One
Foundations: Before "Addiction"
I get an immediate sense of how Susan's doing from the moment she walks through my office door. When she's not drinking, she's meticulously groomed, hair just so, sharp business-formal blazers and crisp shirts over her tense, thin frame. But today, I can tell, she's slightly off. Over the years I've learned the tells. A little too much perfume to mask the smell of morning drinks. Hair askew. Rumpled shirt. Slightly sloppy makeup.
I've also seen her in total crisis, with dirt caked under her fingernails and alcohol fumes lingering in the room long after she leaves. But to her, just to be drinking at all feels like a crisis. She identifies as an alcoholic, she is certain that she wants to stop drinking, and yet she does not, and this is what she hates the most-the disorder, the lack of control. I can see she is struggling with this feeling now.
She tells me about the most recent relapse. Alone in her room, she felt restless, and she couldn't get the thought of drinking out of her mind. She had firmly decided that she wouldn't have wine that night. She absolutely would not go to the liquor store. Then, in a twisted compromise, she watched herself walk to the corner store and buy a few bottles of vanilla extract.
The vile liquid made her drunk, then sick to her stomach, she tells me. Eyes wide, she says, "It was ridiculous."
These days in my psychiatry practice, I mostly see people with complicated substance use problems: people who still struggle after spending thousands of dollars on rehabs and outpatient programs, people for whom the traditional treatments don't work nearly often enough. Susan has gone to those programs-both the old-school abstinence-based rehabs and the more modern and flexible treatment programs-but she's never stopped drinking. For months, she's lingered in that in-between place, still doing some minimal work in her private legal practice, making enough to get by, but well below what she could.
She is in a notable minority: the fewer than 5 percent of people in the United States with substance use problems who actually believe they have a problem and want treatment. Even so, despite the alcohol withdrawal seizure she had a few months ago, despite the blackouts, despite losing her corporate job, she has not been able to stop.
She is not in any physical danger now. She hasn't had enough to be in alcohol withdrawal. Still, she says, this is awful for her. She dwells on the last month of failed resolutions and unsuccessful attempts to cut down, and as she goes around and around, butting up against the limits of language and reason and trying to make sense of it all, a note of frustration, even desperation, enters her voice.
"I know what I need to do. I want to do it. But I don't do what I want to do. And then I'm drinking again, and I just don't know why or how."
Addiction is a terrifying breakdown of reason. People struggling with addiction say they want to stop, but, even with the obliterated nasal passages, scarred livers, overdoses, court cases, lost jobs, and lost families, they are confused, incredulous, and, above all, afraid. They are afraid because they cannot seem to change, despite the fact that they so often watch themselves, clear-eyed, do the very things they donÕt want to do.
For thousands of years, people have struggled with the frightening phenomenon that Susan faced. It's not always easy to find, as few ancient cultures had a term for what we would recognize as addiction. For example, the ancient Greeks had the word philopots, a "lover of drinking sessions," but the word itself didn't necessarily indicate that someone had a problem.
And yet, in other times and cultures, addiction is clearly present. Teng Cen (AD 1137-1224), a Chinese poet of the Song dynasty, described how he made a pact with the gods to stop drinking, only to succumb to cravings during a banquet-he ultimately rationalized it by convincing himself that it was in his "true nature" to drink. The Chinese literature scholar Edwin Van Bibber-Orr has documented several other Song dynasty works describing shi jiu, a love of drinking marked by craving, desire, and thirst that bears striking similarities to what we call addiction today.
But one of the oldest examples of addiction in history concerns not substances but gambling, a behavior nearly as old as human civilization itself. In the Rig Veda, an ancient compilation of Vedic Sanskrit hymns from India, among the oldest surviving compositions in any language, an evocative poem known as the "Gambler's Lament" presents an unambiguous description of gambling addiction. In a text that likely dates to before 1000 BC, a fourteen-line poem captures in vivid detail the despair of a man who struggles unsuccessfully against his desire to play at dice.
At the start of the poem, we learn that the dice have already inflicted a heavy toll. The gambler has driven away his true community, his devoted wife and mother. Yet despite that wreckage, for much of the poem, he struggles to stop. He resolves not to play with his fellow gamblers-but then, at the sound of the dice's voice, he rushes to them "like a girl with her lover." His body is aflame. He feels as if the dice themselves have power over him:
The gambler goes to the hall of play asking himself, "will I win?" puffing himself up with "I will win!"
The dice run counter to his desire, conferring the winning throws on his opponent.
They are just "dice"-but hooking, goading, debasing, scorching, seeking to scorch,
giving (temporarily) like a child, then in turn slapping down the victor,
infused with honey, with power over the gambler.
The power of the dice is mystifying. (Note: the dice acquire their own agency, going from "scorching" to "seeking to scorch.") The gambler swings between guilty excitement, anger at the dice, scorn at his weakness, and shame. The very roll of the dice evokes the gambler's own descent into the pit of addiction: "Downward they roll, and then spring quickly upward, and, handless, force the man with hands to serve them." Still, the gambler is not completely compelled, as there is a paradoxical play between the gambler's agency and helplessness; at times he is able to exert some choice; at others he is completely overpowered.
The final stanza of the poem is intriguingly ambiguous; contemporary scholars have arrived at drastically different translations. In one possibility, the man is freed from the shackles of gambling and he beseeches his friends not to resent him for it and to seek their own release. In another version, he begs the dice to have pity on him, to calm their inner fury, and to move on to another victim. In yet another interpretation, somewhat chillingly, the dice themselves speak of how it is futile to be angry at the awful, sublime, and timeless power of addiction over humanity: "Old gambling friends, be kind to us! Don't be disgusted with our power. / Calm your resentment from within, and pass us to another foe to conquer."
IÕve been using the word Òaddiction,Ó but before going further, itÕs important to reemphasize that addiction is not a tumor or a bacterium but an idea-or, more correctly, a set of ideas. Addiction is not outside of the historical process, sitting there as an independent fact waiting to be discovered. The term ÒaddictionÓ was not adopted until recent centuries, but the concept of addiction, loosely conceived, could include everything from the notion of addiction as a disease to sweeping philosophical formulations of will and self-control. Well before our modern notions of addiction took shape, thinkers puzzled over those concepts-in fact, they form the foundation of our ideas about addiction.
Addiction is often explained in terms of a dichotomy of free choice versus total compulsion. By claiming that addictive behaviors are simply a kind of choice, people have justified punitive measures for centuries, from putting drunkards in the stocks to imprisoning people for drug possession. If their drug use is a free choice like any other, the argument goes, people should accept responsibility for their behavior, including punishment. The opposite view, which these days is commonly presented as a compassionate counterargument by neuroscientists and advocates, is that addictive behaviors are involuntary and uncontrollable compulsions, and thus people with addiction deserve compassion and treatment, rather than punishment.
But in cases from the gambler of the Rig Veda to my patient Susan, this dichotomy between choice and compulsion is unsatisfying. Lived experience flies in the face of such a stark binary, and many people with addiction feel themselves occupying a confusing middle ground between free choice and total loss of control. The thing that is terrifying to Susan, and to many others like her, is that they watch themselves making a choice even while feeling there is something wrong with the choosing. It is, in other words, an issue of disordered choice: a problem with choice, choice gone awry.
The ancient Greeks had a word for this experience of acting against your present judgment: akrasia, often translated as "weakness of the will." Akrasia isn't just doing something that is arguably harmful, like eating too much pie or spending too much money on clothes. Everyone indulges, even though indulgence is rarely the best option according to a cold, utilitarian calculus. Akrasia is doing something even though you truly believe it would be better not to, of recognizing in the moment that you are acting against your better judgment.
Akrasia was a controversial concept from the start. Socrates (as depicted by Plato) developed one argument in the Phaedrus that dismissed akrasia out of hand as a simple matter of choice. There could be internal conflict-pleasure and judgment often "quarrel inside us"-but people never truly act against their better judgment. Though Socrates allowed that people could be buffeted by desires and aversions leading up to a decision, at the moment of truth, he said, people always choose what they think is best for them at the time. They might come to regret their choices later, but that doesn't mean they were suffering from a lack of self-control. As he famously declared in the Protagoras, "No one who either knows or believes that there is another possible course of action, better than the one he is following, will ever continue on his present course."
Aristotle, on the other hand, was deeply invested in the idea of akrasia. To him, it was self-evident that people sometimes acted against their better judgment. He saw more nuance in the notion of choice, and he believed there were various ways that internal conflict might interfere with that choice. Surely, he asked, emotions or misguided reason can often get in the way of one's better judgment? The contemporary philosopher Alfred Mele has described the process in terms that might sound familiar: "Fred" decides to take a month off from after-dinner snacks. Around the fifteenth, his resolve starts to waver. He sees a slice of pie in the fridge. He recognizes the temptation and says to himself, It would really be best not to eat the damn thing. Then, even as he's telling himself that it's a bad idea, Fred calmly takes it out, carries it to the table, and scarfs it down. Socrates attributed poor choices to ignorance, but in this description of akrasia, Fred seems to fully understand the decision he's making.
Socrates's student Plato later arrived at a different point of view. He understood the problem of self-control partly as the result of a divided and conflicted self, one he illustrated through the famous metaphor of the chariot: the intellect is the charioteer attempting to wrangle the two horses of positive moral impulses and irrational, passionate drives. The notion is also found widely in classical narrative, such as Medea's psychological struggle in Ovid's Metamorphoses, torn between love and duty: "But a strange power attracts me against my will-desire urges one thing, reason another."
In the study of addiction today, the divided self is a prominent explanation of how choice can be disordered. For example, behavioral economics research describes the psychological feature of "delay discounting," in which smaller but more immediate rewards are favored over larger, delayed ones-this process is universal to humankind but more pronounced in addiction. Immediate rewards are grossly overvalued, causing extreme impulsivity that feels like loss of control. This can be seen not as a "control failure" but as a breakdown in a process called "intertemporal bargaining," in which the present self negotiates with-and irrationally overwhelms-the future self.
Nudging these types of choices can be a highly effective component of addiction treatment. The most obvious example originates from the 1980s, when Stephen Higgins, a psychologist at the University of Vermont, developed a "contingency management" program to treat people with cocaine addiction. In addition to the usual counseling, Higgins added a voucher system that gave people small rewards, such as sports equipment and movie passes, for cocaine-negative urine samples, and gave them a bonus for longer stretches of abstinence. This strategy was highly successful. One of the early experiments found that 55 percent of the voucher subjects were continuously drug-free for ten weeks, compared with fewer than 15 percent of subjects receiving the usual treatment.
After decades' more research, contingency management now has strong evidence in its favor, especially for stimulant problems, for which there aren't good medication treatments. My own monitored treatment, which required regular urine screens to test for drug or alcohol use, was a form of negative contingency management. I wasn't totally committed to abstinence at first, but my license was on the line, so I chose not to drink. This powerful contingency is, in large part, why these physician health programs have extraordinary five-year success rates of 75 percent or higher, eclipsing the effectiveness of essentially all other addiction treatments.
Yet some people don't stop, no matter what the cost. There is still that nagging 25 percent of people who don't make it to the five-year mark, for example. Some of my friends and colleagues from the physician health program did relapse, and they were trying their best-none thought in the moment that it would be better to start drinking or using again. Those outcomes are a testament, I think, not to the power of a simplistic compulsion, but to the complexity of the enigmatic internal forces that lie beneath the stereotype.
During my first year out of college, as my friends were starting graduate school or their first jobs, I was in the back of a taxi weaving its way through the jumbled streets of Seoul, South Korea, any sense of direction long since lost. My new friend Ravi and I were there for a one-year fellowship, and we were supposed to have been studying Korean the whole summer, but I had mostly drunk away my stipend and enjoyed my freedom. When I left, our private Korean tutor had one last request: ÒIf you meet anyone who knows me, please donÕt tell them I taught you.Ó Now we couldnÕt even communicate with our driver.
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