis,
“Narcotic Use in Southeast Asia and Afterward: An Interview Study of 898
Vietnam Returnees,” Archives of General Psychiatry 32 (1975): 955–961.
17. Heyman, 106–108.
18. Adrian Carter and Wayne Hall, Addiction Neuroethics: The Promises and Perils
of Neuroscience Research on Addiction (Cambridge: Cambridge University
Press, 2012) cite several recent studies, the point of which is either to show
that drug use in addicts is compulsive or to describe the mechanism behind
such compulsion. See, for example, J. Feil, D. Sheppard et al., “Addiction,
Compulsive Drug Seeking, and the Role of Frontostriatal Mechanisms in
Regulating Inhibitory Control,” Neuroscience and Biobehavioral Reviews 35
(2010): 248–275; J. D. Jentsch and J. R. Taylor, “Impulsivity Resulting from
Frontostriatal Dysfunction in Drug Abuse: Implications for the Control
of Behavior by Reward-Related Stimuli,” Psychopharmacology 146 (1999):
373–390; M. Yucel and D. I. Lubman, “Neurocognitive and Neuroimiaging
Evidence for Behavioral Dysregulation in Human Drug Addiction:
Implications for Diagnosis, Treatment, and Prevention,” Drug and Alcohol
Review 26 (2007): 33–39.
180 Notes

19. John Monterosso and George Ainslie, “The Picoeconomic Approach to

Addictions: Analyzing the Conflict of Successive Motivational States,”
Addiction Research and Theory 17, no. 2 (2009): 115–134.
20. Nichomachean Ethics. For this reason, Aristotle says at 1152a18 that the
weak of will “is not wicked, since his purpose is good.” He simply behaves
irrationally.
21. See Donald Davidson’s “How Is Weakness of the Will Possible?,” in Essays on
Actions and Events, (Oxford: Clarendon Press, 1970), 21–42.
22. Davidson, 23.
23. Neil Levy, “Resisting ‘Weakness of Will’,” Philosophy and Phenomenological
Research 82, no. 1 (2011): 134.
24. Levy cites R. F. Baumeister, E. Bratslavsky, M. Muraven, and D. M. Tice,
“Ego-Depletion: Is the Active Self a Limited Resource?,” Journal of Personality
and Social Psychology 74 (1998): 1252–1265, and R. F. Baumeister, “Ego
Depletion and Self-Control Failure: An Energy Model of the Self’s Executive
Function,” Self and Identity 1 (2002): 129–136. See also Mark Muraven,
Dianne M. Tice, and R. F. Baumeister, “Self Control as a Limited Resource:
Regulatory Depletion Patterns,” Journal of Personality and Social Psychology
74 (1998): 774–789; Mark Muraven and E. Slessareva, “Mechanisms of Self-
Control Failure: Motivation and Limited Resources,” Personality and Social
Psychology Bulletin 29 (2003): 894–906.
25. Matthew T. Gaillot, Roy F. Baumeister, C. Nathan DeWall, Jon K. Maner, E. Ashby
Plant, and Dianne M. Tice, “Self-Control Relies on Glucose as a Limited Energy
Source: Willpower Is More Than a Metaphor,” Journal of Personality and Social
Psychology 92 (2007): 325–336; Matthew T. Gailliot and Roy F. Baumeister, “The
Physiology of Willpower: Linking Blood Glucose to Self-Control,” Personality
and Social Psychology Review 11 (2007): 303–327; Roy F. Baumeister, Kathleen
D. Vohs, and Dianne M. Tice, “The Strength Model of Self-Control,” Current
Directions in Psychological Science 16, no. 6 (2007): 351–355.
26. Keith E. Stanovich and Richard F. West, “Individual Differences in Reasoning:
Implications for the Rationality Debate?” Behavioral and Brain Sciences 23
(2000): 645–726; Jonathan St. B. T. Evans, “In Two Minds: Dual-Process
Accounts of Reasoning,” Trends In Cognitive Sciences 7, no. 10 (2003): 454–459;
John Pollock, “OSCAR: A General Theory of Rationality,” in Philosophy and
AI, ed. Robert Cummins and John Pollock (Cambridge, MA: The MIT Press,
1995), 257–275. The most popular version of this distinction is found in
Daniel Kahneman, Thinking, Fast and Slow (New York: Farrar, Straus and
Giroux, 2011).
27. William James, Principles of Psychology (New York: Henry Holt & Company,
1890), 543.
28. Carter and Hall, 47.
29. Bennett Foddy, “Addiction and its Sciences: Philosophy,” Addiction 106
(2010): 25–31, doi:10.1111/j.1360—443.2010.03158.x.
30. Foddy, 27.
31. In fact there is a significant philosophical literature around this point, and
around the converse, that people can be compelled without knowing that
they are.
32. Most who argue this, for example Daniel Wegner, The Illusion of Conscious
Will (MIT Press, 2002) and Sam Harris Free Will (New York: Free Press, 2012),
 Notes 181

suggest that even without free will there is moral responsibility, and so the
fact that free will is an illusion is practically unimportant. Others, such
as Patricia Churchland (see, for example, her essay at Newscientist.com,
November 18, 2006) has argued that the concept needs to be revised, and
Daniel Dennett has argued in numerous essays and books since his 1978
Brainstorms (Cambridge, MA: MIT Press, 1981), but most concertedly in his
Elbow Room: The Varieties of Free Will Worth Wanting (Cambridge, MA: MIT
Press, 1984), that human beings have all the free will that anyone could
want.
33. James Ladyman and Don Ross, with David Spurrett and John Collier,
Everything Must Go: Metaphysics Naturalized (New York: Oxford University
Press, 2007), 4.
34. Ladyman and Ross, 4.
35. Ladyman and Ross, 4.
36. John H. Holland, Complexity: A Very Short Introduction (Oxford: Oxford
University Press, 2014).
37. Terrence W. Deacon, Incomplete Nature: How Mind Emerged from Matter (New
York: Norton, 2012), 244.
38. Five reasons for believing this are listed on p. 4 of Mark Bickhard, “Some
Consequences (and Enablings) of Process Metaphysics,” Axiomathes 21,
no. 1 (2011): 3–32. See also Mark H. Bickhard and Richard J. Campbell,
“Physicalism, Emergence, and Downward Causation,” Axiomathes 21, no. 1
(2011): 33–56
39. Ladyman and Ross, 20.
40. These examples are paraphrased from Mark Bickhard, “Interactivism:
A Manifesto” New Ideas in Psychology, 27 (2009): 85–89, doi:10.1016/j.
newideapsych.2008.05.001.
41. Deacon, 177.
42. J. C. Anthony and J. E. Helzer, “Syndromes of Drug Abuse and Dependence,”
in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study,
eds. Lee N. Robins and Darrel A. Regie (New York: Free Press, 1991),
116–154; R. C. Kessler, W. T. Chiu, O. Demler, K. R. Merikangas, and
E. E.Walters, “Prevalence, Severity, and Comorbidity of 12-month DSM-IV
Disorders in the National Comorbidity Survey Replication,” Archives of
General Psychiatry 62 (2005): 617–627; L. N. Robins and D. Regier, Psychiatric
Disorders in America (New York: Free Press, 1991); F. S. Stinson, B. F. Grant,
D. Dawson, W. J. Ruan, B. Huang, and T. Saha, “Comorbidity between
DSM-IV Alcohol and Specific Drug Use Disorders in the United States:
Results from the National Epidemiological Survey on Alcohol and Related
Conditions,” Drug and Alcohol Dependence 80 (2005): 105–116; L. A. Warner,
R. C. Kessler, M. Hughes, J. C. Anthony, and C. B. Nelson, “Prevalence and
Correlates of Drug Use and Dependence in the United States. Results from
the National Cormorbidity Survey,” Archives of General Psychiatry, 52 (1995):
219–229.
43. Deacon, ch. 10.
44. Deacon, 291.
45. John Stuart Mill, System of Logic: Rationative and Inductive. (1843) Collected
Works, Vols. 7 and 8 (Toronto: University of Toronto Press: 1996), 371.
46. C. D. Broad, The Mind and Its Place in Nature (London: Kegan Paul, 1925).
182 Notes

47. Carl Hempel and Paul Oppenheim, “Studies in the Logic of Explanation,”
in Hempel’s Aspects of Scientific Explanation (New York: The Free Press, 1965).
Thomas Nagel, The Structure of Science (New York: Harcourt, Brace & World,
1061), ch. 11. Cited in Jaegwon Kim, “Making Sense of Emergentism,”
Philosophical Studies: An International Journal for Philosophy in the Analytic
Tradition 95, no. 1/2 (1999): 3–36.
48. Kim, (1999).
49. Bickhard mentions this in “Representational Content in Humans and
Machines,” Journal of Experimental and Theoretical Artificial Intelligence 5
(1993): 285–333, and in “The Biological Emergence of Representation,” in
Emergence and Reduction: Proceedings of the 29th Annual Symposium of the Jean
Piaget Society, eds. T. Brown and L. Smith (Hillsdale, NJ: Erlbaum, 2002),
105–131, as well as in (2004).
50. Deacon, 265.
51. Deacon, 266.
52. Deacon, 309.
53. Bickhard (2004), 130.
54. Deacon, 535.
55. Deacon, 323.
56. Mark Bickhard, “Consciousness and Reflective Consciousness,” Philosophical
Psychology 18, no. 2 (2005): 218.

3 Addiction and the Individual

1. It was so characterized by T. Trotter in 1788. Reproduced in An Essay, Medical,
Philosophical, and Chemical on Drunkenness and its Effects on the Human Body,
ed. R. Porter (London: Routledge, 1988), and by B. Rush, an American physi-
cian, in an 1808 book, An Inquiry into the Effects of Ardent Spirits upon the
Human Body and Mind: With an Account of the Means of Preventing, and of the
Remedies for Curing Them (Philadelphia: Thomas Dobson, 1808), according
to M. Valverde, in Diseases of the Will: Alcohol and the Dilemmas of Freedom
(Cambridge: Cambridge University Press, 1998), 2. According to the Baldwin
Research Institute, Rush also believed that dishonesty, political dissent, and
being African American were diseases.
2. Neuroscience of Psychoactive Substance Use and Dependence (Geneva, Switzerland:
World Health Organization, 2004).
3. George F. Koob and Nora D. Volkow, “Neurocircuitry of Addiction,”
Neuropsychopharmacology 35 (2010): 217–138. doi: 10.1038/npp.2009.110.
4. Koob and Volkow, 217.
5. The case that Joseph LeDoux studied was fear, but perhaps the point can
be generalized (LeDoux “Emotion, Memory and the Bain: The Neural
Routes Underlying the Formation of Memories about Primitive Emotional
Experiences, Such as Fear, Have Been Traced,” Scientific American, June 1994,
50–57).
6. As we will see below, it is not just the amount of pleasure that one expe-
riences that provokes repetition of use or gambling but also the pleasure
that one anticipates. See Hans C. Breiter, Itzhak Aharon, Daniel Kahneman,
Anders Dale, and Peter Shizgal, “Functional Imaging of Neural Responses
 Notes 183

to Expectancy and Experience of Monetary Gains and Losses,” Neuron 30

(May 2001): 619–639. In some cases, anticipation seems to play an even
more provocative role. In some problem gamblers, almost winning may lead
them to gamble even more than winning does. See Henry W. Chase and Luke
Clark, “Near-win Situations May Encourage Problem Gamblers to Gamble
More,” Journal of Neuroscience 30, no. 18 (2010): 6180–6187.
7. R. L. Solomon and J. D. Corbit, “An Opponent-Process Theory of Motivation.
II. Cigarette Addiction,” Journal of Abnormal Psychology 81 (1983): 158–171;
R. L. Solomon, “Addiction: An Opponent-Process Theory of Acquired
Motivation: The Affective Dynamics of Addiction,” in Psychopathology:
Experimental Models, ed. J. D. Maser (San Francisco: Freeman, 1977), 66–103.
8. T. E. Robinson and K. C. Berridge, “The Neural Basis of Drug Craving: An
Incentive-Sensitization Theory of Addiction” Brain Research. Brain Research
Reviews 18 (3) (1993): 247–291; Robinson and Berridge, “The Psychology and
Neurobiology of Addiction: An Incentive-Sensitization View,” Addiction 95,
Supplement 2 (2000): S91–117; Robinson and Berridge, “Review. The Incentive
Sensitization Theory of Addiction: Some Current Issues,” Philosophical
Transactions of the Royal Society of London. Series B, Biological Sciences 363,
no. 1507 (2008): 3137–3146; K. C. Berridge, “Pleasure, Pain, Desire and
Dread: Hidden Core Processes of Emotion,” in Well Being: The Foundations of
Hedonic Psychology, ed. D. Kahneman, E. Diener, and N. Schwarz (New York:
Sage Foundation: 1999), 527–559.
9. K. C. Berridge and Terry E. Robinson, “Drug Addiction as Incentive
Sensitization,” in Addiction and Responsibility, ed. Jeffrey Poland and George
Graham (Cambridge, MA: MIT Press, 2011), 21–53. Clayton Hickey, Leonardo
Chelazzi, and Jan Theeuwes, “Reward Changes Salience in Human Vision via
the Anterior Cingulate,” Journal of Neuroscience 30, no. 33 (2010): 30(33),
11096–11103 suggests that incentive sensitization is achieved through the
dopamine reward system.
10. A. J. Tindell, K. C. Berridge, J. Zhang, S. Pecifia, and J. W. Aldridge, “Ventral
Palladal Neurons Code Incentive Motivation: Amplification by Mesolimbic
Sensitization and Amphetamine,” European Journal of Neuroscience 22,
no. 10 (2005): 2617–2634; P. Vezina, “Sensitization of Midbrain Dopamine
Neuron Reactivity and the Self-Administration of Psychomotor Stimulant
Drugs,” Neuroscience and Biobehavioral Reviews 27, no. 8 (2004): 827–839;
N. D. Volkow, G. J. Wang, F. Telang, J. S. Fowler, J. Logan, A. R. Childress et al.,
“Cocaine Cues and Dopamine in Dorsal Striatum: Mechanism of Craving
in Cocaine Addiction, Journal of Neuroscience 26, no. 24 (2006): 6583–6588;
C. L. Wyvell and K. C. Berridge, “Intra-accumbens and Amphetamine Increases
the Conditioned Incentive Salience of Sucrose Reward: Enhancement of
Reward ‘Wanting’ without Enhanced ‘Liking’ or Response Reinforcement, “
Journal of Neuroscience 20, no. 21 (2000): 8122–8130.
11. B. J. Everitt, A. Dickinson, and T. W. Robbins, “The Neuropsychological Basis
of Addictive Behavior,” Brain Research Review (2001) 36: 129–138; J. D. Berke
and S. E. Hyman, “Addiction, Dopamine, and the Molecular Mechanisms of
Memory,” Neuron 25 (2000): 515–532; T. W. Robbins and B. J. Everitt, “Drug
Addiction: Bad Habits Add Up,” Nature 398 (1999): 567–570.
12. G. D. Logan and W. Cowan, “On the Ability to Inhibit Thought and Action:
A Theory of an Act of Control,” Psychological Review 91 (1984): 295–327.
184 Notes

13. Daniel Wegner, “Who Is the controller of Controlled Processes?,” The New
Unconscious, ed. Ran R. Hassin, James S. Uleman, and John A. Bargh (Oxford:
Oxford University Press, 2005), 19–37. John A. Bargh, ed. Social Psychology
and the Unconscious: The Automaticity of Higher Mental Processes (New York:
Psychology Press, 2007); David D. Franks, Neurosociology: The Nexus Between
Neuroscience and Social Psychology (New York: Springer, 2010), Chapter 4.
14. D. B. Newlin and K. A. Strubler, “The Habitual Brain: An ‘Adapted Habit’
Theory of Substance Use Disorders,” Substance Use and Misuse 42, no. 2–3
(2007): 503–526; George Messinis, “Habit Formation and the Theory
of Addiction,” Journal of Economic Surveys 13, no. 4 (2009): 417–442. doi:
10.1111/1467–6419.00089.
15. Daniel J. Siegal, The Developing Mind (New York: Guilford Press, 1999),
28–32.
16. Reinout W. Wiers and Alan W. Stacy, “Implicit Cognition and Addiction,”
Current Directions in Psychological Science 16, no. 6 (Dec. 2006): 292–296.
17. A. E. Kelley and K. C. Berridge, “The Neuroscience of Natural Rewards:
Relevance to Addictive Drugs,” Journal of Neuroscience 22 (2002): 3306–3311.
18. A. E. Kelley and K. C. Berridge, “The Neuroscience of Natural Rewards:
Relevance to Addictive Drugs,” Journal of Neuroscience 22 (2002): 3306–3311;
Steven E. Hyman, Robert C. Malenka, and Eric J. Nestler, “Addiction: The
Role of Reward-Related Learning and Memory,” Annual Review of Neuroscience
29 (2006): 565–598; Koob and Volkow (2010).
19. But even this is not without dispute, as some researchers have argued that
more than one “type” of alcoholism exist, and require independent discussion.
One sort, it is argued, the susceptibility to lose control after drinking begins,
is genetically distinct from the susceptibility to lose control after drinking
begins, and requires a different analysis. While the first kind of alcoholism
may be accounted for in terms of dopamine and hedonic experiences, the
other, characterized by impulse control problems, is attributed to a dysfunc-
tion in serotonin regulation. Both of these “types” of alcoholism, however, are
seen as the result of the interaction of genetic and environmental factors. See
C. R. Cloninger, “Neurogenetic Adaptive Mechanisms in Alcoholism,” Science
236 (1987): 410–416; also Christina S. Barr, Melanie L. Schwandt, Timothy K.
Newman, and J. Dee Higley, “The Use of Adolescent Nonhuman Primates to
Model Human Alcohol Intake: Neurobiological, Genetic, and Psychological
Variables,” Annals of the New York Academy of Sciences 1021 (2004): 221–233.
20. N. D. Volkow, G. J. Want, J. S. Fowler, S. J. Gatley, Y. S. Ding, J. Logan et al.,
“Relationship between Psychostimulant-induced ‘High’ and Dopamine
Transporter Occupancy,” Proceedings of the National Academy of Sciences USA
93 (1996): 10388–10392; N. D. Volkow and J. M. Swanson, “Variables That
Affect the Clinical Use and Abuse of Methylphenidate in the Treatment of
ADHD,” American Journal of Psychiatry 160 (2003): 1909–1918; A. A. Grace,
“The Tonic/Phasic Model of Dopamine System Regulation and Its Implications
for Understanding Alcohol and Psychostimulant Craving,” Addiction 95,
Suppl. 2 (2000): S119–S128.
21. T. E. Robinson and K.C. Berridge, “Addiction,” Annual Review of Psychology
54 (2003): 25–53.
22. T. E. Robinson and B. Kolb, “Alterations in the Morphology of Dendrites and
Dendritic Spines in the Nucleus Accombens and Pre-frontal Cortex Following
 Notes 185

Repeated Treatment with Amphetamine or Cocaine,” European Journal of

Neuroscience 11 (1999): 1598–1604;
23. G. F. Koob, S. B. Caine, L. Parsons, A. Markous, and F. Weiss, “Opponent
Process Model and Psychostimulant Addiction,” Pharmacological Biochemistry
and Behavior 57 (1997): 513–521; G. F. Koob and M. Le Moal, “Drug Abuse:
Hedonic Homeostatic Dysregulation,” Science 278 (1997): 52–58.
24. Wolfram Schultz, Peter Dayan, and P. Read Montague, “A Neural Substrate
of Prediction and Reward,” Science 275, no. 5306 (1997): 1593–1599;
K. A. Hadland, M. F. S. Rushworth, D. Gaffan, and R. E. Passingham, “The
Anterior Cingulate and Reward-Guided Selection of Actions,” Journal of
Neurophysiology 89, no. 2 (2003): 1161–1164; Celine Amiez, Jean-Paul Joseph,
and Emmanuel Procyk, “Anterior Cingulate Error-related Activity Is Modulated
by Predicted Reward,” European Journal of Neuroscience 21 (2005): 3447–3452.
25. B. J. Everitt and T. W. Robbins, “Neural Systems of Reinforcement for Drug
Addiction: From Actions to Habits to Compulsion,” Nature Neuroscience 8
(2005): 1481–1489.
26. Everett, Dickinson, and Robbins (2001), 134.
27. Terry E. Robinson and Kent C. Berridge, “Addiction,” Annual Review of
Psychology 54 (2003): 25–53.
28. Robinson and Berridge, (1993) and (2000).
29. W. D. Yao, R. R. Gainetdinov, M. I. Arbuckle, T. D. Sotnikova, M. Cyr,
J. M Beaulieu et al., “Identification of PSD-95 as a Regulator of Dopamine-
Mediated Synaptic and Behavioral Plasticity,” Neuron 41 (1004): 625–638.
30. N. D. Volkow, J. S. Fowler, G. J. Wang, and J. M. Swanson, “Dopamine in
Drug Abuse and Addiction: Results from Imaging Studies and Treatment
Implications,” Molecular Psychiatry 9 (2004): 557–569.
31. A parallel assumption, which we will address later, is made about the resem-
blance of effects in animal models to those in human beings.
32. Martin Sarter, Gary G. Berntson, and John Cacioppo, “Brain Imaging and
Cognitive Neuroscience: Toward Strong Inference in Attributing Function
to Structure,” American Psychologist 51, no. 1 (1996): 13–21; Karl Friston,
“Beyond Phrenology: What Can Neuroimaging Tell Us about Distributed
Circuitry?,” Annual Review of Neuroscience 25 (2002): 221–250. doi: 10.1146//
annurev.neuro.25.112701.142846.
33. The New Phrenology: The Limits of Localizing Cognitive Processes in the Brain
(Cambridge, MA: MIT Press, 2001); Mind and Brain: A Critical Appraisal of
Cognitive Neuroscience (Cambridge, MA: MIT Press, 2011).
34. Neuropod (September, 2012), podcast of Nature.com.
35. Donald B. Douglas, “Alcoholism as an Addiction: The Disease Concept
Reconsidered,” Journal of Substance Abuse Treatment 3, no. 2 (1986): 115–120.
36. N. D. Volkow, G. J. Want, J. S. Fowler, S. J. Gatley, Y. S. Ding, J. Logan et al.,
“Relationship between Psychostimulant-induced ‘High’ and Dopamine
Transporter Occupancy,” Proceedings of the National Academy of Sciences USA
93 (1996): 10388–10392; N. D. Volkow and J. M. Swanson, “Variables That
Affect the Clinical Use and Abuse of Methylphenidate in the Treatment of
ADHD,” American Journal of Psychiatry 160 (2003): 1909–1918; A. A. Grace,
“The Tonic/Phasic Model of Dopamine System Regulation and Its Implications
for Understanding Alcohol and Psychostimulant Craving,” Addiction 95,
Suppl. 2 (2000): S119–S128.
186 Notes

37. Douglas, 116.

38. Stanton Peel, “Denial – of Reality and of Freedom – in Addiction Research
and Treatment,” Bulletin of the Society of Psychologists in Addictive Behaviors 5,
no. 4 (1986): 149–166.
39. Mark R. Hutchinson et al. “Opioid Activation of Toll-Like Receptor 4
Contributes to Drug Reinforcement,” Journal of Neuroscience: The Official
Journal of the Society for Neuroscience, 32, no. 33 (2012): 11187–11200.
40. Mark R. Hutchinson (2012), Press release http://www.colorado.edu/news/
releases/2012/08/14/new-study-involving-cu-boulder-shows-heroin-
morphine-addiction-can-be.
41. Peele, 154.
42. Stanton Peele, Diseasing of America: Addiction Treatment Out of Control
(Lexington, MA: Lexington Books, 1989).
43. George Ainslie, Breakdown of Will (Cambridge: Cambridge University Press,
2001); also Ainslie, “The Core Process in Addictions and Other Impulses:
Hyperbolic Discounting Versus Conditioning and Framing,” in What Is
Addiction? eds D. Ross, H. Kincaid, D. Spurrett, and P. Collins (Cambridge,
MA: MIT Press, 2009), 211–245.
44. George Ainslie, “Beyond Microeconomics: Conflict Among Interests in a
Multiple Self as a Determinant of Value” in The Multiple Self, ed. John Elster
(Cambridge: Cambridge University Press, 1986), 133–175.
45. George Anslie and V. Haendel, “The Motives of the Will,” in Etiology
Aspects of Alcohol and Drug Abuse, ed. E. Gottheil, K. Druley, T. Skodals, and
H. Waxman (Springfield, IL: Charles C. Thomas, 1983), 119–140; W. K. Bickel,
A. L. Odum, and G. J. Madden, “Impulsivity and Cigarette Smoking: Delay
Discounting in Current, Never, and Ex-smokers,” Psychopharmacology 146,
no. 4 (1999): 447–454; A. L. Bretteville-Jensen, “Addiction and Discounting”
Journal of Health Economics 18, no. 4 (1999): 393–407; V. R. Fuchs, “Time
Preferences and Health: An Exploratory Study,” in Economic Aspects of Health,
ed. V. R. Fuchs (Chicago: University of Chicago Press, 1956), 92–120);
K. N. Kirby, N. M Petry, and W. K. Bickel, “Heroin Addicts Have Higher
Discount Rates for Delayed Rewards Than Non-drug-using Controls,” Journal
of Experimental Psychology: General 128, no. 1 (1999): 78–87; G. J. Madden,
N. M. Petry, G. J. Badger, and W. K. Bickel, “Impulsive and Self-control Choices
in Opioid-dependent Patients and Non-drug-using Control Participants:
Drug and Monetary Rewards,” Experimental and Clinical Psychopharmacology
5, no. 3 (1997): 256–262; S. Mitchell, “Measures of Impulsivity in Cigarette
Smokers and Non-Smokers Psychopharmacology 146, no. 4 (1999): 455–464;
J. Monterosso, G. Ainslie, J. Xu, X. Cordova, C. P. Domier, and E. D. London
“Frontoparietal Cortical Activity of Methamphetamine-dependent and
Comparison Subjects Performing a Delay Discounting Task,” Human Brain
Mapping 28, no. 5 (2007): 383–393; R. E. Vuchinich, “Hyperbolic Temporal
Discounting in Social Drinkers and Problem Drinkers,” Experimental and
Clinical Psychopharmacology 6, no. 3 (1998): 292–305.
46. George Ainslie, “Free Will as Recursive Self-Prediction,” in Addiction and
Responsibility, ed. Jeffrey Poland and George Graham (Cambridge, MA: MIT
Press, 2011), 64.
47. Ainslie (2011), 65.
 Notes 187

48. Mark Muraven and Elisaveta Slessareva, “Mechanisms of Self-Control Failure:

Motivation and Limited Resources,” Personality and Social Psychology Bulletin
29 (2003): 894–906; Mark Muraven, Dianne M. Tice, and Roy F. Baumeister,
“Self-Control as a Limited Resource: Regulatory Depletion Patterns,” Journal
of Personality and Social Psychology 74 (1998): 774–789.
49. Kathleen D. Vohs and Todd F. Heatherton, “Self-Regulatory Failure: A Resource-
Depletion Approach,” Psychological Science 11, no. 3 (2000): 249–254; also see
D. Kahn, J. Polivy, and C. P. Herman, “Conformity and Dietary Disinhibition:
A Test of the Ego Strength Model of Self-Regulation,” International Journal of
Eating Disorders 33, no. 2 (2003): 165–171.
50. Neil Levey, “Addiction, Responsibility, and Ego Depletion,” in Addiction and
Responsibility, ed. Jeffrey Poland and George Graham (Cambridge, MA: MIT
Press, 2011), 101–111.
51. Levey (2011), 102, original emphasis.
52. G. Loewenstein, “Willpower: A Decision Theorist’s Perspective,” Law and
Philosophy 19, no. 1 (2000): 51–76.
53. James MacKillop and Christopher W. Kahler, “Delayed Reward Discounting
Predicts Treatment Response for Heavy Drinkers Receiving Smoking Cessation
Treatment,” Drug and Alcohol Dependence 104, no. 3 (2009): 197–203.
54. Bruce D. Perry, “Childhood Experience and the Expression of Genetic
Potential: What Childhood Neglect Tells Us about Nature and Nurture,”
Brain and Mind 3, no. 1 (2002): 79–100.

4 The Ecology of Addiction

1. Gregory Bateson, “The Cybernetics of Self: A Theory of Alcoholism,” in Steps
to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution and
Epistemology (San Francisco: Chandler Publishing Company, 1982), originally
published in Psychiatry 34, no. 1 (1971): 1–18.
2. Bateson, 4.
3. We agree on this point. The remainder of Bateson’s analysis of alcoholism,
and in particular his view regarding a higher power, prayer, and etc. stand in
stark contrast to the view presented here.
4. This is according to Bateson scholar Peter Harries-Jones, A Recursive Vision:
Ecological Understanding and Gregory Bateson (Toronto: University of Toronto
Press, 1995), 38.
5. Lisa A. Briand and Julie A. Blendy, “Molecular and Genetic Substrates
Linking Stress and Addiction.” Brain Research 1314 (2010): 219–234;
S. A. Brown, P. W. Vik, J. R. McQuaid, T. L. Patterson, M. R. Irwin, and I. Grant,
“Severity of Psychosocial Stress and Outcome of Alcoholism Treatment.,”
Journal of Abnormal Psychology 99 (1990): 344–348; S. A. Brown, P. W. Vik,
T. L. Patterson, I. Grant, and M. A. Schuckit, “Stress, Vulnerability and Adult
Alcohol Relapse” Journal of the Study of Alcohol, 56, no. 5 (1995): 538–545;
P. Ouimette, D. Coolhart, J. S. Funderburk, M. Wade, P. J. Brown, “Precipitants
of First Substance Use in Recently Abstinent Substance Use Disorder Patients
With PTSD,” Addictive Behaviors 32, no. 8 (2007): 1719–1727.
6. A. N. Schore, Affect Regulation and the Origin of the Self (Hillsdale, NJ: Lawrence
Erlbaum Associates, 1994), 12.
188 Notes

7. Megan Gunnar and Karina Quevedo, “The Neurobiology of Stress and

Development,” Annual Review of Psychology 58 (2007): 145–173.
8. Shanta R. Dube, Vincent J. Felitti, Maxia Dong, Daniel P. Chapman, Wayne
H. Giles, and Robert F. Anda, “Childhood Abuse, Neglect, and Household
Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood
Experiences Study,” Pediatrics 111, no. 3 (2003): 564–572.
9. These results were corroborated in a later study: Shanta Dube, J. Miller,
D. Brown et al., “Adverse Childhood Experiences and the Association with
Ever Using Alcohol and Initiating Alcohol Use During Adolescence,” Journal
of Adolescent Health 35, no. 4 (2006): 444.e1–444.e10, and also by Emily
F. Rothman, Erika M. Edwards, Timothy Heeren, and Ralph W. Hingson,
“Adverse Childhood Experiences Predict Earlier Age of Drinking Onset:
Results from a Representative U.S. Sample of Current or Former Drinkers,”
Pediatrics 122, no. 2 (2008): e298–e304, doi: 10.1542/peds.2007–3412.
10. Bruce D. Perry et al., “Childhood Trauma, the Neurobiology of Adaptation
and ‘Use-dependent’ Development of the Brain: How ‘States’ become ‘Traits’”
Infant Mental Health Journal 16, no. 4 (1995): 271–291.
11. R. S. Falck, R. W. Nahhas, L. Li, and R. G. Carlson, “Surveying Teens in School
to Assess the Prevalence of Problematic Drug Use,” Journal of School Health 82,
no.5 (2012): 217–224.
12. Michael D. DeBellis, Andrew S. Baum, et al., “Developmental Traumatology
Part I: Biological Stress Systems,” Biological Psychiatry 45, no. 10 (1999):
1259–1270.
13. B. D. Perry and R. Pollard, “Homeostasis, Stress, Trauma, and Adaptation:
A Neurodevelopmental View of Childhood Trauma,” Child and Adolescent
Psychiatric Clinics of North America 7 (1998): 33–51.
14. Darlene D. Francis and Michael J. Meaney, “Maternal Care and the
Development of Stress Responses,” Current Opinion in Neurobiology 9, no. 1
(1999): 128–134.
15. M. Mar Sanchez, Charlotte O. Ladd, and Paul M. Plotsky, “Early Adverse
Experience as a Developmental Risk Factor for Later Psychopathology:
Evidence from Rodent and Primate Models,” Development and Psychopathology
13, no. 3 (2001): 419–149; Joan Kaufman, Paul Plotsky, Charles B. Nemeroff,
Dennis S. Charney, “Effects of Early Adverse Experiences on Brain Structure
and Function: Clinical Implications,” Biological Psychiatry 48, no. 8 (2000):
778–790.
16. Christian Caldiji, Beth Tannenbaum, Shakti Sharma, Darlene Francis, Paul
M. Plotsky, and Michael J. Meaney, “Maternal Care During Infancy Regulates
the Development of Neural Systems Mediating the Expression of Fearfulness
in the Rat,” Proceedings of the National Academy of Science of the U.S.A. 95,
no. 9 (1998): 5335–5340.
17. D. D. Francis et al. (1998), 130; Michael J. Meaney, David H. Aitken, Seema
Bhatnagar, Robert M. Sapolsky, “Postnatal Handling Attenuates Certain
Neuroendocrine, Anatomical, and Cognitive Dysfunctions Associated with
Aging in Female Rats,” Neurobiology of Aging 12, no. 1 (1991): 31–38.
18. Alison S. Fleming, Gary W. Kraemer, Andrea Gonzalez, Vedran Lovic,
Stephanie Rees, and Angel Melo, “Mothering Begets Mothering: The
Transmission of Behavior and Its Neurobiology Across Generations,”
Pharmacology Biochemistry and Behavior 73, no. 1 (2002): 61–75.
 Notes 189

19. C. M. Berman, “Intergenerational Transmission of Maternal Rejection Rates

among Free-Ranging Rhesus Monkeys on Cayo Santiago,” Animal Behavior 44
(1990): 247–258.
20. Francis Champagne and Michael Meaney, “Chapter 21: Like Mother, Like
Daughter: Evidence for Non-Genomic Transmission of Parental Behavior and
Stress Responsivity,” Progress in Brain Research 133 (2001): 287–302.
21. Stanley I. Greenspan and Stuart Shanker, The First Idea: How Symbols,
Language, and Intelligence Evolved From Our Primate Ancestors to Modern Humans
(Cambridge, MA: Da Capo Press, 2004), 102.
22. Greenspan and Shanker (2004), 201.
23. Greenspan and Shanker (2004), 102.
24. Michael J. Meaney, Wayne Brake, Alain Gratton, “Environmental Regulation
of the Development of Mesolimbic Dopamine Systems: A Neurobiological
Mechanism for Vulnerability to Drug Abuse?,” Psychoneuroendocrinology 27
(2002): 127–138.
25. Paul Plotsky, “Early Life Adversity, Allostasis, and Resilience,” presentation
at Culture, Mind, and Brain: Emerging Concepts, Methods, Applications 5th
Foundation for Psychocultural Research-UCLA Interdisciplinary Conference.
Also see Christine Helm, Paul M. Plotsky, and Charles B. Nemeroff,
“Importance of Studying the Contributions of Early Adverse Experience to
Neurobiological Findings in Depression,” Neuropsychopharmacology 29, no. 4
(2004): 205–217.
26. Rajita Sinha, “How Does Stress Increase Risk of Drug Abuse and Relapse?”
Psychopharmacology 158 (2001): 343–359; George Koob, Mary Jeanne
Kreek, “Stress, Dysregulation of Drug Reward Pathways, and the Transition
to Drug Dependence,” American Journal of Psychiatry 164, no. 8 (2007):
1149–1159.
27. Gary W. Kraemer and William T. McKinney, “Social Separation Increases
Alcohol Consumption in Rhesus Monkeys,” Psychopharmacology 86 (1985):
182–189.
28. Claudia Fahlke, Joseph G. Lorenz, Jeffrey Long, Maribeth Champous,
Stephen J. Soumi, J. Dee Higley, “Rearing Experiences and Stress-Induced
Plasma Cortisol as Early Risk Factors for Excessive Alcohol Consumption
in Nonhuman Primates,” Alcoholism: Clinical and Experimental Research 24,
no. 5 (2000): 644–650.
29. B. K. Alexander, R. B. Coambs, and P. F. Hadaway, “The Effect of Housing
and Gender on Morphine Self-Administration in Rats,” Psychopharmacology
58 (1978): 175–179.
30. Bruce Alexander, “The Myth of Drug-Induced Addiction,” Report to the
Parliament of Canada (January 2001). http://www.parl.gc.ca/content/sen/
committee/371/ille/presentation/alexender-e.htm.
31. Marian Logrip, Eric P. Zorrilla, George F. Koob, “Stress Modulation of Drug
Self-Administration: Implications for Addiction Comorbidity with Post-
traumatic Stress Disorder,” Neurophyarmacology 62, no. 2 (2012): 552–564;
E. G. Triffleman, C. R. Marmar, K. L. Delucchi, H. Ronfeldt, “Childhood
Trauma and Posttraumatic Stress Disorder in Substance Abuse Inpatients,”
Journal of Nervous and Mental Disease 183, no. 3 (1995): 172–176.
32. P. V. Piazza and M. Le Moal, “The Role of Stress in Drug Self-Administration,”
Trends in Pharmacological Sciences 19, no. 2 (1998): 67–74.
190 Notes

33. Uri Shalev, David Highfield, Jasmine Yap, and Yavin Shaha, “Stress and
Relapse to Drug Seeking in Rats: Studies on the Generality of the Effect,”
Psychopharmacology 150, no. 3 (2000): 337–346; Yavin Shaham, Suzanne Erb,
and Jane Steward, “Stress Induced Relapse to Heroin and Cocaine Seeking in
Rats: A Review,” Brain Research Reviews 33, no. 1 (2000): 13–33.
34. Mara Mather and Nichole R. Lighthall, “Risk and Reward Are Processed
Differently in Decisions Made Under Stress,” Current Directions in Psychological
Science 21, no. 1 (2012): 36–41.
35. Xiao-li Zhang, Jie Shi, Li-yan Zhao, Li-li Sun, Jun Wang, Gui-bin Wang,
David Epstein, and Lin Lu, “Effects of Stress on Decision-Making Deficits in
Formerly Heroin-Dependent Patients after Different Durations of Abstinence,”
American Journal of Psychiatry 168, no. 6 (2011): 610–616.
36. Mary-Anne Enoch and David Goldman, “The Genetics of Alcoholism and
Alcohol Abuse,” Current Psychiatry Reports 3 (2001): 144–151.
37. International Human Genome Sequencing Consortium, “Initial Sequencing
and Analysis of the Human Genome,” Nature 409, no. 6822 (2001): 860–921;
International Human Genome Sequencing Consortium, “Finishing the
Euchromatic Sequence of the Human Genome,” Nature 431, no. 7011 (2004):
931–945.
38. J. Hirsch, “Some History of Heredity-vs-Environment, Genetic Inferiority at
Harvard (?) and The (Incredible) Bell Curve,” Genetica 99 (1997): 207–224.
39. Heyman (2009), 91.
40. C. Robert Cloninger, Michael Bohman, Soren Sigvardsson, “Inheritance of
Alcohol Abuse: Cross-Fostering Analysis of Adopted Men,” Archives of General
Psychiatry 38, no. 8 (1981): 861–868.
41. M. Bohman, S. Sigvardsson, and C. R. Cloninger, “Maternal Inheritance of
Alcohol Abuse: Cross-fostering Analysis of Adopted Women,” Archives in
General Psychiatry 38, no. 9 (1981): 861–868.
42. Jay Joseph, “The ‘Missing Heritability’ of Psychiatric Disorders: Elusive Genes
or Non-Existent Genes?,” Applied Developmental Science 16, no. 2 (2012): 72.
43. R. Plomin, R. Corley, A. Caspi, D. W. Fulker, and J. C. DeFries, “Adoption
Results for Self-Reported Personality: Evidence for Nonadditive Genetic
Effects?,” Journal of Personality and Social Psychology 75 (1998): 211–218.
44. Gabor Maté, In the Realm of Hungry Ghosts: Close Encounters with Addiction
(Berkeley, CA: North Atlantic Books, 2010), 433–437.
45. Maté (2010), 438.
46. Maté (2010), 439.
47. Joshua P. Smith and Sarah W. Book, “Comorbidity of Generalized Anxiety
Disorder and Alcohol Use Disorders among Individuals Seeking Outpatient
Substance Abuse Treatment,” Addictive Behaviors 35, no. 1 (2010): 42–45.
48. F. R. Schneier, T. E. Foose, D. S. Hasin, R. G. Heimberg, S. M. Liu,
B. F. Grant, and C. Blanco, “Social Anxiety Disorder and Alcohol Use Disorder
Co-morbidity in the National Epidemiologic Survey on Alcohol and Related
Conditions,” Psychological Medicine 40, no. 6 (2010): 977–988.
49. D. A. Regier, M. E. Farmer, D. S. Rae, B.Z. Locke, S. J. Keith, L. O. Judd, and
F. K. Goodwin, “Comorbidity of Mental Disorders with Alcohol and Other
Drug Abuse: Results from the Epidemiological Catchment Area (ECA) Study,”
Journal of the American Medical Association 264 (1990): 2511–2518.
 Notes 191

50. Joseph M. Boden and David M. Fergusson, “Alcohol and Depression,”

Addiction 106, no. 5 (2011): 906–914.
51. David A. Shoham, Liping Tong, Peter J. Lamberson, Amy H. Auchincloss,
Jun Zhang, Lara Dugas, Jay S. Kaufman, Richard S. Cooper, and Amy Luke,
“An Actor-Based Model of Social Network Influence on Adolescent Body Size,
Screen Time, and Playing Sports,” Public Library of Science ONE, published
June 29, 2012.
52. B. F. Grant and D. A. Dawson, “Age at Onset of Alcohol Use and Its
Association with DSM-IV Alcohol Abuse and Dependence: Results from the
National Longitudinal Alcohol Epidemiologic Survey,” Journal of Substance
Abuse 9 (1997): 103–110; B. F. Grant and D. A. Dawson, “Age of Onset of Drug
Use and Its Association with DSM IV Drug Abuse and Dependence: Results
from the National Longitudinal Alcohol Epidemiologic Survey,” Journal of
Substance Abuse 10, no. 2 (1998): pp. 163–173.
53. B. F. Grant, “Age at Smoking Onset and Its Association With Alcohol
Consumption and DSM-IV Alcohol Abuse and Dependence: Results from the
National Longitudinal Alcohol Epidemiologic Survey,” Journal of Substance
Abuse 10, no. 1 (1998): 59–73.

5 The Culture of Addiction

1. James Barber, “Alcohol Addiction: Private Trouble or Social Issue?,” Social
Service Review 68, no. 4 (1994): 521–535
2. David T. Courtwright, Forces of Habit: Drugs and the Making of the Modern
World (Cambridge, MA: Harvard University Press, 2001136–139.
3. Jan Rogozinski, Smokeless Tobacco in the Western World, 1550–1950 (New York:
Praeger, 1990), ch. 4.
4. Courtwright, 135–138.
5. World Health Organization, “The Tobacco Epidemic: A Global Public Health
Emergency,” http://www.who/int/inf-fs/en/factus8.html, June 29, 2000.
6. Courtwright, 19.
7. Courtwright, 59. He notes that “it is probably no coincidence that the rapid
growth of European distilling, and the explosive growth of tobacco imports,
took place during what historians call ‘the general crisis of the seventeenth
century,’” a period in which Europeans suffered “inflation, unemployment,
pestilence, frigid weather, crop failures, riots, massacres, and warfare with
parallel since the grimmest days of the fourteenth century.”
8. Courtwright, 75.
9. T. Smollett, The History of England from the Revolution in 1688, to the Death of
George the Second (Philadelphia: M’Carty and Davis, 1839), 452.
10. Gerda Reith, “Consumption and Its Discontents: Addiction and the Problems
of Freedom,” The British Journal of Sociology, 55, no. 2 (2004): 283–300.
11. Reith, 287
12. S. Ewen and E. Ewen, Channels of Desire (New York: McGraw-Hill, 1982),
250.
13. Daniel Bell, The Cultural Contradictions of Capitalism (London: Heinemann,
1976), 31.
192 Notes

14. Robin Room, “Treatment-seeking Populations and Larger Realities,” in Alcohol

Treatment in Transition, ed. Griffith Edwards and Marcus Grant (London:
Croom Helm, 1980), 205–224.
15. C. M. Weisner and Robin Room, “Financing and Ideology in Alcohol
Treatment,” Social Problems 32, no. 2 (1984): 167–184.
16. Substance Abuse and Mental Health Services Administration, “Projections
of National Expenditures for Mental Health Services and Substance Abuse
Treatment 2004–2014,” http://store.samhsa.gov/product/SMA08–4326
17. Elayne Rapping, The Culture of Recovery: Making Sense of the Self-Help Movement
in Women’s Lives (Boston: Beacon Press, 1996), 69.
18. Michelle Alexander, The New Jim Crow: Mass Incarceration in the Age of
Colorblindness (New York: The New Press, 2010), 59.
19. G. D. Jaynes and R. M. Williams, Jr., eds., A Common Destiny: Blacks and the
American Society (Washington: National Academy Press, 1989).
20. William Kornblum, “Drug Legalization and the Minority Poor,” Milbank
Quarterly 69, no. 3 (1991): 415–435.
21. Kornblum, 426
22. Sam Mitrani, “Stop Kidding Yourself: The Police Were Created to Control
Working Class and Poor People,” Laboronline (December 29, 2014), Labor and
Working-Class History Association. Lawcha.org/wordpress/2014/12/29/stop-
kidding-police-created-control-working-class-poor-people/.
23. Alexander, 4.
24. Alexander, 4. To illustrate Alexander’s point, we have only to consider the
numerous cases of brutality against black young men that have surfaced in
recent months, including those involving the deaths of Trayvon Martin at
the hands of George Zimmerman, Freddie Gray at the hands of the Baltimore
police, and Walter Scott, shot in the back by North Charleston police officer
Michael Slager.
25. J. E. Helzer, G. J. Canino, E. K. Yeh, R. C. Bland, C. K. Lee, H. G. Hwu, and
S. Newman, “Alcoholism – North America and Asia: A Comparison of
Population Surveys with the Diagnostic Interview Schedule,” Archives of
General Psychiatry, 47, no. 4 (1990): 313.
26. Martin Levine and Richard Troiden, “The Myth of Sexual Compulsivity,” The
Journal of Sex Research 25, no. 3 (1988): 347–363.
27. Levine and Troiden, 347.
28. Levine and Troiden, 351.
29. Levine and Troden, 360.
30. Heyman (2009), 2.
31. I. Nelson Rose, “Compulsive Gambling and the Law: From Sin to Vice to
Disease,” Journal of Gambling Behavior 4, no. 4 (1988): 240–260.
32. Credit Suisse AG, Paradeplatz 8 P. O. Box CH-8070, Zurich, Switzerland, redia.
relations@credit-suisse.com.
33. Data from New York City Department of Homeless Services.
34. National Alliance to End Homelessness, National Coalition for the Homeless,
the National Health Care for the Homeless Council, the National Association
for the Education of Homeless Children and Youth, the National Law Center
on Homelessness and Poverty, National Low Income Housing Coalition, and
National Policy and Advocacy Council on Homelessness, “Foreclosure to
Homelessness 2009: The Forgotten Victims of the Subprime Crisis.”
 Notes 193

35. Oxfam, “Even It Up: Time to End Extreme Inequality,” oxfamamerica.org,

http://www.oxfamamerica.org/static/media/files/even-it-up-inequality-
oxfam.pdf.
36. Amy Goodman, video interview, “Drugs Aren’t the Problem”: Neuroscientist
Carl Hart on Brain Science and Myths About Addiction,” Truthout, (Tuesday
7 January 2014), http://www.truth-out.org/news/item/21078-drugs-arent-
the-problem-neuroscientist-carl-hart-on-brain-science-and-myths-about-
addiction.
37. Carl L. Hard, Baroline B. Marvin, Rae Silver, and Edward E. Smith, “Is
Cognitive Functioning Impaired in Methamphetamine Users? A Critical
Review,” Neuropsychopharmacology 37, no. 3 (2012): 586–608.
38. Gene Heyman, “Addiction and Choice: Theory and New Data,” Frontiers in
Psychiatry 4, no. 31 (2013): p. 3. doi: 10.3389/fpsyt2013.00031.
39. Karamat Ali, “Causes of Drug Addiction in Pakistan,” Pakistan Economic and
Social Review 18, no. 3/4 (1980): 102–111.
40. Ali, 106.
41. Ali, 106.
42. Daniel H. Lende, “Wanting and Drug Use: A Biocultural Approach to the
Analysis of Addiction,” Ethos 33, no. 1 (2005), Special Issue: Building
Biocultural Anthropology, 100–124.
43. Judith S. Brook et al., “Pathways to Marijuana Use Among Adolescents:
Cultural/Ecological, Family, Peer, and Personality Influences,” Journal of the
American Academy of Child & Adolescent Psychiatry 37, no. 7 (1998): 759–766.
44. Gilbert Quintero and Sally Davis, “Why Do Teens Smoke? American Indian
and Hispanic Adolescents Perspectives on Functional Values and Addiction,”
Medical Anthropology Quarterly, New Series, 16, no. 4 (2002): 439–457.
45. Quintero and Davis, 446.
46. Paul Hayes, “Many People Use Drugs – But Here’s Why Most Don’t Become
Addicts,” The Conversation, US Addition (January 6, 2015), https://thecon-
versation.com/many-people-use-drugs-but-heres-why-most-dont-become-
addicts-35504.
47. Lee Fang, “The Anti-Pot Lobby’s Big Bankroll: The Opponents of Marijuana-Law
Reform Insist That Legalization Is Dangerous, But the Biggest Threat Is to
Their Own Bottom Line,” The Nation, 299, nos. 3–4 (2014): 112–117, https://
www.thenation.com/article/anti-pot-lobbys-big-bankroll/.
48. Fang, 14.
49. Barbara Starfield, “Is U.S. Health Really the Best in the World?,” Journal of the
American Medical Association 284, no. 4 (2000): 483–485.
50. Centers for Disease Control and Prevention, “Prescription Drug Overdose in
the United States: Fact Sheet,” cdc.gov, http://www.cdc.gov/homeandrecrea-
tionalsafety/overdose/facts.html.
51. Sasha Knezev and Gregory A. Smith, MD, American Addict, directed by Sasha
Knezev (Torrance, CA: Pain MD Productions, 2014), DVD.
52. Lende, 105
53. Ali, 104.
54. Timothy S. Paul, “Obesity Kills More Americans Than Previously Thought,”
report by Columbia Mailman School of Public Health, August 14, 2013,
mailman.columbia.edu, http://www.mailman.columbia.edu/news/obesity-
kills-more-americans-previously-thought.
194 Notes

55. Kornblum, 422.

56. Kornblum, 433.
57. Alfred Lindesmith, “A Sociological Theory of Addiction,” American Journal of
Sociology 43, no. 4 (1938): 593–613.
58. Darin Weinbert, “Lindsmith on Addiction: A Critical History of a Classic
Theory,” Sociological Theory 15, no. 2 (1997): 150–161.
59. Weinbert, 153.
60. Weinbert, 157.

6 Addiction and Meaning

1. Paul Churchland, Neurophilosophy at Work (New York: Cambridge University
Press, 2007), 138–140.
2. Jerry Fodor, The Language of Thought (New York: Crowell, 1975); also Jerry
Fodor, RePresentations (Cambridge, MA: MIT Press, 1981) and others. In
Jerry Fodor, Concepts: Where Cognitive Science Went Wrong (Oxford: Oxford
University Press, 1998), he denies the existence of innate ideas, or concepts,
opting instead for innate mechanisms (142) – but this is all compatible with
classical innatism, at least as put forth in the philosophy of Gottfried Wilhelm
Leibniz, and arguably in that of Descartes.
3. Jerry Fodor, “Concepts: A Potboiler,” Cognition 50 (1994): 107.
4. Fodor (1994), 107.
5. Jerry Fodor, “Semantics, Wisconsin Style,” Synthese 59 (1984): 231–250,
reprinted in A Theory of Content and Other Essays (Cambridge, MA: MIT Press,
1990).
6. Jerry Fodor, A Theory of Content and Other Essays, chapter 4.
7. Walter J. Freeman, How Brains Make Up Their Minds (Cambridge, MA: MIT
Press, 1999), 25.
8. Freeman (1999), 41.
9. John Searle, “Minds, Brains, and Programs,” Brain and Behavioral Science 3,
no. 3 (1980): 417–457.
10. Levine and Bickhard, 19.
11. Antonio Damasio, The Feeling of What Happens: Body and Emotion in the
Making of Consciousness (New York: Harcourt, 1999), 320–321.
12. Churchland (2007), 135. Original emphasis.
13. Damasio, 321.
14. David Hume, Inquiry Concerning Human Understanding, Project Gutenberg,
section 2, paragraphs 13, 14. www.gutenberg/org/ebooks/9662.
15. Hume, Inquiry, paragraph 14.
16. Churchland (2007), 135.
17. Churchland (2007), 135.
18. Greenspan and Shanker (2004), 104.
19. Greenspan and Shanker (2004), 47.
20. Greenspan and Shanker (2004), 48.
21. S. I. Greenspan, The Growth of the Mind and the Endangered Origins of Intelligence
(Reading, MA: Addison Wesley Longman, 1997).
22. Gene Heyman, Addiction: A Disorder of Choice (Cambridge, MA: Harvard
University Press, 2009), 84–86.
 Notes 195

23. See H. Mercier and D. Sperber, “Why Do Humans Reason? Arguments for
an Argumentative Theory,” The Behavioral and Brain Sciences (April 1, 2011),
57–74, for an argument that the function of reasoning in humans is not to
determine optimal behavior or beliefs, but rather to persuade others of what
we are already inclined to do or believe. We “look for arguments that support
a given conclusion, and ceteris paribus, favor conclusions for which argu-
ments can be found.” (p. 57).

7 Phenomenology and Its Implications

1. Susan Cheever, My Name Is Wilson: His Life and the Creation of Alcoholics
Anonymous (New York: Washington Square Press, 2005).
2. Owen Flanagan, “What Is It Like to Be an Addict?” Addiction and Responsibility,
ed. Jeffrey Poland and George Graham (Cambridge, MA: MIT Press, 2011),
269–292.
3. Owen Flanagan, “Phenomenal Authority: The Epistemic Authority of
Alcoholics Anonymous,” Addiction and Self-Control: Perspectives from
Philosophy, Psychology, and Neuroscience, ed. Neil Levy (New York: Oxford
University Press, 2013), p. 67–93.
4. Rachael R. Hammer, Molly J. Dingel, Jenny E. Ostergren, Katherine E.
Nowakowski, and Barbara A Koenig, “The Experience of Addiction as Told
by the Addicted: Incorporating Biological Understandings into Self-Story,”
Culture, Medicine, and Psychiatry 36, no. 4 (2012): 712–734.
5. Hammer et al., 732.
6. Hammer et al., 720.
7. Lance Dodes, “Psychodynamic Practice: Individuals, Groups and Organisations,”
Psychodynamic Practice: Individuals, Groups and Organizations, Special Issue: The
Psychodynamics of Substance Abuse 15, no. 4 (2009): 381–393.
8. Caroline Knapp, Drinking: A Love Story (New York: Bantam Doubleday Dell
Publishing Group, 1996), 4.
9. Clark Collis, “Kristen Johnston Talks about Her Drug Addiction, Her Life-
Threatening Illness, Her Recovery, and Her New Memoir, ‘Guts,’” Entertainment
Weekly (January 18, 2015) online supplement, http://www.ew.com/article/
2012/03/10/kristen-johnston-talks-about-her-drug-addiction-her-life-
threatening-illness-her-recovery-and-her-new-memoir-guts.
10. Jeanette Kennett, “Just Say No? Addiction and the Elements of Self-Control,” in
Addiction and Self-Control: Perspectives from Philosophy, Psychology, and Neuroscience,
ed. Neil Levey (New York: Oxford University Press, 2013), 144–164.
11. Gabor Maté, In the Realm of Hungry Ghosts (Berkeley, CA: North Atlantic
Books, 2010), 64–74.
12. Maté, 20.
13. Allison Moore, Shards: A Young Vice Cop Investigates Her Darkest Case of Meth
Addiction – Her Own (New York: Touchstone, 2014), 23.
14. Hammer et al., 717.
15. Kristen Johnston, Guts: The Endless Follies and Tiny Triumphs of a Giant Disaster
(New York: Gallery Books, 2012), 49.
16. Moore, 228.
17. Moore, 86.
196 Notes

18. Hammer et al., 724.

19. Moore, 87.
20. Hammer et al., 727.
21. Knapp, 117.
22. Johnston, 143.
23. Moore, 79
24. Knapp, 5.
25. Johnston, 109.
26. E. J. Khantzian, “The Self-Medication Hypothesis of Addictive Disorders:
Focus on Heroin and Cocaine Dependence,” American Journal of Psychiatry
142 (1985): 1259–1264. Also see E. J. Khantzian, “Psychological (Structural)
Vulnerabilities and the Specific Appeal of Narcotics, Annals of the New York
Academy of Sciences 398 (1982): 24–32.
27. E. J. Khantzian, K. S. Halliday, and W. E. McAuliffe, Addiction and the Vulnerable
Self: Modified Dynamic Group Therapy for Substance Abuser (New York: Guilford,
1990). See also Khanztian (1985) and Khantzian (1982).
28. J. J. Suh, S. Ruffins, C. E. Robins, M. J. Albanese, and E. J. Khantzian, “Self-
Medication Hypothesis: Connecting Affective Experience and Drug Choice,”
Psychoanalytic Psychology 25, no. 3 (2008): 518–532. Also see D. M. Eschbaugh,
D. J. Josi, C. N. Hoyt, and M. A. Murphy, “Some Personality Patterns and
Dimensions of Male Alcoholics: A Multivariate Description, “A Clinician’s Guide
to the Personality Profiles of Alcohol and Drug Abusers: Typological Descriptions
Using the MMPI, ed. D. J. Tosi, D. M. Eshbaugh, and M. A. Murphy (Springfield,
IL: Charles C. Thomas Publisher, 1993), 17–30. See also C. Wells, D. J. Tosi,
D. M. Eshbaugh and M. A. Murphy, “Comparison and Discrimination of Male
and Female Alcoholic and Substance Abusers,” 73–73 in that volume.
29. Moore, 79.
30. Thomas de Quincy, Confessions of an Opium Eater, open access e-book through
Project Gutenberg.
31. Personal communication, in a conversation that happened in the fall of
2013.
32. Kyle Keegan, “Chasing the High” (New York: Oxford University Press, 2008), 8.
33. Maté, 14.
34. Flanagan, 278
35. Dan Waldorf, Craig Reinarman, and Sheigla Murphy, Cocaine Changes: The
Experience of Using and Quitting (Philadelphia: Temple University Press, 1991),
191.
36. Waldorf et al., 193.
37. Waldorf et al., 202.

8 Possibilities for Change

1. The book Alcoholics Anonymous says, “[R]arely have we seen one fail, who has
thoroughly followed our path.” 4th Edition, online, Chapter 5, p. 58.
2. National Institute on Drug Abuse: The Science of Drug Abuse & Addiction.
“Drugs, Brains, and Behavior: The Science of Addiction,” drugabuse.gov,
http://www.drugabuse.gov/publications/drugs-brains-behavior-science-
addiction/treatment-recovery.
 Notes 197

3. Charles Duhigg, The Power of Habit: Why We Do What We Do in Life and

Business (New York: Random House, 2012), 70–72.
4. N. C. Maisel, J. C. Blodgett, P. L. Wilbourne, K. Humphreys, and J. W. Finney,
“Meta-analysis of Naltrexone and Acamprosate for Treating Alcohol Use
Disorders: When Are These Medications Most Helpful?” Addiction 108, no. 2
(2013): 275–293.
5. J. R. Volpicelli, A. I. Alterman, M. Hayashida, and C. P. O’Brien, “Naltrexone
in the Treatment of Alcohol Dependence,” Archives of General Psychiatry 49,
no. 11 (1992): 876–880.
6. Raymond F. Anton et al., “Combined Pharmacolotherapies and Behavioral
Interventions for Alcohol Dependence/The COMBINE Study: A Randomized
Controlled Trial,” Journal of the American Medical Association 295, no. 27 (2006):
2003–2017. http://jama.jamanetwork.com/article.aspx!articleid=202789.
7. Kristin V. Carson, Malcolm P. Brinn, Thomas A. Robertson, Rachada To-A-Nan,
Adrian J. Esterman, Matthew Peters, and Brian J. Smith, “Current and
Emerging Pharmacotherapeutic Options for Smoking Cessation” Substance
Abuse 7 (2013): 85–105.
8. Michael T. Bowen, Sebastian T. Peters, Nathan Absalom, Mary Chebib, Inga
D. Neumann, and Iain S. McGregor, “Oxcytocin Prevents Ethanol Actions
at ʓ Subunit-Containing GABAA Receptors and Attenuates Ethanol-Induced
Motor Impairment in Rats,” Proceedings of the National Academy of Sciences of
the United States of America, 112, no. 10 (2015): 3104–3109. Published online
before print February 23, 2015. doi: 10.1073/pnas.1416900112.
9. Jason Cherkis “Dying to Be Free: There’s a Treatment for Heroin Addiction
That Actually Works: Why Aren’t We Using It?” Huffington Post, January 28,
2015.
10. National Center for Addiction and Substance Abuse, “Addiction Medicine:
Closing the Gap between Science and Practice,” Columbia University, June
2012.
11. Charles Duhigg, The Power of Habit: Why We Do What We Do in Life and
Business (New York: Random House, 2012), 72–73.
12. N. Li, J. Wang, X. L. Wang, C. W. Chang, S. N. Ge, L. Gao, H. M. Wu,
H. K. Zhao, N. Geng, and G. D. Gad, “Nucleus Accumbens Surgery for
Addiction,” World Neurosurgery 80, no. 3–4 (September–October 2013): S28
e9–19.
13. Antoine Lutz, Heleen A. Slagter, Nancy B. Rawlings, Andrew D. Francis,
Lawrence L. Greischar, and Richard J. Davidson, “Mental Training Enhances
Attentional Stability: Neural and Behavioral Evidence, Journal of Neuroscience
29, no. 42 (2009): 13418–13427; B. Rael Cahn and John Polich, “Meditation
(Vipassana) and the P3a Event-related Brain Potential,” International Journal
of Psychophysiology 72 (2009): 51–60.
14. Andres B. Newberg, Nancy Wintering, Mark R. Waldman, Daniel Amen,
Dharma S. Khalsa, and Alavi Abass, “Cerebral Blood Flow Differences between
Long-term Meditators and Non-meditators,” Consciousness and Cognition, 19,
no. 4 (2010), 899–905.
15. Heleen A. Slagter, Antoine Lutz, Lawrence L. Greishar, Andrew D. Francis,
Sander Nieuwenhuis, James M. Davis, Richard J. Davidson, “Mental Training
Affects Distribution of Limited Brain Resources,” Plos Biology 5, no. 6 (2007):
1228–1235.
198 Notes

16. John Ratey, with Eric Hagerman, Spark: The Revolutionary New Science of
Exercise and the Brain (New York: Little, Brown and Co., 2008), 167–190 and
217–232.
17. Jolanda Mass, Robert A. Verheij, Peter P. Groenewegen, Sjerp de Vries, and
Peter Spreeuwenberg, “Green Space, Urbanity, and Health: How Strong Is the
Relation?,” Journal of Epidemiology and Community Health 60, no. 7 (2006):
587–592, online.
18. Amanda Gardner, “Green Spaces Boost the Body and the Mind,” abcnews.
go.com, October 16, 2009, http://abcnews.go.com/Health/Healthday/green-
spaces-boost-body-mind/story?id=8835912&page=2.
19. www.acestudy.org.
20. Lisa M. Najavits, R. D. Weiss, and S. R. Shaw, “The Link Between Substance
Abuse and Posttraumatic Stress Disorder in Women: A Research Review,”
American Journal on Addictions 6 (1997): 273–283.
21. Bessel van der Kolk with Lisa M. Najavits, “Interview: What Is PTSD Really?
Surprises, Twists of History, and the Politics of Diagnosis and Treatment,”
Journal of Clinical Psychology: In Session, 69, no. 5 (2013): 516–522.
22. Matthew W. Johnson et al., “Pilot Study of the 5-HT2AR Agonist Psilocybin
in the Treatment of Tobacco Addiction,” Journal of Psychopharmacology 28,
no. 11 (2014): 983–992.
23. Many such memoirs are included among addiction self-help books, including,
for example, Caroline Knapp’s Drinking: A Love Story (New York: Dial Press
Trade, 1997).
24. Susan Brison, “Violence and the Remaking of a Self,” The Chronicle of Higher
Education, January 18, 2002, B7. See also Susan Brison, Aftermath: Violence
and the Remaking of a Self (Princeton: Princeton University Press, 2002; Paris:
Editions Chambon, 2003; Munich: C. H. Beck Verlag, 2004).
25. Donna J. Bridge and Joel L. Voss, “Hippocampal Binding of Novel Information
with Dominant Memory Traces Can Support Both Memory Stability and
Change,” The Journal of Neuroscience 34, no. 6 (2014): 2203–2213.
26. Al-Anon is the sister organization to AA, created to provide support and its
own version of the 12 steps for spouses and others who are in close relation-
ships with addicted individuals. Al-Ateen and Adult Children of Alcoholics
are other such programs available in certain areas.
27. Sarah Huggins Scarbrough, “Breakthroughs in Offender Treatment: A Virginia
Program Makes Inroads with Peer Support, Behavior Modification,” Addiction
Professional 10, no. 5 (2012): 13–15. The research for this article was done
as part of Dr. Scarbrough’s dissertation work. Her study is entitled “Drugs,
Crime, and the Gateway Effect: A Study of Federal Crime Defendants.”
28. UK Home Office Report, “Drugs: International Comparators,” www.gov.uk,
October, 2014, https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/368489/DrugsInternationalComparators.pdf.
29. UK Home Office Report, 46.
30. Wiebke Hollersen, “‘This Is Working:’ Portugal, 12 years after Decriminalizing
Drugs,” Spiegel Online International, March 27, 2013, http://www.spiegel.de/
international/europe/evaluating-drug-decriminalization-in-portugal-12-
years-later-a-891060.html.
31. UK Home Office Report, 5.
 Notes 199

9 Conclusion
1. Walter Sinnott-Armstrong, “Are Addicts Responsible?” Perspectives from
Philosophy, Psychology, and Neuroscience, ed. Neil Levy (New York: Oxford
University Press, 2013), 126.
2. Amanda Lenhart, “Teens, Social Media and Technology Overview 2015,”
Pew Research Center, Internet, Science, and Tech, www.pewinternet.org,
April 9, 2015, http://www.pewinternet.org/2015/04/09/teens-social-media-
technology-2015/.
3. Richard E. Nisbett and Timothy DeCamp Wilson, “Verbal Reports about
Causal Influences on Social Judgments: Private Access versus Public Theories,”
Journal of Personality and Social Psychology 35, no. 9 (1977): 613–624; Richard
E. Nisbett and Timothy DeCamp Wilson, “Telling More Than We Can
Know,” Psychological Review 84, no. 3 (1977): 231–359, doi: 10.1037/0033–
295X.84.3.231. Petter Johansson, Lars Hall, Sverker Sikstrom, Betty Tarning,
and Andreas Lind, “How Something Can Be Said about Telling More Than We
Can Know: On Choice Blindness and Introspection,” Conscious and Cognition
15, no. 4 (2006): 673–692.
4. Daniel Dennett, Consciousness Explained (Boston: Little, Brown, and Company,
1991), 115–138.
5. Ryan T. McKay and Daniel C. Dennett, “The Evolution of Misbelief,” Brain and
Behavioral Sciences 32 (2009): 493–561.
6. John H. Holland, Hidden Order: How Adaptation Builds Complexity (New York:
Helix Books, 1995), 39–40, 93–97, and 165–167.
7. C. L. Hart, M. Haney, R. W. Foltin, and M. W. Fischman, “Alternative
Reinforcers Differentially Modify Cocaine Self-Administration by Humans,”
Behavioral Pharmacology 11, no. 1 (2000): 87–91. Also see William W. Stoops,
Joshua A. Lile, Paul E. A. Glaser, Lon. R. Hays, and Craig R. Rush, “Alternative
Reinforcer Response Cost Impacts Cocaine Choice in Humans,” Progress in
Neuro-Psychopharmacology and Biological Psychiatry 36, no. 1 (2012): 189–193.
Bibliography

Alexander, Michelle. The New Jim Crow: Mass Incarceration in the Age of
Colorblindness. New York: The New Press, 2010.
American Psychiatric Association Committee on Nomenclature and Statistics.
Diagnostic and Statistical Manual of Mental Disorders IV-TR. Washington DC:
American Psychiatric Association, 1994.
Bateson, Gregory. “The Cybernetics of Self: A Theory of Alcoholism,” in Steps
to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution and
Epistemology. San Francisco: Chandler Publishing Company, 1982, 315–345.
Bickhard, Mark, “Process and Emergence: Normative Function and
Representation,” Axiomathes: An International Journal in Ontology and Cognitive
Systems 14 (2004): 135–169.
Churchland, Paul. Neurophilosophy at Work. New York: Cambridge University
Press, 2007.
Courtwright, David T. Forces of Habit: Drugs and the Making of the Modern World.
Cambridge, MA: Harvard University Press, 2001.
Damasio, Antonio. The Feeling of What Happens: Body and Emotion in the Making of
Consciousness. New York: Harcourt, 1999.
Deacon, Terrance W. Incomplete Nature: How Mind Emerged from Matter. New York:
Norton, 2012.
Dennett, Daniel. Elbow Room: The Varieties of Free Will Worth Wanting. Cambridge,
MA: MIT Press, 1984.
Dennett, Daniel. Consciousness Explained. Boston: Little, Brown, and Company,
1991.
Dodes, Lance. “Psychodynamic Practice: Individuals, Groups and Organisations,”
Psychodynamic Practice: Individuals, Groups and Organizations, Special Issue: The
Psychodynamics of Substance Abuse 15, no. 4 (2009): 381–393.
Dube, Shanta R., Felitti, Vincent J., Dong, Maxia, Chapman, Daniel P., Giles,
Wayne H., and Anda, Robert F. “Childhood Abuse, Neglect, and Household
Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences
Study,” Pediatrics 111, no. 3 (2003): 564–572.
Everitt, B. J., Dickinson, A, and Robbins, T. W. “The Neuropsychological Basis of
Addictive Behavior,” Brain Research Review 36 (2001): 129–138.
Everitt, B. J., and Robbins, T. W. “Neural Systems of Reinforcement for Drug
Addiction: From Actions to Habits to Compulsion,” Nature Neuroscience 8
(2005): 1481–1489.
Flanagan, Owen. “What Is It Like to Be An Addict?”, in Addiction and Responsibility,
ed. Jeffrey Poland and George Graham. Cambridge, Mass: MIT Press. 2011,
269–292.
Flanagan, Owen. “Phenomenal Authority: The Epistemic Authority of Alcoholics
Anonymous,” in Addiction and Self-Control: Perspectives from Philosophy,
Psychology, and Neuroscience, ed. Neil Levy. New York: Oxford University Press.
2013, 269–292.

200
 Bibliography 201

Foddy, Bennett. “Addiction and Its Sciences: Philosophy,” Addiction 106 (2010):
25–31.
Fodor, Jerry. The Language of Thought. New York: Crowell, 1975.
Fodor, Jerry. RePresentations. Cambridge, MA: MIT Press, 1981.
Greenspan, Stanley I., and Shanker, Stuart. The First Idea: How Symbols, Language,
and Intelligence Evolved From Our Primate Ancestors to Modern Humans. Cambridge,
MA: Da Capo Press, 2004.
Helm, Christine, Plotsky, Paul M. and Nemeroff, Charles B. “Importance of
Studying the Contributions of Early Adverse Experience to Neurobiological
Findings in Depression,” Neuropsychopharmacology 29, no. 4 (2004): 205–217.
Heyman, Gene. Addiction: A Disorder of Choice. Cambridge, MA: Harvard University
Press, 2009.
Kahneman, Daniel. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux,
2011.
Kennett, Jeanette. “Just Say No? Addiction and the Elements of Self-Control,” in
Addiction and Self-Control: Perspectives from Philosophy, Psychology, and Neuroscience,
ed. Neil Levey. New York: Oxford University Press, 2013, 144–164.
Knapp, Caroline. Drinking: A Love Story. New York: Bantam Doubleday Dell
Publishing Group. 1996.
Koob, G. F., and Le Moal, M. “Drug Abuse: Hedonic Homeostatic Dysregulation,”
Science 278 (1997): 52–58.
Koob, G. F. et al. “Opponent Process Model and Psychostimulant Addiction,”
Pharmacological Biochemistry and Behavior 57 (1997): 513–521.
Koob, George F., and Volkow, Nora D. “Neurocircuitry of Addiction,”
Neuropsychopharmacology 35 (2010): 217–138.
Ladyman, James, and Ross, Don, with David Spurrett and John Collier. Everything
Must Go: Metaphysics Naturalized. New York: Oxford University Press, 2007.
Levy, Neil. “Resisting ‘Weakness of Will,’” Philosophy and Phenomenological
Research 82, no. 1 (2011): 134–155.
Maté, Gabor. In The Realm of Hungry Ghosts: Close Encounters with Addiction.
Berkeley, CA: North Atlantic Books, 2010.
Perry, B. D., and Pollard, R. “Homeostasis, Stress, Trauma, and Adaptation:
A Neurodevelopmental View of Childhood Trauma,” Child and Adolescent
Psychiatric Clinics of North America 7 (1998): 33–51.
Perry, Bruce D. “Childhood Experience and the Expression of Genetic Potential:
What Childhood Neglect Tells Us about Nature and Nurture,” Brain and Mind
3, no. 1 (2002): 79–100.
Rapping, Elayne. The Culture of Recovery: Making Sense of the Self-Help Movement in
Women’s Lives. Boston: Beacon Press, 1996.
Ratey, John, with Eric Hagerman. Spark: The Revolutionary New Science of Exercise
and the Brain. New York: Little, Brown and Co., 2008.
Robinson, T. E., and Berridge, K. C. “The Neural Basis of Drug Craving: An
Incentive-Sensitization Theory of Addiction,” Brain Research Reviews 18, no. 3
(1993): 247–291.
Index

12 step programs, 4, 51, 125, 133, 147, anticipation, 36, 43, 119, 159,
156–9, 170 anxiety, 10, 35–6, 66, 76–7, 85,
91,122–3, 138–9, 145–6, 152–3,
A.A. (See Alcoholics Anonymous), 155, 164, 175
84, 131 apathy, 81, 95
abuse, 2, 12–14, 37–8, 42, 52, 60, Aristotle (See Self-Control), 15, 17, 24
62–4, 68, 71, 74–7, 84–9, 92–3, asymmetric dependence, 107
127, 129, 131, 138, 143, 146–8, atomic linguistic theory, 119
152, 157, 167, 169 attachment, 7, 34, 42, 63, 66, 74, 126,
activity-dependent, 122 154, 166
addiction attitudes, 8, 10, 21, 64, 81, 85, 89–90,
history of, 118,130 98, 115, 141, 157, 167, 169
culture of, 79–99 attractor Well, 144–5, 164, 167,
addicted self, 176 173, 175
addictive autonomy, 90, 174
behavior, 132, 134–8, 140–1,
145–147, 149–53, 155, 157–9, baby (See Newborn), 63, 65–6, 74, 113,
162, 164–6, 168–9, 171–4 115, 129, 139
career, 173 Bateson, Gregory, 60, 187
experiences, 126, 141 behavioral economists, 4, 54
thinking, 16, 167–71 belief, 21, 29, 60–1, 89, 93, 104,
patterns, 1, 25, 27, 33, 47, 50, 57–8, 106, 115, 119–20, 155, 158–60,
75, 113, 115, 119, 121, 128, 144, 169–70, 175
148, 150, 167, 169, 170, 172, 175 bias
personality, 95, 133 attentional bias, 170–1
Adverse Childhood Experiences better than average effect, 170
(ACE’s), 63, 65, 152 confirmation bias, 169
adolescence, 62, 64 conservatism bias, 169, 171
advertisement, 83 binge, 36, 95, 127
African American, 86, 166, 182 brain disease, 82
affluent communities, 86 brain imaging, 44, 48, 149, 185
akrasia (See Self-Control), 15–16 Buddhist monks, 149
Alcoholics Anonymous
history of, 84 caffeine, 79
alcoholism, 50–1, 53, 60, 72, 74, 84, Campril, 175
127, 130, 148, 170 cannabis (See Marijuana), 79, 81,
allergy to alcohol, 84 163–4
American culture, 16, 83, 85 capitalism, 83–4
amulets, 175 caregiver, 63, 65–7, 76, 105, 113–15,
anguish, 123 164
animal studies cause and effect, 50, 77, 103
primates, 68–9, 184 certainty, 138
rat rark, 69–70, 93

203
204 Index

cessation, 38, 44, 113, 141, 146, 148, depression, 10, 44, 77, 91, 94, 137,
155, 171, 173 139, 152, 175
childhood, 60, 62–5, 130, 152–3, 164 discounting, 54, 57
choice theory, 4, 15, 20–1, 53 discourse, 11, 19, 25, 83, 124, 173
Christian, 124 disease model, 4, 11, 14–15, 20, 35–6,
cigarettes (See tobacco), 37, 42, 80, 40–2, 46–7, 50–3, 57–8, 73, 76,
94, 97, 111, 113, 123, 132, 140, 84–5, 88, 91, 95, 99, 132
155, 167 disparity, 92
class, 81, 86–7, 95,130–1 divorce, 130, 161
cocaine, 37, 54, 70, 81, 87, 93, 96–7, desire, 17–21, 90, 119, 143, 145, 168,
106, 126, 129, 137–41 173, 175
coffee (See caffeine), 17, 61, 79–81, dogma, 98, 120, 147, 167, 169
142, 164–5 DSM (Diagnostic And Statistical
cognitive biases, 168, 170 Manual), 3, 10–14, 16, 19, 42, 48,
cognitive dissonance, 169, 171 79, 91, 99, 179
cognitive load, 128–9 dopamine, 18, 39, 42–7, 60, 63, 65,
comorbidity 67, 109, 116, 151
anxiety disorders, 77, 91, 152 drug of choice, 9, 38
bipolar, 77, 91, 175 drug policy, 92, 95
depression, 10, 44, 77, 91, 94, 137, dualism, 20–1, 33, 36, 100
139, 152, 175 dual systems, 126, 128, 130, 133–4
complex dynamic system, 6, 25, DUI, 20, 173–4
28, 33, 40, 61, 105, 126, 163, Dynamic Systems Approach, 6
173, 175 dynamical psychological approach,
confidence, 73, 123, 138, 174 137
confirmation bias, 169
conservatism bias, 169, 171 early adolescence, 64
consumer capitalism, 84 ecology, 60–1, 123
consumption, 68, 80, 83–4, 89, 146, ecology of addiction, 60, 187
149, 163 ego depletion, 17, 55, 57, 125–7, 129,
competition, 80, 170 149–50
communication, 40, 42, 102, 120, emergence model (emergent), 6–7,
160–1 23–5, 28–31, 33, 36, 61, 67, 82,
concept, 2, 6–7, 10–11, 13–14, 17–18, 100–1, 109, 121, 143, 166
20, 22–3, 28–30, 33, 35, 41, 50–2, emotional reactivity, 153, 156
82, 84–5, 87, 89, 100–1, 103–21, employment, 87, 127, 162
128–31, 137, 156, 165, 167, 173 emotional responses, 64, 114–15
crack, 87, 93, 97 entropy, 28, 30–2, 105
craving, 18, 35–6, 38–9, 45, 123, environment, 6–9, 14, 22, 24–5, 28,
146–9, 157 31–3, 44, 47–8, 57–8, 61–4, 68–77,
crystals, 175 79, 83, 86, 93, 95, 100, 105, 109,
control, 6, 9, 13–15, 17–21, 24, 36–7, 111, 114–15, 118, 121–22, 137,
40, 48, 51, 53–7, 59, 65, 71, 80, 151–2, 156, 165–8, 184, 189, 190
82–5, 87–8, 90–1, 96–7, 126–35, expectations, 42, 44, 62, 64, 114, 116,
137–8, 141–2, 149–51, 156, 118, 131, 167–8, 171
164–6, 172, 174 exposure, 3, 9, 35–8, 44, 46, 56, 62,
69, 86, 152, 167
denial, 88, 168–9 evolution, 2, 31, 66, 84, 104, 117,
Dennett, Daniel, 168 156–7, 167–8, 170, 172
 Index 205

family, 88, 94, 101–2, 108, 114, 117, industry, 53, 81, 82, 84, 87, 96–7,
124, 130–1, 167, 172, 176 140
fast food, 79, 81 industrialization, 82
fate, 135 inequalities, 10
faith, 162 infant (See Newborn), 65–6, 74, 114,
fear, 4–5, 37, 66, 81, 114, 122–3, 162 164
Flanagan, Owen, 123 informational atomism, 105–6
Fodor, Jerry, 105 inhibition, 18
food addiction, 79, 97, 99 innate, 103–5
free will, 14, 21, 53 interpersonal bargaining, 132
freedom, 20, 83, 85, 102, 123, 157 intervention, 18, 36, 46, 85, 88, 144,
friends, 77, 101–3, 111, 122, 130, 152, 156, 171, 176
164, 168 intentionality, 16
fMRI (See Brain Imaging), 48–9 intentional self-control, 129
isolation, 4, 22, 60, 65–6, 77, 95,
gambling, 2, 12, 37–9, 43, 70, 88, 91, 135–6
95, 97–8, 135, 167, 174
genetics, 25, 33, 35, 58, 72–6 Korean culture, 89
gestalt, 8, 102, 117, 119–20, 156–7
gestation, 62, 74–5 labor, 79–80, 82, 93, 192
globalization, 82 language of thought, 108
God, 4, 104, 111, 124, 156, 159 lever points, 6, 172–3
guilt, 91, 94, 161–2, 175 life
life changes, 173, 175–6
habituation, 39–40, 45, 127, 144–5 life circumstances, 129
habitual behavior, 145, 169 Lifering Secular Recovery, 157, 173,
hallucinogens, 155 175–6
happy hour, 81, 95 Locke, John, 103
hedonic theory, 132 LSD, 97
healthcare, 81 Ledoux, Joseph, 37
hemp (See marijuana), 81, 182 love, 88, 107, 117, 128, 131–2, 135–6,
heritability (See genetics), 72–3 140, 153–4, 160–1, 173, 176
Heyman, Gene (See choice theory), low-income, 87
3, 13, 52, 73, 90, 117
hitting bottom, 88, 173–4 mantra, 114, 149, 158
Hume, David, 103, 111 Mate, Gabor, 75, 122, 129
hyperbolic discounting, 57 maternal care, 68
hypothalamic-pituitary-adrenal marijuana, 13, 77–8, 86, 96–8
(HPA-axis), 65 meaning holism, 119–20
meditation, 11, 145, 149–51, 164,
identity, 31, 47, 83, 123 175–6
illegal drug, 85–7 mental representation, 105–6,
immigrant, 87 108, 111
imprinting, 103 memory, 37, 41, 45, 48, 64, 66, 144,
impossibility, 104 148, 150, 153
impulse Control, 37, 90, 150, 156 mereology, 22–3
incarceration, 86–7, 97–8, 162, 174 metaphysics, 6, 12, 20, 22, 26–7, 31
incentive sensitization, 38, 45–6, 123 methamphetamine, 37, 54, 92,
incentive salience phenomenon, 127 130–1
206 Index

mind, 4–7, 12, 14, 20–1, 25–9, 32, 36, poor, 10, 21, 40, 56, 80, 86–7, 89, 92,
47, 62, 99–100, 106–114, 120, 94, 97–8
149, 152, 154, 168 post-traumatic stress disorder (PTSD),
mind altering chemical, 142, 147 91, 121, 152–4
miscommunication, 120 poverty, 86–7, 92, 94, 192
modularity, 49, 50 pragmatism, 105
motivation, 21, 36, 38–9, 42–6, 48, 51, prescription drugs, 81, 86, 96–7
53–6, 58, 68, 136, 143, 148, 156, price, 81, 93, 113
158, 172–4 prison, 86, 97, 118, 158, 161
protestant work ethic, 83
Naltrexone, 146, 175 profit, 46, 80, 82, 84, 97, 165
naturalism, 104, 109 prohibition, 84, 90, 98
nature, 25, 73–4, 83 prototypes, 109, 112, 115, 119,
Neil Levy, 17, 56 120, 125
nicotine (See Tobacco), 13, 37, 42–3, psychostimulants, 37, 42–3
47, 146 psychodynamic Theory, 136
necessity, 104 punctuated equilibrium, 126–7, 132
neural networks, 144 punishment, 71, 93, 174
neural systems, 2, 7, 40, 110, 144, 149
neuropsychology, 62 rage, 137, 139
neurotransmitter, 2–3, 6–7, 21–2, race, 77, 86
41, 43–4, 63, 65, 108, 144, 148, Rational Recovery, 173
151, 154 recovery, 3–4, 8, 10, 102–3, 105, 117,
normal/normality, 18, 22, 27, 42, 46, 142, 157, 159–60, 173, 175–6
64, 67–70, 90, 99, 106–7, 123, reductionism, 23, 33, 100
129–31, 137, 144–5, 153–4, Reiki, 175
162, 164 reinforcement, 43, 114, 157, 174
normative self-control, 128–9 rejection, 99, 122
nurturing, 62, 69, 114 relapse, 39, 42, 44–5, 50–1, 54, 56–7,
nutrition, 86, 94, 166, 175 62, 68, 71, 102, 121, 130, 143–4,
146–7, 150, 153, 167, 173
obsession, 95 release, 41, 63, 123
opium, 18, 37, 79–80, 93–4, 97, 137 remorse, 1, 20, 95, 102, 158
opioid manufacturers, 96 repression, 139
oxycontin, 37, 96 responsibility, 51, 84, 90–1, 125, 127,
morphine, 1, 37, 51–2, 69–70 136, 141, 157–8, 161, 166
reward
peers, 68, 77–8, 93–4, 115 reward circuit, 21, 43–4, 48, 60
perceptual apparatus, 109 reward seeking, 123, 127
personality, 73–4, 95, 132–3, 148
phenomenal authority, 124 salience, 3, 18, 33, 39–40, 45–6, 48,
phenomenology, 8, 122–3 125, 127, 136, 145
pharmaceutical, 96–7, 147 secrets, 135
philosophy, 15, 28, 99 sedatives, 139
Plato, 103–4 self-control, 17, 55–7, 126, 128–9,
plasticity, 7, 14, 41, 68, 151, 159 137, 150, 156
pleasure, 2, 37–8, 42, 44, 46–7, 63, 70, self-esteem, 167
84, 113, 115, 119, 127, 132, 138, self-medicate, 137, 139
148,158–9 self-regulation, 42, 65, 83, 153
 Index 207

self-medicating hypothesis, 137, 139 tipping point, 173, 175

semantic connections, 112 tobacco, 78–81, 132, 149
sensitization, 38, 40, 45–6, 64, 123, 153 treatment, 1, 4, 8, 11–14, 21, 27, 46,
sexual abuse, 63, 88 51–3, 58, 76, 82, 84–5, 88–90,
shame, 81, 97, 136, 161, 175 95, 99, 101, 124–5, 131–3, 140,
sin, 91 143, 147–9, 152–3, 155–6, 158,
smoking (See tobacco), 39, 47, 77–8, 160–63, 168, 173, 175
80, 94, 132, 134, 146, 148, treatment centers, 84–5, 99, 124
155, 173 trauma, 1, 7, 34, 46, 58, 64–5, 68, 76,
sobriety, 13, 39, 127, 130–1, 142–3, 87, 91, 114, 122, 125, 132–3, 135,
156, 160, 171, 175 137, 139, 152, 153–5, 160, 164,
sober self, 176 166, 172, 174–5
social triggers, 9, 39, 45, 56, 117–9, 121, 127,
social agenda, 90 159, 171
social anxiety, 77, 122 truth, 12, 51, 61, 107, 112, 121, 138
social control, 84, 87 twin studies, 11, 35, 58, 75–6
social construct, 2, 8, 82, 89, 99,
103, 126, 172 unconscious, 41, 60, 75, 118–19,
social environments, 64, 75, 77, 145, 159
83, 100
social problem, 103, 192 values, 13, 45, 83, 104, 121, 151,
social systems, 23, 161, 172 155–6, 169
soul, 6, 103, 178 video Games, 12, 37, 95, 123
spiritual awakening, 117, 156, 176 vulnerability, 58, 62, 66–7, 72, 75–6,
stigma, 3, 51, 85, 87, 90, 97–8 100, 136, 141
stimulant, 37, 42–3, 80, 91, 137, 142,
183–5, 201 weakness of will (See Self-Control),
stress, 13, 34, 42, 45–6, 55–6, 58, 15, 17–18, 53
62–72, 74, 77, 83, 86–8, 91, 94–5, wealth, 80, 86, 92, 161
99, 114, 117, 126–8, 145, 152, Wilson, Bill, 84, 123
154, 164, 166, 175–6 withdrawal, 36, 38, 44, 69, 125, 127,
suboxone, 142, 175 132–4, 137, 146, 151, 154
syntax, 112 working class, 81, 192
symbolic encoding, 108 working memory, 150
worldview, 66, 102, 112, 157
talk therapy, 8, 164, 175
tax revenue, 80, 82 yoga, 151, 153, 175–6
teenagers, 94, 115, 166
the good life, 129–31, 137 Zohydrol, 96