By Steve K.

In the field of addiction studies there is an ongoing debate in relation to how much voluntary choice is involved in addiction to alcohol and other drugs. During a recovery group discussion meeting that I attended recently different viewpoints were expressed in relation to this topic. The majority of the people involved in the discussion considered themselves to have lost all control during their active drinking and drug using careers. However, not everyone was so certain about this and the idea of choice, particularly in relation to their recovery, was important to some people in the meeting.

The two models relating to addiction that represent the positions of ‘choice’ vs ‘compulsion’ are, respectively, the ‘moral’ model, and the ‘medical’ or ‘disease’ model.

Simply put, the ‘choice’ or ‘moral’ model suggests that people make decisions about payoffs and pleasure, particularly in the short term, and the decision to use alcohol or other drugs is often most attractive at the time and in the circumstances. It’s a view that’s given to explain people’s decision to stop using when the consequences of doing so become too unpleasant, or when their circumstances change.

The ‘disease-concept’ advocated by mainstream medicine views addiction in the following way:

“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to harmful behaviours seen in people who abuse drugs. The disease of addiction affects both brain and behaviour, and scientists have identified many of the biological and environmental factors that contribute to the development and progression of the disease.”

Recognizing Addiction as a Disease Act 2007

These models are viewed by many as opposing each other – the ‘choice’ or ‘moral’ model suggesting that addiction is the result of voluntary action, and the ‘medical model’ suggesting that addiction is the result of a compulsion, and therefore, not voluntary.

The Twelve Step Perspective

The 12-Step approach strongly suggests that addiction is the result of a ‘merciless obsession’, which then renders the sufferer virtually no control over the choice to ‘use’ or drink:

“The fact is that most alcoholics, for reasons yet obscure, have lost the power of choice in drink. Our so called will power becomes practically non-existent. We are unable, at certain times, to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago. We are without defense against the first drink.”

Alcoholics Anonymous, 3^rd ed, p.24.

The 12-Step approach is viewed as strongly aligned with the medical model of addiction. It is also often considered responsible for creating the ‘disease-concept’, which isn’t strictly true. (1) It is more accurate to say that Alcoholics Anonymous (AA) adopted the medical viewpoint and language of the time (1930’s) in line with its members’ experience of addiction to alcohol.  A point made clear by the recovery historian William L White:

“AA’s use of medical metaphors served as a reminder of its belief that the alcoholic could never again safely drink alcohol.” (2) 

In addition, AA views alcoholism as primarily a spiritual illness, and, confusingly for many, conflates this idea with the medical viewpoint.  Personally I’m ok with the integration of spiritual and medical (“mind, body and soul”), as I can understand how spiritual disconnection, in a secular sense, can contribute to the development of addiction. Think of the native peoples of North America whose displacement and disconnection from their homelands, cultural values, traditions, and spiritual practices created feelings of painful and meaningless existence, in turn leading to great problems in relation to addiction and mental illness.  Spiritual disconnection through active addiction is also a common consequence according to many sufferers of the condition.

The Middle Way

For me, the ‘choice vs compulsion’, ‘black or white’ distinction in relation to addiction is too simplistic. Addiction is complex involving various bio-psycho-social-spiritual influences that impact upon an individual’s ability to make healthy and rational choices.  I do think that as addiction develops the power of choice is significantly diminished and corrupted. The experience of most addicts “will abundantly confirm this”. (3) However, I don’t believe that the addict’s power of choice is completely removed either, and there is plenty of research evidence to validate this contention. (4) Given enough incentive even the most addicted can choose not to drink or use in the short-term. The problem is maintaining this choice in the longer-term due to the “insane urge” of addiction. (5)

Ignoring the complexities of the philosophical debate in relation to the existence of “free will” (6), I think that the human capacity for choice plays an important role in recovery from addiction for most of us. Once we are broken enough by our suffering we become willing to choose recovery activity and connection. For me, this engagement with recovery activity, people and principles, which support my decision to live a sober way of life, empowers me to continue to make the right choices. My capacity to choose healthy sobriety is progressively strengthened through voluntarily attending 12-Step meetings and connecting with people in recovery and their example and support. I’ve also found that the principles contained within the 12-Step ‘program’ have greatly influenced my ability to choose continued sobriety.

In the same way that my addiction to alcohol and other drugs was strongly influenced and directed by both internal and external determining factors, so is my continued recovery from addiction. In line with the humanistic presumption of ‘free will’, I believe that we humans have the capacity to interact with the influencing forces in our lives, creating new direction, purpose and change for ourselves and others. This perspective is often referred to as ‘soft-determinism’ (7), which can be described as the middle ground between ‘choice’ and ‘no choice’.

This position feels right for me and accords with my experience of addiction and recovery, as well as research in relation to choice. (8) It also avoids the extremes of a black or white debate and wisely chooses a grey picture instead, which as I grow older is increasingly how I see things in this mysterious existence that we call life.

 

References:

1. AA and the Disease Concept: A Complex Connection. By William L White.
2. Ibid.
3. Alcoholics Anonymous, p.23, 3^{rd ed.}
4. Addiction: A Disorder of Choice.  By Gene Heyman Ph.D.
5. Twelve Steps and Twelve Traditions, p.22.
6. Freewill vs Determinism. By Saul McLeod, updated 2019.
7. Ibid.
8. Addiction: Choice or Compulsion?  By Edmund Henden, Hans Olav Melberg, and Ole Jorgen Rogeberg.

Recommended Reading:

Choice Isn’t Simple.  By Marc Lewis Ph.D.  

The Biology of Desire.   By Marc Lewis Ph.D.

The Multiple Pathways to Addiction and Recovery.  By Steve K.