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    Addiction

    'The Addict' – the danger of a single story

    Reyna Ramaswamy looks to remove morality from our concept of addiction.

    10 June 2024

    In Johann Hari's 2015 TedTalk, 'Everything you think you know about addiction is wrong', he concludes: 'For 100 years now, we've been singing war songs about addicts. I think all along we should have been singing love songs to them, because the opposite of addiction is not sobriety. The opposite of addiction is connection'. With increasing rates of drug related deaths (3127 in 2022) (Office for National Statistics, 2023), heightening rates of drug use (9.5 per cent of all people aged 16-59 reporting using a controlled drug in the year up to March 2023) (Office for National Statistics, 2023b), this perspective feels more pertinent than ever. 

    We've reached a time where mental health problems are largely recognised as real struggles and are being treated with increasing understanding, yet addiction remains highly stigmatised. Crisp et al. (2000) conducted a survey to determine opinions of the British adult population about those with both alcohol and drug addiction: 47-78 per cent of responses viewed those with addiction as being a danger to others, at fault for their addictions, and as needing to 'pull themselves together'. Moreover, further studies have also shown how health professionals view those with Substance Use Disorder as being violent, manipulative and lacking motivation (van Boekel et al., 2013). 

    Despite considerable advancements in understanding addiction, society continues to face challenges in embracing a more compassionate approach towards people struggling with this condition. The prevailing perception of this disorder remains rooted in moral judgement rather than a holistic and nuanced understanding of its complexities. 

    Beyond dichotomies

    As Carl Erik Fisher says in his novel The Urge, 'centuries of policy, stigma, and racism are all inseparable from how we currently understand and treat, or fail to treat, addiction. We have long wielded the concept of addiction as a weapon, using it to wage war – not just "on drugs" but also on people who use drugs'.

    The stigma around addiction is unequivocally one of the main things that serves as a barrier to individuals attempting to seek support. Although there has been progress in the mitigation of terms such as the derogatory 'drunkard' or 'junkie', the prejudice remains apparent.

    Chimamanda Ngozi Adichie discusses the 'danger of a single story' in her 2009 TedTalk. She explores the consequences that arise from stereotypes, and how generalisations and preconceived notions give way to harmful attitudes and prejudice. Though her focus is primarily on racism, her overarching idea can be applied parallel to addiction, where the far from sympathetic single story of 'The Addict' perpetuates harmful stigma. 

    The formation of schemas and stereotypes is a characteristic of human nature. Despite our efforts to avoid this, the prevailing archetype of addiction reflects perceptions of selfishness, weakness and immorality. Society tends to impose strict guidelines on what constitutes an 'acceptable' mental health struggle – 'The Addict' veers from that checklist, imposing barriers on their ability to pursue help. 

    To understand the damage of this 'single story', we need to look beyond the dichotomies of addiction we've established. Clear-cut concepts of consequence, responsibility and blame enable a short-sighted and biased view of 'The Addict', encouraging stigma. It's hard to understand complexities in situations where actions seem justifiably 'wrong', but it's important to ask ourselves: is it really this black and white? Is the principle behind The Addict's choices representative of their character and values? Are we overlooking the internal struggle clouding the distinctions of the binary 'choice or compulsion'?

    As Marcus Aurelius famously said in 'Meditations VII': 'All things are interwoven with one another; a sacred bond unites them; there is scarcely one thing that is isolated from another' (Marvelly, 2016). To be able to treat addiction effectively, we need to realise that it surpasses centuries of medicine, psychology and philosophy, and is far from a discrete entity. We need to delve into the grey.

    The morality of addiction

    Any move towards change begins with a foundational understanding. Why do we view addiction as immoral? What criteria define addiction, and how do we even define 'immoral'?

    For centuries, philosophers have tried to explore the complexities of morality and immorality. Kant proposes morality to be based on duty, where individuals must act with autonomy and without personal incentives. The principle of an action is viewed as a universal law, prioritising treating others with respect and dignity. 

    Hume, however, argues that morality is based on emotions and sentiments rather than duty and reason alone. Distinctions between a 'virtuous or vicious' character are based on the human capacity for sympathy and disapproval, thereby determining moral responsibility.

    A more modern interpretation is that of Robert Kane. He suggests morality to be dependent on Libertarian Free Will, where an action has to be fully autonomous and without effect of a causal chain. For an individual to be wholly responsible for an action, they need to be morally responsible for the formation of their character and motives.

    My proposed rationale is this: for an action to be deemed immoral, its intention is solely to violate basic ethical guidelines. When judging intent, the extent of the individual's ability to exercise Libertarian Free Will should be accounted for. Consequences that arise unprecedented or separate from intent are disregarded when determining morality.

    It's impossible to find a 'test for morality' that everyone agrees upon and can wholly encapsulate the complexities of this concept. Differing views of free will based around determinism, compatibilism and libertarianism mean we will never reach a definition that pleases everyone. Philosophy in itself is characterised by its diverging viewpoints, and instead of eradicating questions about addiction, it builds more. It's essential to look below the surface to understand why a choice gets made and what affects the decision-making process.

    A key fact is that an addicted brain is a different brain. Free will is curbed, actions are not representative of a person's 'true self' or the decisions they might have made with their 'normal' brain. 'The Addict' didn't choose to develop an addiction and make aberrant decisions – they are not the bad people we view them as. As 2006 Miss USA Tara Conners said in her 2016 TedTalk: 'I wasn't a bad person trying to act good; I was a sick person that needed to get well'. Addiction is an amoral condition and it's vital that it is understood as such.

    Are addictive behaviours volitional or non-volitional?

    Responsibility and accountability are both vessels driving our stigmatised view of addiction. If 'The Addict' isn't inherently bad or immoral, why aren't they able to take accountability for their actions, see the effects of their addiction and make a change? Can't they be held responsible for the aberrant consequences of their condition?

    The DSM-5 refers to addiction as 'Substance Use Disorder' (SUD). The key characteristics are described as being dependency and tolerance, loss of control, social problems and risky or detrimental usage. One of the most critical aspects of the criteria is 'repeated attempts to quit/control use' – relapse. 

    In The Urge, Fisher describes addiction as being 'a terrifying breakdown of reason', where individuals 'often watch themselves, clear-eyed, do the very things they don't want to do'. With drug-relapse rates as high as 85 per cent within the first year of treatment (Sinha, 2011), it's easy to assume that these statistics are due to excuse making, a lack of motivation, or an inability to take enough responsibility to 'really try hard in recovery' and make the right decision.

    Steve Hyman discusses how 'there continues to be a debate on whether addiction is best understood as a brain disease or a moral condition. This debate … is often motivated by the question of whether and to what extent we can justly hold addicted individuals responsible for their actions.' (Hyman, 2007). This raises the question: should volition determine our ability to hold 'The Addict' responsible?

    As mentioned by Nick Heather in his 2017 article for The Psychologist, the characteristic trait of addiction is the 'interplay between volitional and non-volitional processes that constitute the addict's predicament'. Moving beyond the dichotomy, he allows for a more complicated understanding of this mental illness that can be further explained by delving into other fields.

    One crucial distinction to make is that liking things and wanting things are two different cognitive processes. 'Wanting' is linked with the release of dopamine, whereas 'liking' is not dependent on it. The Incentive Sensitisation Theory (IST) proposes that addiction is an interplay of the cognitive cues of 'wanting', without necessarily 'liking'. 'Wanting' is largely linked with reward cues caused by the release of dopamine (Berridge & Robinson, 2016). The abnormal dopamine levels within the brain released after the use of substances is largely indicative of addiction and cravings (Sinha, 2013). This then leads to dependence, and the inevitable addiction follows. 

    The psychological theory of motivational salience suggests how an individual is encouraged/discouraged towards a behaviour depending on either wanting, or fear. Coupled with the idea of relative reinforcement where 'individuals are likely to engage in a behaviour if it is more reinforcing and readily available than other possible options' (Foxx et al., 2022), it helps expand on the IST, suggesting why 'volitional' may not be the right word to describe 'The Addict's' actions. To further explore the area between the two binaries, we need to revisit Philosophy.

    Is 'The Addict' really weak-willed?

    The Greek word Akrasia is described as being the tendency to act against one's better judgement. In other words, a lack of willpower and mental strength. Addiction is often characterised as being representative of akrasia, yet generalisations mean this concept helps support our stigma of 'The Addict' being weak-willed. 

    The relationship between akrasia and addiction is vastly different from its common manifestations in someone's day to day life. It's not the simple matters of procrastination or having another slice of cake. Considering the biological aspects of addiction is imperative to understand how akrasia manifests within addiction. 

    The struggle experienced when going against the individual's better judgement is a part of akrasia not hugely explored, but is most representative of addiction. The struggle is expanded in metaphor of the chariot, which better illustrates the conflicted nature of addiction. It suggests that 'reason' is the action of driving the chariot, but you're being pulled in two different directions by two different horses; one represents 'noble' intention, the other represents 'ignoble' intention. 

    'The Addict' might clearly know which is the better option and might realise the consequences of their aberrant behaviours yet feel unable to make a change. This is not solely due to a weakness of will. 

    Brendan de Kennesy, in an article published in The Vox, says 'An addicted person behaves the way she does not because she has bad judgement or skewed priorities, but because she is blocked from acting on her true values by her supercharged "wanting system."… It may not be impossible to resist these cravings, but it is extraordinarily difficult.' 

    Addiction isn't a condition that wholly obviates responsibility. It can't act as an excuse for the consequences, yet the interplay between volitional and non-volitional behaviours is critical to understand. When we see the single story of 'The Addict', we are blind to their internal struggle, unable to understand the strength of cravings, ignorant to the fact that 'The Addict' is a victim to their addiction. 

    Causation

    It's human nature to want an easier solution, to want to escape negative emotions and feel good. It's easy to view the first decision to take substances with prejudice, yet this fuels our single story of 'The Addict'. Addiction may begin with an unwise decision, but situations always differ and this single story disregards the unique emotions and experiences underlying a 'choice'. A plethora of risk factors and protective factors can affect an individual's ability to develop an addiction. We cannot continue to stigmatise others because of a choice that spiralled, that we ourselves could be vulnerable to were situations different.

    40-60 per cent of someone's risk of addiction is determined by epigenetic factors (National Institute on Drug Abuse, 2020), making some people more prone to addiction. The biased observer doesn't understand that everything is situational, everyone is different and responds to things differently. The development of merely using substances to dependence and then addiction is rapid and unpredictable, and once someone is established as being 'The Addict', understanding, compassion and care is the last thing they receive. 

    The prefrontal cortex is largely associated with the ability to make decisions, assess situations and keep wants under control (National Institute on Drug Abuse, 2020). It is only fully developed at the age of 25 (Arain et al., 2013). Adolescence is a key period of time for brain development, and is associated with impulsivity due to constant development of the prefrontal cortex. Almost three-quarters of individuals being treated for substance use begin substance use at 17, and 1 in 10 at the age of 11 or younger (Poudel & Gautam, 2017). With constantly declining ages of alcohol consumption (from 24 to 17) (Nair et al., 2016), it's essential to consider why we continue to blame 'The Addict' for a choice they might have made when their brain wasn't even fully developed.

    It's easy to say 'The Addict' is at fault for having developed their addiction. The biggest difference between addiction and other mental health disorders such as depression is that addiction is perceived to be controllable and its severity in the hands of those struggling with it. We attribute it to a 'bad choice', interacting with the wrong people, an easy way out, and so much more. None of us views that choice as a mistake, as something 'The Addict' themselves might regret. We all make unwise decisions, yet for those with addiction, we let that decision define them and perpetuate our 'single story'. 

    Moving beyond dichotomies

    Our established dichotomies of addiction being 'voluntary or involuntary, 'volitional or non-volitional' and a 'choice or compulsion' have split this condition into a debate. The answers to these questions are messy and it's impossible to encapsulate the nuances of addiction within such strict guidelines. Biology, psychology, philosophy, sociology and circumstances both explain yet cease to explain addiction. What we need is humanity, love, connection. Addiction is paradoxical – it's neither of the binaries yet both at once. Despite all these contradictions, one definite truth remains: we need to treat it.

    We can observe vastly differing responses to addiction where some seek help and recover, some spend years in treatment with constant relapses, some don't even realise they have an addiction, some don't appear to care or want to overcome their struggles. Despite this, the overarching story is that of struggle, desperation and loss of free will. 

    Addiction is a brain disease, a mental illness, a coping mechanism, a biological abnormality, a form of self-medication, an uncontrollable chain of events, a voluntary action that cascades into a blur between dichotomies, and so much more. As messy as addiction is, the only clear aspect is what it isn't: a moral failing, a character flaw, a sign of a bad person. 

    We need to eradicate our single story and replace it with one of compassion. We've so long viewed 'The Addict' as immoral, yet it's important to consider: are we the immoral ones, defiantly neglecting help and empathy to those who are victims to their illness?

    • Reyna Ramaswamy is in the last year of a IB diploma at Tanglin Trust School, Singapore. 

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