Reflections

Occasional observations on life

Tag: Stoicism

Mental illness or bad behaviour?

Marc Lewis

The Biology of Desire

Why addiction is not a disease

(Brunswick, Victoria: Scribe, 2016)

A review essay[1]

The Biology of Desire - Cover
Introduction
In a recent interview with Rachel Cooke, Swedish philanthropist, anthropologist and publisher, Sigrid Rausing, discusses her brother and sister-in-law’s much publicized drug addiction. Although she suspects that a vulnerability to addiction may be inherited (her great-grandfather was an alcoholic), she ponders the fact that neither she nor her sister shared their brother’s fate. Why did he give in to the temptation of heroin, when it was offered on a Goan beach? ‘I came to the conclusion that it is more mysterious than we think: a no man’s land, halfway between mental illness and bad behaviour’. Her words encapsulate the enigma of addiction, and hence my title for this review essay.

I came across Marc Lewis’s The Biology of Desire while I was reviewing Damian Thompson’s The Fix. There are several points of comparison between these authors. Like Thompson, Lewis has personally experienced addiction, although opiates rather than alcohol were his drug of choice. Also like Thompson, he overcame his addiction and attained academic credentials, in neuroscience rather than sociology. Finally, Lewis shares with Thompson a rejection of the medical model of addiction: ‘Addiction is unquestionably destructive, yet it is also uncannily normal: an inevitable feature of the basic human design.’ (p. xii)

In the earlier review, I hinted at parallels between Thompson’s account and some ancient views of human nature. In what follows, I would like to elaborate upon this theme. If there were some points of philosophical interest in Thompson’s book, it seems even more the case with Lewis. The latter explicitly refers to addiction as a ‘habit’, a term with a long history in philosophy, being central to Aristotle’s moral philosophy and the ‘virtue ethics’ that developed from it: ‘But is addiction really a disease? This book makes the case that it isn’t. Addiction results, rather, from the motivated repetition of the same thoughts and behaviours until they become habitual.’ (p. xii)

The book is structured rather symmetrically, with two theoretical chapters at the beginning, two at the end, and five biographical case histories sandwiched between them. The first two chapters provide a scientific basis for understanding what might be going on in the brains of the addicts described in the case histories, and there are many references back to this information as we progress through the book. The intertwining of the biological with the social and psychological (the ‘biographical’) represents a worthy attempt to put a human face to the science. At the same time, it highlights the philosophical problem of reconciling two very different types of discourse (‘scientific’ explanation versus ‘subjective’ description), and uncovers a tension at the heart of the book: the age-old problem of free will versus determinism (in this case, biological determinism). This tension manifests at various stages, but it is there from the very beginning. Consider the following passages from the Introduction:

‘We’ve begun to separate our ideas about addiction from assumptions about moral failings. We’re less likely to dismiss addicts as simply indulgent, spineless, lacking in willpower.’ (p. xi)

‘Addiction is a habit, which, like many other habits, gets entrenched through a decrease in self-control. Addiction is definitely bad news for the addict and all those within range. But the severe consequences of addiction don’t make it a disease … What they make it is a very bad habit.’ (p. xiii)[2]

The tension disappears if there is no element of choice in habit formation, but that is not self-evidently true, and we’ll have to see whether the book justifies such a conclusion. Regardless of the outcome, however, Lewis has good pragmatic reasons to avoid making moral judgments about addicts, since feelings of guilt can reinforce low self-esteem and the already self-destructive tendencies of addicts, in a vicious downward spiral. Furthermore, we can hardly criticise him for failing to resolve a problem that has tested philosophers for millennia. Notwithstanding his laudable motives, however, and his pardonable philosophical fallibility, his failure to make the abovementioned tension explicit adds up to a philosophical elephant in the room. Does this mean that he also fails in his attempt to explain addiction? We may be better equipped to answer that question after a more detailed examination of the book.

The science of addiction
The first chapter (‘Defining Addiction’) begins by pointing out that definitions of addiction can be ‘narrowed down to three broad categories: disease, choice, and self-medication’ (p. 1). The disease model defines addiction as an incurable chronic disease of the brain: ‘it does a good job of explaining why some individuals are more vulnerable to addiction than others, based on genetic differences and other dispositional factors’ (p. 2). The choice model portrays addiction as a rational response to circumstances, particularly adverse ‘environmental or economic conditions beyond the addict’s control, including poverty and social isolation’. This model is better at explaining how addicts quit, due to changes in circumstances, but it also ‘provides a convenient platform for those who consider addiction indulgent and selfish’ (p. 2). The self-medication model is ‘grounded in developmental thinking’, portraying addiction as a strategy to overcome early adversity: ‘The point is that drugging and drinking make you feel better. Until they don’t. A nasty side effect of addictive drugs is that the addiction itself becomes a source of stress – often the major source of stress – especially when tolerance is going up, your bank balance is going down, and withdrawal symptoms set in’ (p. 3).

Lewis points out that the three models overlap, but that each has different implications for research, funding, and care. The high cost of these provides the imperative to understand addiction better: ‘What is it? How does it work? Why is it so hard to stop?’ (p. 4). Lewis tells us that the disease model is currently the front-runner, for three reasons: first, it accounts for the loss of control experienced by addicts; second, medicine ‘doctrinally’ defines human problems as disease, and this is backed up by financial investment in research; third, the disease model ‘enfolds’ the other two models – bad choices may themselves be a symptom of underlying disease, and self-medication may trigger disease (pp. 5–6). By way of summary, Lewis writes:

The fact is that we in the West embrace the logic of pigeonholing problems, giving them unique names, and finding technical solutions – the more targeted the better – for alleviating them. That is, to a T, the logic of Western medicine. (p. 6)

For Lewis, two pillars support the brain disease model. First, there is substantial evidence that the brain does change with addiction, apparently placing it in the same category as other diseased organs (a pancreas with diabetes, a heart with heart disease, a liver with hepatitis, and lungs with lung cancer). Second, disease and disorder are both out of our control, and addicts also seem to have no control: ‘At least that’s what they say, and that’s how it looks’ (p. 8).

Lewis recognizes pragmatic reasons for treating addiction as a disease. Doing so ‘mitigates massive volumes of stigma and guilt’ (p. 8), and it is also more likely to lead to some sort of treatment (pp. 8–9). He approves of the move away from ‘denigrating addicts for their lack of willpower and moral decrepitude’ as a ‘step in the right direction’:

Despite the despicable things that addicts sometimes do, intense shame and guilt are more likely to thwart recovery than facilitate it. After all, these are painful emotions, and most addictive substances and acts provide some form of pain relief. The disease model has also served to stimulate volumes of new research, promote the development of useful medications, and consolidate our understanding that addiction involves biological factors. (p. 9)

Pragmatic as they may be, however, such considerations do not make for good science. ‘And bad science makes for models of treatment that are distorted and ineffective’ (p. 9). Furthermore, in the long run the disease model may be counterproductive. Seeing oneself as the passive victim of disease is neither self-empowering nor in keeping with addicts’ self-image. Some research even suggests that the extent to which recovering addicts adhere to the disease model is the most significant predictor of relapse (p. 10).

Most of the recovered addicts I’ve talked to would rather think of themselves as free – not cured, not in remission. Having overcome their addictions by dint of hard work, intense self-examination, and the courage and capacity to regrow their perspectives (and their synapses), they’d rather see themselves as having developed through addiction and become stronger as a result. Neuroscientific findings actually support this intuition – once neuroscience steps away from the funding priorities set by the medical mainstream. And that’s another reason I’m writing this book: to give addicts what they need, and what they deserve, by interpreting the scientific data in a way that actually corresponds with their experience of what they’ve been through and their sense of who they are. Science, meet subjective experience. Subjective experience, meet science. I’d like you two to try to get along. (pp. 10–11)

The disease model has a long history, having been ‘promoted and rebutted since the time of Aristotle’ (p. 11). Lewis quotes from a 1913 medical text that specifically describes the terms ‘morphine habit’ and ‘opium habit’ as inaccurate and misleading, since the word ‘habit’ implies ‘something that can be corrected by an exercise of the will … [which] is not true of narcotic disease’ (quoted on p. 12). This ‘scientific’ view was still at odds with public perception, however, and addicts continued to be regarded as morally depraved in the era of temperance movements and Prohibition (p. 12).

A decisive shift in public attitudes began with the formation of Alcoholics Anonymous in the 1930s (1940s in Australia and Britain). Notwithstanding the benefits of this society for mutual support, it inculcated an attitude of helplessness in the face of alcohol addiction, seeing it as ‘a lifelong disorder that remained treatable, though never actually curable’, and calling for ‘a commitment to trust in a higher authority’ (p. 13). This has been reinforced by ‘institutional thinking [that] asserts the need for treatment through recognized programs’, despite research indicating that most addicts ‘recover without any treatment’ (p. 15).

Lewis locates the shift from ‘explanation’ to ‘model’ in 1990’s brain research, which provided evidence of brain change in addicts, particularly relating to the ‘release and absorption of dopamine’ (p. 17). He identifies four primary beneficiaries of this model. First, medical practitioners (especially psychiatrists) who have an interest in ‘medicalizing’ psychological problems (pp. 18–19). Second, the lucrative rehab industry, for which the disease model is ‘the most powerful marketing tool’ (p. 19). Third, the insurance industry (p. 19). And fourth, addicts’ families, ‘because it makes the disgraceful behaviour of their loved ones comprehensible and even forgivable’ (pp. 19–20).

Lewis acknowledges that he isn’t the first to criticise the disease model, and he specifically mentions those who regard it as a ‘disorder of choice’. His problem with the disease–choice dichotomy lies in its portrayal of ‘choice’:

The leak in the logic is the assumption that choice is a deliberate, rational function we can apply at will. But choice is nearly always irrational – which is only to say that it is executed by the same brain that gives rise to hope, need, fear, and uncertainty, a brain that’s highly sensitive to learned associations and contextual cues, a brain that forges new connections based on the activation of existing connections and the strong emotions they render. (p. 22)

At this point he inserts a curious anecdote that he recognizes might contradict the description of choice just provided, in which a friend-of-a-friend related how he simply quit his £1000-per-week heroin and cocaine addiction of over 30 years, without any treatment of any kind (p. 23).

As a final nail in the coffin of the disease model, Lewis points out that ‘behavioural addictions assume the same characteristics, the same trajectory, and often the same outcomes as substance addictions’ (p. 23), which supports the idea that it is the behaviour that changes the brain, rather than a diseased brain causing the behaviour.

In contrast with those who see ‘disease’ as the sole alternative to ‘choice’, and for whom neuroscience is only compatible with the former because ‘they assume that a neuroscientific description will somehow replace a more psychological or humanistic perspective’ (p. 24), Lewis suggests it is time to fight fire with fire and use neuroscience to complement such a perspective. He agrees that ‘multiple levels of analysis’ are important, but that neuroscience should be one of the levels (pp. 24–5):

I see the brain as fundamental to our humanity – and as fundamental to addiction. Whether we construe addiction as a disease, a choice, a complex sociocultural process, self-medication, or a string of bad-hair days, we only have one brain, and it’s central to everything we do, everything we are. So a very important question is simply this: what does the brain do in addiction? (p. 25)

Fundamental to understanding what happens to the brain during addiction is ‘neuroplasticity’, which underlies all development:

Brains have to change for learning to take place. Without physical changes in brain matter, learning is impossible. Synapses appear and self-perpetuate or weaken and disappear in everyday learning. Learning alters the communication patterns between brain regions and builds unique configurations of synapses (synaptic networks) that house knowledge, skill, and memory itself. (p. 25)

Lewis is aware that neuroscientists who subscribe to the disease model understand brain plasticity, but he says that ‘they must view the brain change that accompanies addiction as extreme or pathological’ (p. 26). In doing so, they ‘step onto thin ice’ because such changes are observed in other, more ‘acceptable’ activities and experiences, such as becoming absorbed in a sport or falling in love: ‘The brain contains only a few major traffic routes for goal seeking. Like the main streets of a busy city, the same routes get dug up and paved over time and time again, no matter who’s in charge’ (p. 26)

The second chapter (‘A Brain Designed for Addiction’) describes the brain structures and processes that correlate with the subjective experience of addiction. Lewis is better qualified than Thompson to describe the biological correlates of addictive behaviour, and, not surprisingly, he goes into greater detail. Importantly, he distinguishes levels of analysis: subjective experiences like desire or fear are properly attributed to people, and only metaphorically to brains. That said, brain processes may contribute to our understanding of subjective experiences.

The basis for this analysis is what has been termed the brain’s ‘reward’ system: a combination of ‘membranes, molecules, proteins, blood, and constantly fluctuating levels of electricity’ (p. 27), which has evolved to help us identify those things that are useful to us. From this perspective, experiences that promote pleasure are normal, and the pleasure that leads to addiction is no exception. As Lewis puts it, addiction may be ‘the uncanny result of a brain doing exactly what it’s supposed to do’ (p. 28). Moreover, on this view the ‘computer model’ of the brain is outmoded, as modern psychology has demonstrated just how ‘biased and irrational our thinking can be … the brain is a body part whose concern is the slaking of desires and avoidance of risk, goals carried out by hand, tongue, teeth, feet, and genitals’ (p. 29).

So to say that addiction isn’t rational is just stating the obvious. The irrationality (including self-destructiveness) of addiction does not indicate that the brain is malfunctioning, as it would if diseased. It just shows that it’s a human brain. Thinkers from Homer to Dennett and writers from Shakespeare to Nabokov have made it abundantly clear that irrationality is an essential feature of being human. (p. 29; see also p. 43)

Mammalian brains, unlike their reptile predecessors, are designed for learning. This adaptability applies both to the cerebral cortex, and, perhaps less obviously, to the limbic system, ‘which includes the amygdala, hippocampus, and striatum – regions that play a major role in emotion, memory, and goal pursuit’ (p. 30). There are over twenty billion neurons in the cortex and limbic system, and trillions of synapses connecting them. It is the latter that change in response to experience, in turn affecting subsequent experience, thereby establishing a ‘feedback loop’ between experience and brain: ‘the mind and the brain shape each other’ (p. 31).

Brain change is particularly sensitive to strong emotions – such as attraction, fear, pleasure, or relief – which focus our attention and thinking, and the feedback loop means that certain emotions and behaviours become entrenched over time. Of all the emotions, desire shapes the brain most acutely: ‘desire-laced experiences mould the brain into a vehicle for creating similar experiences, also rooted in desire, for a long time to come’ (p. 31).

Brain plasticity, however, is only half of the mammalian learning story. Unregulated flexibility would make life far too unpredictable. The counterpart to adaptability is ‘habit’, which provides us with stability in our experience. Neuronal pathways may start off tentative and fluctuating, but they become entrenched through repetition. Learning is a combination of change and stabilization, described by William James as a process involving ‘habit loops’ (p. 32).

Lewis identifies three things that distinguish addiction from more benign habits:

First, it’s a habit of thinking and feeling – a mental habit – not just a behavioural habit. It’s easier to stop singing in the shower than it is to stop seeing the world as violent or unfair. Second, the feeling part of addiction always includes the feeling of desire, which is of course the theme of this book. And third, it’s a habit that becomes compulsive … Perhaps all habits, once formed, are compulsive to some degree. The brain is certainly built to make any action, repeated enough times, into a compulsion. But the emotional heart of addiction – in a word, desire – makes compulsion inevitable, because unslaked desire is the springboard to repetition, and repetition is the key to compulsion. (p. 33)

If addiction is the outcome of a normally functioning brain, rather than a diseased one, then why is it such an extreme outcome? For Lewis, the explanation lies in the power of the feedback loop, which, in any form, simply makes things grow. The pleasure experienced when doing something as simple as eating chocolate may alter synapses in a limited way, but still enough to induce a desire to repeat the experience, thereby further strengthening the synaptic link, and so on until a habit is crystallized. Attraction, desire, depression and anxiety all develop through feedback: ‘The result is the sculpting of neural flesh into a breeding ground of personal habits. And one way to capture the combination of those habits is with the word “personality”’ (p. 36).

Normal personality development, then, can be seen as the formation of interrelated habits, and addiction, rather than requiring ‘an external cause like “disease”’ (p. 37), is simply an extreme outcome of the same process:

Bad habits self-organize like any other habits. Bad habits like addiction grow more deeply and often more quickly than other bad habits, because they result from feedback fuelled by intense desire, and because they crowd out the availability or appeal of alternative pursuits. But they are still, fundamentally, habits – habits of thinking, feeling, and acting. The brain continues to shape itself with each repeat of the addictive experience, until the addictive habit converges with other habits lodged within one’s personality. (p. 37)

Lying to conceal one’s behaviour, for example, can easily converge with other addictive habits, such as self-medication to cope with anxiety. The problem is that addiction itself eventually becomes the chief source of anxiety and shame, thereby increasing the desire for self-medication.

What we call ‘experience’ is, at the level of brain analysis, a flow of electrochemical energy along neurons via the synapses, in response to some input. When a sufficient number of molecules pass from a group of sender neurons to receiver neurons, the electrical charge of the latter changes, resulting in an increase (excitation) or decrease (inhibition) of firing rate. This effect is passed along to subsequent neurons, resulting in a ‘synaptic pathway’. The difference between ‘simple experience’ and ‘learning’ comes down to the ‘degree of connection’ between neurons at the synapse level: ‘Neurons either become more connected (so that more molecules get through) or less connected (so that fewer molecules get through)’ (p. 39).

The three primary factors in learning are ‘emotional significance’, ‘attention’, and ‘repetition’: ‘Brain change equals synaptic modification, and synaptic modification results from synaptic activity that is boosted by emotion, attention, and repetition’ (p. 40). This is a whole-brain process, involving ‘the perceptual cortex, in charge of seeing and hearing; the prefrontal cortex, in charge of thinking and planning; and the motor regions, in charge of putting those plans into action … [as well as] the limbic regions involved in feelings and motives – the amygdala and hippocampus, as well as the striatum … it’s the whole brain that programs itself, self-organizes, develops a habit – a habit that eventually becomes integrated with all your other habits’ (p. 41).

Habits, then, can be seen as ‘networks’ of neurons that fire together: ‘an ensemble of neurons, connecting different brain parts, forms a single learning trajectory’ (p. 41). They may be ‘bad’ habits, such as those we think of as addictions, but they are also ‘good’ habits, like the skills acquired in dancing, playing sports, or cooking. Furthermore, although some configurations fade with disuse, they are just as likely to be modified and become components of a new configuration: ‘habits at one point in development influence habits at the next point, which influence habits at the next point, and so on’ (p. 41). This can obviously mean a vicious cycle of habit formation, but it can also mean a virtuous one. This is important for Lewis’s model of addiction and recovery, since a destructive habit can be strategically used to establish a new habit leading out of addiction: ‘ruminations about getting high can lead to strategies for self-distraction – components of a network for successful recovery … recovery can build on lessons learned in addiction, and it can build on itself over time’ (pp. 41–2).

Rather than being a disease, then, brain science confirms that addiction is simply an extreme case of habit formation, part of our natural capacity to learn (later in the book, he even describes the brain as ‘a habit-forming machine’, p. 93). The following passage drives home the point, as well as providing a useful summary of the foregoing:

To say that addiction changes the brain is really just saying that some powerful experience, probably occurring over and over, forges new synaptic configurations that settle into habits. And these new synaptic configurations arise from the pattern of cell firing on each occasion. In other words, repeated (motivating) experiences produce brain changes that start to define future experiences – at least those in the same realm. So getting drunk a lot will sculpt the synapses that determine future drinking patterns. Whether it’s sacramental wine or beer at the ball game, it’ll soon become part of the same familiar drama, if it isn’t already … These changes don’t result from addictive substances. They are not caused by booze or drugs. They result from having a string of similar experiences. Nice experiences. Experiences of relief. Experiences that feel good, or at least better than the rest of your boring and depressing life. These brain changes are caused by motivated repetition – repetition of something special – and how the brain responds to it. The powerful experiences that get the ball rolling are simply events that affect us deeply. Because they are engaging. Because they mean something. As they become even more meaningful, the corresponding brain changes gather more momentum, building on themselves, digging their own ruts – rainwater in the garden. Experiences that change the brain most rapidly or extensively might involve drugs or alcohol, and it’s no accident that those substances can be highly addicting … But high-powered brain-changing experiences also include gambling, binge eating, having a lot of sex, sitting back and watching other people have a lot of sex … or simply falling in love. (pp. 42–3)

The chapter concludes with a closer look at the brain regions most relevant to addiction. Lewis refers to the first four collectively as the ‘motivational core’: the midbrain (sends dopamine to parts of the limbic system and cortex, including the striatum, amygdala, and prefrontal cortex); the striatum, subdivided into the ventral striatum or accumbens (‘responsible for impulsive actions leading to goals, feelings of attraction, desire, anticipation, craving, and some aspects of reward itself’), and the dorsal striatum (‘activated when goal-directed behaviours shift from impulsive to compulsive’); the amygdala (‘acquires and maintains emotional associations’); and the orbitofrontal cortex or OFC (‘generates expectancies and helps initiate an appropriate response’). Above these is the prefrontal cortex (PFC), containing regions involved in self-comprehension and self-regulation, and subdivided into the medial prefrontal cortex (‘crucial for self-awareness, identity development, and interpreting others’ thoughts and feelings’), and the dorsolateral prefrontal cortex (‘responsible for bringing memories to mind, sorting and comparing them, and using insight, judgement, and logic to fashion new perspectives, make decisions, and adjust previous decisions’). Lewis refers to the latter as ‘the bridge of the ship’ (p. 45).

This ‘map’ of the most significant brain regions involved in addiction establishes the biological groundwork for the case histories in the following chapters.

The biography of addiction
Each of the five ‘biographical’ chapters is devoted to a particular type of addiction, the first four being substances and the fifth a behavioural addiction: Chapter Three (‘When Craving Comes to Power: Natalie’s Story’) is about heroin; Chapter Four (‘The Tunnel of Attention: Brian’s Romance with Meth’) concerns methamphetamine; Chapter Five (‘Donna’s Secret Identity’) is a story of prescription painkillers; Chapter Six (‘Johnny Needs a Drink’) is, unsurprisingly, about alcohol; and Chapter Seven (‘Nothing for Alice: The Double-Edged Sword of Self-Control’) takes us into the world of eating disorders.

Although the biological basis for the case histories was set out in the first two chapters, the details are elaborated in the biographical chapters. For example, there is the crucial role of dopamine: ‘Craving intensifies when the midbrain sends dopamine to the accumbens. The more dopamine, the more the accumbens is activated, and the more we experience craving’ (p. 58). This leads to a point that was also made by Thompson, that the process is more about ‘desire’ than ‘pleasure’:

Wanting something is not the same as liking something, and most of the accumbens is devoted to wanting. Pleasure is a pastry puff, a dessert, a flash in the pan. Desire is what gets us moving, whether that means calling your dealer, driving to the liquor store, or stealing twenty bucks from your aunt’s purse. Dopamine – at least where it’s absorbed in the striatum – is the fuel of desire, not fun. (p. 58)

Lewis goes on to cite research with rodents (by Kent Berridge and Terry Robinson) that demonstrates how a ‘cue’ can stimulate dopamine production. It’s basically Pavlovian conditioning, updated with recent brain science. Even ‘secondary cues’ (i.e. cues that predict other cues) have that ‘eerie potency’: ‘So you could have one cue predicting another cue that predicted getting high, and then the first cue in line – for example, the buzzing of Natalie’s cell phone – would start the ball rolling, start the dopamine flowing’ (p. 59; see also p. 126 for Pavlov).

Furthermore, the biology–biography interface in each case history is an opportunity for Lewis to refine his own theory of addiction, walking a fine line between biological determinism and free choice, and often employing an evocative image. In Natalie’s case, an ‘unfortunate experiment injecting heroin’ precipitated a gradual ceding of control:

She couldn’t help the avalanche of excitement, desire, and anxiety triggered by that first hint of drugs on the horizon. This didn’t mean she was fated to go and get more heroin. Her actions were not bound and determined by the changes taking place in her brain. But her feelings and thoughts were changing in step. More and more often there came an unrelenting cascade of craving and a narrowing of attention – two streams converging into one – as long as the link between cue and outcome lit up the synaptic networks in her striatum like strings of Christmas bulbs. And, of course, every time those bulbs lit up, it got harder to find the off switch. Every time she introduced a new stimulus to the ‘heroin’ club, like a ringtone for the phone at Steve’s parents’ house [Steve was Natalie’s friend and supplier], it got initiated into the fraternity and acquired power over the dopamine pump. Now there were more roads leading to Rome. Now there were more ‘heroin’ synapses linked with each other, so firing rates would climb more quickly, more easily, more predictably, from a greater range of starting points. (p. 59)

I should point out that I have jumped into the middle of Natalie’s story here, at the point where Lewis links biology and biography. It would take too long to go into Natalie’s backstory, her upbringing, education and relationships, as well as the insights into her psychology, particularly her anxiety about failure. These are significant, nonetheless, and provide a context for her behaviour, including her first experiments with drugs. There was clearly an intertwining of personality and opportunity – predisposing circumstances that fed into a choice, leading to a new constellation of circumstances. Lewis sums it up in a couple of sentences: ‘That’s how Natalie developed a serious habit. It’s not that she was forced to act on cue – but it became harder and harder to resist the temptation’ (p. 60).

The rest of the chapter documents Natalie’s downfall: declining academic performance, a friend’s traffic accident leading to a drug bust, a treatment program, relapse, and finally a spell in a maximum-security prison. Then there’s more detail about some unhappy aspects of her childhood, but nothing extreme, and nothing that would necessarily lead to heroin addiction. Finally, there is her climb out of addiction, a process initiated in prison, perhaps a combination of reflection and self-taught meditation:

We could just call it self-control, bolstered by a nasty set of associations between heroin and all the wrong things that had happened. But it’s not that simple. Natalie had to find a self before she could find self-control. She needed the time to reflect, to meditate, to remember and mourn her wounded childhood. All that time in the worst possible environment became the silver lining to a very dark cloud. But the wide avenue of synapses between Natalie’s striatum and her prefrontal cortex was a two-way street. And now a lot of the traffic was coming from the other direction. Now her prefrontal cortex (PFC) – the part of the brain that plans, regulates, and controls impulses – began to form new patterns, new habits, based on a more coherent, more conscious sense of who she was. Those patterns became strong enough to survive, to resist disintegration, so they could help stave off the cresting of desire from her striatum. Finally, abstinence itself became a pattern, a habit of its own. Natalie learned that there is a space between craving and doing, and that space could be stretched indefinitely by her own determination, her own commitment to care for herself. Over the next year, the cravings lessened in frequency and finally disappeared. (pp. 67–8)

There was one final incident with a prescription painkiller, but the experience filled Natalie with such self-disgust that she never repeated it. Her memories of drug-induced states were now tainted with ‘too much loneliness, too much remorse, too much anxiety and suffering’ (p. 68):

Attraction and repulsion now came in one package. Yet the striatal engines of desire were not extinguished. That would have left a zombie in place of a striving, growing human being. Instead, desire was rerouted. It was now in league with other goals: self-preservation, self-control, a respite from her weariness … new habits must include remnants of the old – synaptic residue that won’t go away. But new habits also transform old habits in unforeseeable ways. For Natalie, heroin no longer meant relief. Now abstinence meant relief. (p. 68)

Lewis wonders whether Natalie would have made this journey if she hadn’t gone to prison. The answer is that we can’t know what will lead to recovery in any individual case, but research suggests that most heroin users eventually quit, on average about fifteen years after starting. Of course, a minority don’t, and many die, and ‘even for those who do quit, there’s always that disturbing question: how much damage was done along the way?’ (p. 69).

The chapter finishes on an upbeat note, with Natalie finishing her undergraduate degree, going to graduate school, followed by a postgraduate qualification and a career in social work:

Now Natalie works in an outpatient treatment centre for hard-core drug addicts. And while she tries to help them get on with their lives, she knows, better than most of her colleagues, that there isn’t much help she can provide. Until they’re ready. Until they’ve already begun to move on, or at least to imagine moving on. That’s when a little nudge can go a long way. (p. 69)

The pattern for the rest of the biographical chapters repeats that of Natalie’s story. An opening biographical account of the slide into addiction is followed by a description of the brain processes involved, based on the information in the first two chapters, although with elaborations. Then there is a crisis, a turning point, and a gradual emergence from addiction into a better life, though frequently accompanied by backsliding. The account of the emergence is couched in psychotherapeutic terms, providing an analysis of the factors that may have led to the original downward spiral. Just as the pathways to addiction, and the forms of addiction, vary from one individual to another, so also the recovery is described in terms of an individual journey, rather than ‘recovery’ from a disease (see, for example, p. 115).

Although the pattern repeats, albeit with elaborations of the biological account, there are psychological insights in the remaining case histories, and some new psychological terms are introduced. Consider the following passages:

The triumvirate of the amygdala, OFC [orbitofrontal cortex], and accumbens – the motivational core of the brain – evolved precisely for the purpose of linking cognition with emotion, thought with feeling, and then putting the best available plan into action. (p. 81)

The OFC is the bottom floor of the most sophisticated structure in the primate brain, the prefrontal cortex (PFC). In that role it deserves considerable credit for translating the raw glare of emotion into thoughts, expectancies, and a readiness to compare potential outcomes, advocating some and rejecting others. This requires the OFC to recruit its more advanced cortical neighbours, those dedicated more to reflection than passion. That’s its job! (p. 82)

In this role, however, it is subject to previous experience, resulting in ‘motivated repetition’ (p. 82). That’s true of the normal brain, but for addicts there’s a catch, which is ‘enough to break the tie in the tug-of-war between attraction and willpower’ (p. 83). The psychological term for this catch is ‘delay discounting’, which Lewis refers to as ‘now appeal’:

the tendency for humans, other mammals, and even birds to value immediate rewards over long-term benefits. Delayed rewards are discounted. Their value is reduced. Delayed negative consequences are also discounted – in other words, delayed punishments seem less severe than immediate ones. (p. 83)

Addicts may be well aware of the long-term benefits of overcoming addictive behaviours, and of the long-term suffering of failing to do so, but this awareness is discounted by the ‘now appeal’ of the immediate reward. Dopamine is the villain, as it rises with anticipation: ‘Its hypnotic attraction to immediate goodies distorts the perspective we could have (otherwise) achieved using our more advanced cognitive abilities’ (p. 84).

Lewis emphasizes that ‘delay discounting’ is a normal evolutionary adaptation ‘that has allowed us to survive and thrive, maximizing opportunities for enhancing our lives and those of our offspring’ (p. 92).

Another psychological term, complementary to ‘delay discounting’, is ‘ego fatigue’ (also called ‘ego depletion’ or ‘self-control depletion’). Lewis describes them as the two Achilles’ heels of the addict. Indeed, he goes so far as to describe ‘ego fatigue’ as ‘the scourge of addicts’ (p. 151):

Some people can maintain some kinds of self-control for indefinite periods. And yet, especially in tasks that require you to suppress your desires, hide your emotions, or ignore important information, self-control begins to blink and fizzle like a dying light bulb … after suppressing one’s desires, impulses, or habitual responses for some period of time, the cognitive machinery of self-control gets worn down and dysfunctional. (p. 149)

Lewis favours the metaphor of the ‘bridge of a ship’ for cognitive control, over the ‘horse-and-rider model’ employed by some addiction experts (the latter is reminiscent of Plato’s comparison of the relation between reason and the emotions to that of a charioteer and his horses), because he believes it better captures the complexity of the neural structures. The dorsolateral PFC plays the role of the ship’s bridge, while the striatum is the ‘engine’. In ‘ego fatigue’ the communication between the bridge and the engine is weakened; and in full-blown addiction that breakdown in communication becomes entrenched. What may have started as ‘impulsive’ behaviour becomes ‘compulsive’, as the dorsolateral PFC is cut out of the loop: signals (i.e. neuronal firing) from the striatum lead straight to behaviour. According to this model, pure suppression doesn’t work because it is a primitive form of self-control, ‘powered by lower regions of the prefrontal cortex, [which] have taken over from higher regions such as the dorsolateral PFC’ (p. 157; see also pp. 126–7, 137, 155–8).

Yet there is something precious about the higher levels of prefrontal control, exemplified by the dorsolateral PFC – the bridge of the ship. That kind of control is conscious. It uses conscious attention to adjust one’s actions in a way that will ultimately be most beneficial. It can overcome now appeal, partly by imagining a valued future and making it accessible. And it can overcome ego fatigue. As mentioned, the best way around ego fatigue is to shift perspective and reinterpret one’s emotional situation. That requires moving beyond suppression to insight, which relies on software already installed in the dorsolateral PFC … though it may be ready for an upgrade. (pp. 158–9)

Linking biography and biology
The second-last chapter (‘Biology, Biography, and Addiction’) is largely a recap of Lewis’s argument, now seen in the light of the case histories of the preceding five chapters. It opens with a cautionary assertion: ‘Connecting the biology of addiction to the experience of addiction is no simple matter’ (p. 161). This is followed by a reflection on the difference between scientific explanation, based on the accumulation of a plethora of data, and individual experience, involving ‘reflection on singular moments in a singular life’ (p. 161). Then there is confirmation of the case against the disease model of addiction:

  • All rewarding experiences that are repeated enough times cause brain changes that differ, when they do at all, only in degree from addictive experiences, and not in type (pp. 162–5).
  • Behavioural addictions can be as severe as substance addictions (pp. 165–8).
  • Whatever the type of addiction, the measurable brain changes associated with it usually disappear when the addiction is overcome (p. 168).
  • Loss of synaptic density in certain prefrontal regions is synaptic pruning, a natural aspect of learning that increases neural efficiency (p. 168).
  • The emphasis on genetics by supporters of the disease model is overstated, given that predisposing environmental factors have been understood for decades (p. 168).
  • Diseases are based on exposure rather than experience, but psychological and environmental predictors have more to do with how we experience our environments (p. 168).
  • Attraction to addictive substances and behaviours is a response to psychological suffering, and withdrawal from the addiction usually follows removal of the suffering (pp. 168–9).
  • Pharmaceutical medications only ease withdrawal symptoms, and, even then, are only effective while still in the blood (the exception being drugs that disrupt dopamine metabolism, but these have undesirable side-effects, such as suppressing emotions, libido and drive); their temporary use is usually followed by twelve-step methods that have nothing to do with medicine (p. 169).
  • ‘Many of those who treat addiction believe that the most effective tools target cognitive and motivational processes such as self-determination, insight, willpower, and self-forgiveness … Social processes such as support and love, and contemplative processes such as mindfulness meditation, have also been shown to be effective’ – as far as we know, disease is not cured through such processes (p. 169).

This is followed by a reiteration of the main argument. The central ideas have already been covered in the synopsis above, but some points are particularly worth repeating. The first is the centrality of ‘habit’ to Lewis’s account. Consider the following:

Brian changes naturally settle into brain habits – which lock in mental habits. (p. 170)

… addictive habits come to usurp habits incongruent with addiction – like generosity, integrity, and empathy. (p. 170)

So addiction is not fundamentally different from other unfortunate directions in personality development: a self-reinforcing habit based on intense emotions, encountered repeatedly. (p. 173)

So, what exactly is addition? It’s a habit that grows and self-perpetuates relatively quickly, when we repeatedly pursue the same highly attractive goal. Or, in a phrase, motivated repetition that gives rise to deep learning. (p. 173)

Personality development is really nothing more than the laying down of habits for getting along in the world: habits of attraction, habits of self-regulation, habits for easing emotional concerns, habits for avoiding the rough edges of our lives. (p. 178)

… addiction is a phase of individual development, not only in the addictive habits themselves but also in the transformations shaping the person as a whole. (p. 183)

… habits free themselves from higher-order controls because the striatum no longer sends out requests for prefrontal engagement. (p. 187)

A second point worth repeating is that addiction, although based on normal brain processes, is often a response to early adversity in life. The role of dopamine, strongly correlated with desire, is central. In evolutionary terms, desire is more important than pleasure when it comes to achieving goals. The normal brain processes are, however, augmented by a feedback loop, resulting in a ‘snowball effect’ (p. 170). The resultant loss of control, which we experience psychologically as compulsion and craving, now becomes the major source of adversity for the addict, making addiction a self-defeating process. (See pp. 176–9)

The final point concerns the manner in which addiction is overcome, which was prefigured in the last of the dot points above, and which paves the way for the practical suggestions made in the final chapter. In my opinion, this is one of the most valuable and interesting aspects of Lewis’s argument, and I will have more to say about it in the next section. The re-establishment of communication between the ‘motivational core’ of the brain and higher regions of the PFC (the bridge of the ship) is central to the process:

… the research tells us unambiguously that suppression is the wrong way to go. The best way to resist temptation is to shift perspective and reinterpret your emotional state. Instead of tying yourself to the mast in order to resist the Sirens’ song, you must recognize the Sirens as harbingers of death and reframe their songs as background noise … The higher echelons of self-control count as regal achievements in the synaptic wiring of the brain. And, like other achievements in neural development, they rely in large part on practice – which takes time. (p. 185)

At this juncture, Lewis at least acknowledges the philosophical question of free will:

Once addictive goals are by and large the only goals being sought, there may be little to look forward to, and little ability to look forward to anything, beyond what’s going on in the present. Yet we need something special, some connection between now and later, to get us past the enchantment of the immediate to the possibility of a better future. That something is sometimes called will … Philosophers and neuroscientists argue relentlessly about the existence of free will, but we all know what it feels like to hold out for something better than what’s presently available. We know that it takes not only effort but also vision or insight – the capacity to stretch our sense of ourselves to the possibility of something that doesn’t yet exist … The motivational core of the brain needs to connect to many other regions in order to live up to its evolutionary potential. But of all the regions that can help us negotiate the maze of attractions in this complex world, the higher reaches of the prefrontal cortex, with their exquisite capacities for comparison, evaluation, judgement and choice, are the most essential. (pp. 191–2)

The final chapter (‘Developing Beyond Addiction’) elaborates the foregoing for long-term success in overcoming addiction, although Lewis admits that other tactics may be necessary at certain stages in the process. Once again, neuroplasticity is invoked, with special mention afforded to Norman Doidge (for popularizing the subject), Eric Kandel (who shared a Nobel Prize for his research in 2000), and Donald Hebb (the Canadian neuropsychologist who encapsulated the insight in the clever phrase ‘neurons that fire together wire together’ in the 1940s). As Lewis observes, this natural potential of the brain, central to learning and memory, provides both the slope to addiction and the ‘springboard to recovery’ (p. 194).

Lewis cites an important corollary to Hebb’s pithy phrase, attributed to Barbara Arrowsmith Young, which captures the dual nature of neuroplasticity: ‘what fires together wires together, and what fires apart wires apart’ (p. 195). In other words, the road to recovery involves divergence. He believes that the five case histories demonstrate that recovering addicts ‘start to separate one set of desires from another and to act on them independently’ (p. 197).

He admits that there is still some mystery surrounding addiction, both the decline into it and recovery from it, but he wants to highlight some of the ‘psychological stepping-stones that seem necessary to overcome addiction’ (p. 198). The key to decline and recovery is to see addiction as ‘an aspect of personality development, often an extension of patterns formed by failed attempts to deal with negative emotions in childhood’ (p. 199). In the case of Natalie, the boredom and despair of prison imposed on her the conditions that made reflection, insight, and imagination possible. In the addicted state, her brain had been hijacked by the compulsion to find heroin, thwarting her ability to see her life in perspective. Through meditation she understood her addiction as a continuation of her attempts to avoid her stepfather’s temper during her childhood, by isolating herself in her bedroom.

That insight came with a shift in perspective that diminished the appeal of the drug itself. And it must have relied on a reconnection between the dorsolateral PFC, responsible for insight and judgement, and the motivational circuits shaped by drug seeking. She didn’t put all the puzzle pieces together at once, but she started to arrange them while still in prison. Enough to see heroin for what it was – to her. Enough to avoid it, to be repelled by it, once she returned to the everyday world. (p. 200)

The ability to imagine a different future is a necessary precondition for the motivation to reach it. This motivation is a counter to ego fatigue. It involves a sense of purpose and ongoing personality development in addicts. In the cases of Natalie and Brian: ‘the emergence of new mental habits, new habits of behaviour, and a different sense of who they were as people’ (p. 202).

Lewis cites research into suicide among Native communities in Canada to support the significance of this sense of purpose, in particular the possession of a narrative connecting the present with a past and a future. Addiction is associated with an acute focus on the present, on craving for immediate rewards, with a corresponding neglect of past suffering and future hope. At the brain level, this is characterized by a loss of connection between the ‘motivational core’ (striatum, OFC, and amygdala) and the ‘bridge’ (dorsolateral PFC). The most effective recovery involves rewiring the synaptic pathways, re-establishing the partnership between desire, on the one hand, and judgment, planning, and perspective, on the other. In other words, lasting recovery involves reconnecting the present with the past and the future.

The question is: how to achieve this? Medical treatment, including cognitive behavioural therapy (CBT), has not ignored the importance of insight and perspective. Lewis believes, however, that such approaches haven’t fully grasped ‘the way time collapses in addiction, nor the critical importance of reframing the links between past, present, and future’ (pp. 207–8). Realigning desire, ‘so that it switches from the goal of immediate relief to the goal of long-term fulfillment’ (p. 208), is not an easy task. For Lewis, the evidence suggests that the only way to achieve this is to activate the dorsolateral PFC and the motivational core at the same time, involving divergent pathways or ‘two distinct neural networks, underlying each of two differentiated outcomes’ (pp. 208–9). One of these networks must then be strengthened, and the other allowed to decay (what fires together wires together, and what fires apart wires apart). At the psychological level, this is experienced as a fastening to ‘goals incompatible with addiction – goals such as freedom from suffering, achievement of life projects, access to loving relationships, and the sense of coherence and self-love that can come with abstinence’ (p. 208).

Lewis believes that medical treatment, despite the best intentions, is often self-defeating. On the one hand, the disease model erodes any fledgling sense of self-direction, practically by definition (to be a ‘patient’ is to need expert medical help). The drawbacks of institutional care reinforce this loss of agency, including a variety of delays (e.g. waiting lists), indifferent staff, and ignorance concerning the nature of addiction. All of this amounts to lost opportunities, a failure to capitalize on addicts’ momentary desire for recovery. Educators refer to ‘teachable moments’ (familiar to parents also), a point where the student (or child) is receptive to learning some particular thing. Lewis is describing a similar therapeutic concept, when openness to change is ripe. He refers to a trial program in Birmingham, UK, involving ‘treatment nodes across community sites that are most available to addicts in their day-to-day lives’ (p. 214). Members of the community with regular public contact (e.g. newsagents, bakers, butchers and pharmacists) are trained in ‘brief interventions’, so that they are sensitive to verbal cues from addicts and can support them immediately, either with encouragement or by passing them on to someone else for prompt assistance.

The Birmingham Model was inspired by intuitions about the mercurial nature of desire and the critical role of timing in addiction treatment. But it also rides on the insight that addicts aren’t diseased and they don’t need medical intervention in order to change their lives. What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place – while they reach toward it. (p. 215)

The philosophy of addiction
There is a fundamental philosophical tension at the core of The Biology of Desire, one that manifests in the title itself. Biology denotes an objective science, a third-person study of the body. Desire, by contrast, is a subjective experience, belonging to the realm of the mind (even if it is publicly mediated through language). Each of the two perspectives is associated with its own distinctive discourse, and we generally don’t mix them up. In attempting an explanation of addiction that combines them, Lewis has set himself a formidable task.

In terms of the history of philosophy, this tension is an old one. Plato, for example, in his dramatic portrayal of the final days of his teacher, Socrates, before his execution in 399 BC, has him say the following:

For, by Dog, I fancy these bones and sinews of mine would have been in Megara or Boeotia long ago, carried thither by an opinion of what was best, if I did not think it was better and nobler to endure any penalty the city may inflict rather than to escape and run away. But it is most absurd to call things of that sort causes. If anyone were to say that I could not have done what I thought proper if I had not bones and sinews and other things that I have, he would be right. But to say that those things are the cause of my doing what I do, and that I act with intelligence but not from the choice of what is best, would be an extremely careless way of talking. Whoever talks in that way is unable to make a distinction and to see that in reality a cause is one thing, and the thing without which the cause could never be a cause is quite another thing. And so it seems to me that most people, when they give the name of cause to the latter, are groping in the dark, as it were, and are giving it a name that does not belong to it. (Plato, Phaedo, 99a–b)

Significantly, the distinction here is not simply between the body understood as an objective thing (bones and sinews), and the mind as the seat of subjective experience (in this case, choice); it is also between determinism (the bodily imperative to survive) and freedom (the moral decision not to flee).

Established, therefore, at the very foundation of Western philosophy, the subjective–objective tension has manifested in one form or another ever since. It is an aspect of what modern philosophers call the ‘mind–body problem’, and they turned to it repeatedly in the twentieth century. One milestone was C.I. Lewis’s introduction of the term ‘qualia’ in 1929, to denote the qualitative character of experience as distinct from the properties we attribute to objects. Another was Thomas Nagel’s ‘What is it like to be a bat?’ (1974), in which he argued that some facts can only be grasped subjectively; for example, no matter how much we know about a bat’s physiology, we can never know what it is like to be one. Perhaps the most evocative formulation of the problem is Frank Jackson’s 1982 thought-experiment known as Mary’s Room.

Lewis is treading a well-worn path, philosophically speaking. This is hardly surprising, given that addiction nowadays comes under the purview of psychiatry, the medical specialization that uniquely lies at the interface between the physical and the mental. Even within psychiatry, there is a spectrum of treatment, ranging from more physical interventions (such as surgery, ECT and pharmaceuticals), to more psychological ones (such as psychoanalysis), and individual psychiatrists may prefer one end of the spectrum or the other, although many favour a combined strategy. The tension between the two approaches even allows anti-psychiatrists, like Thomas Szasz, to regard ‘mental disease’ as a sort of category error, claiming that the term ‘disease’ applies only to bodies.[3]

The mind–body problem provides the broad philosophical context for the addiction debate: whether it is a disease to be studied and treated objectively, by means of medical science; or a developmental problem to be grasped and alleviated subjectively, through something like CBT. As Lewis points out, the evidence adduced in support of the disease model can be given an alternative interpretation, especially considering what we now know about brain plasticity. It is clear from The Biology of Desire, however, that philosophy has more to offer than situating the addiction debate theoretically in terms of the mind–body problem. Lewis’s conclusions are congruent with the practical insights of various ‘schools’ within philosophy, and even his terminology evokes pertinent comparisons.

I will begin by alluding to a tension within philosophy itself, one which has been made explicit in recent scholarly work. Beginning in the 1970s, Pierre Hadot (1922–2010), a classical philosopher and historian of philosophy, published a series of books intended to show that philosophy in the ancient world was more than a discursive academic pursuit, and should be described rather in terms of a ‘way of life’, a practical pursuit captured in the etymology of the word ‘philosophy’ itself: ‘love of wisdom’. Philosophers in antiquity identified as members of particular schools, having their own founder-teachers (although the Hellenistic ones all recognized Socrates as an exemplar), sets of practical exercises, and communal living arrangements.

The goal of the ancient philosophies, Hadot argued, was to cultivate a specific, constant attitude toward existence, by way of the rational comprehension of the nature of humanity and its place in the cosmos. This cultivation required, specifically, that students learn to combat their passions and the illusory evaluative beliefs instilled by their passions, habits, and upbringing. (Matthew Sharpe, ‘Pierre Hadot (1922-2010)’, Internet Encyclopedia of Philosophy, accessed 22 October 2017)

Philosophy, according to this view, was more like a religious vocation, although the guiding practice was reason rather than belief in dogma. It is not surprising to learn that the early Christians, before the institutionalization of their religion, described themselves as philosophers. Indeed, Hadot’s thesis is that medieval Christian monasticism took over the ‘practical’ aspect of philosophy, while the latter became limited to the type of discursive activity that we associate with it today (although it must be remembered that the exemplars of medieval philosophy were monks, and they tried to reconcile their religious faith with what they knew of pagan philosophy). Secularization and academic specialization were later developments. Philosophy as ‘discourse’ reaches its zenith (or nadir, depending on your perspective) in the so-called ‘analytic’ tradition, which became widespread in Britain, the United States, and Australia from about the middle of the last century.[4]

There were some exceptions to the ahistorical tendency within analytic philosophy, particularly in ethics. As early as the 1950s, Elizabeth Anscombe (1919–2001) was criticising the dominant approach to moral philosophy, based on duty and the application of universally applicable principles, with its roots in the European Enlightenment.

In its place, Anscombe called for a return to a different way of doing philosophy. Taking her inspiration from Aristotle, she called for a return to concepts such as character, virtue and flourishing. She also emphasized the importance of the emotions and understanding moral psychology. (Nafsika Athanassoulis, ‘Virtue Ethics’, Internet Encyclopedia of Philosophy, accessed 22 October 2017)

This development received a boost from Scottish philosopher Alasdair MacIntyre (b. 1929), who, in parallel with Hadot, published his own series of books on the history of ethics, beginning with After Virtue in 1981. The ideas of people like Anscombe and MacIntyre led to the recognition of ‘virtue ethics’ as a distinct field within moral philosophy, with a greater appreciation of psychology and the history of philosophy.

Another academic who has returned to philosophers of the distant past as exemplars of a ‘practical’ way of doing philosophy is Martha Nussbaum (b. 1947), the Ernst Freund Distinguished Service Professor of Law and Ethics at the University of Chicago. Her well-received 1994 publication, The Therapy of Desire: Theory and Practice in Hellenistic Ethics (Princeton University Press) says of the Hellenistic schools of philosophy in Greece and Rome (Epicureans[5], Skeptics, and Stoics): “They practiced philosophy not as a detached intellectual technique dedicated to the display of cleverness but as an immersed and worldly art of grappling with human misery … In these ways Hellenistic ethics is unlike the more detached and academic moral philosophy that has sometimes been practiced in the Western tradition” (pp. 3–4).

More recently, there has been a popular resurgence of interest in ancient philosophy, largely fuelled by the Internet, with Stoicism having a particular appeal. There are now online groups that describe themselves as neo-Stoic, and even a Facebook group called ‘Stoic Recovery (From Addiction)’.[6] This popular trend is distinct from academic philosophy, and clearly answers to some deeply-felt need. A particularly high-profile example is author and public speaker, Jules Evans, who overcame his own substance addiction through CBT, only to discover that the pioneers of this therapy were inspired by Stoicism.[7]

The appeal of Stoicism lies in its practicality. Although this was probably characteristic of ancient philosophy in general, as Hadot indicated, there is considerable evidence that the Stoics developed practical exercises to a high degree. These included keeping to hand collections of hypomnemata (‘reminders’), to encourage mindfulness of Stoic principles. The Meditations of emperor Marcus Aurelius are perhaps the best known example. Stoics were also encouraged to begin the day by anticipating the sort of emotional challenges that they would face, as a means of circumventing them. Before retiring to bed they were exhorted to review the events of the day, noting instances of failure to abide by their principles. The Stoic ideal was to live well, in accordance with nature, remaining ‘indifferent’ to things beyond one’s control. Stoic quotes are easy to come by, but I offer the following, from Musonius (c. 30–62 CE), as particularly relevant to the topic of addiction:

If we were to measure what is good by how much pleasure it brings, nothing would be better than self-control – if we were to measure what is to be avoided by its pain, nothing would be more painful than lack of self-control.

If you accomplish something good with hard work, the labor passes quickly, but the good endures; if you do something shameful in pursuit of pleasure, the pleasure passes quickly, but the shame endures.

Lewis is writing at a time, then, not only of great progress in brain science, but also after several decades of renewed academic interest in ancient philosophy, and during a swell of popular interest in practical schools of philosophy like Stoicism. That he places ‘habit’ at the centre of his theory of addiction, a concept that is central to virtue ethics, indicates that he is once again, philosophically speaking, walking a road well-travelled. I suggest, therefore, that an understanding of the basic ideas of virtue ethics can provide a broader context for the theory of addiction developed in The Biology of Desire.

For Plato’s student, Aristotle (384–322 BC), ethics is concerned with human well-being, and this must be grounded in human nature. Although his biology is crude by modern standards, his sense of organic life as a continuum is compatible with our understanding of evolution. Humans share certain characteristics with plants and other animals. Every living thing has a ‘soul’, in the sense of an organizing principle that determines its nature. Plants grow, nourish themselves and procreate. Animals also have these capacities, along with the animal powers of perception, desire, and movement. Humans share the plant and animal powers, but in addition we have rationality, the faculty that defines us as a species.

An important characteristic of this ‘hierarchical’ account is that higher powers don’t simply exist side-by-side with lower ones, but ‘inflect’ the latter, so to speak, with something of their nature. The nutritive and procreative powers in animals are subsumed in their powers of perception, desire, and movement. Similarly, in humans, reason is not simply added to the other powers, but affects how the latter are experienced. Aristotle also posited the existence of a unitary faculty in humans and other animals, which receives the impressions of the senses and on the basis of which either pleasure-seeking or pain-avoiding action is taken. In this way, survival is promoted.

Ethics is a practical discipline: its aim is not merely to understand the good life, but to attain it. Since every living thing seeks to flourish, and it achieves this when it lives according to its nature, it follows that human flourishing (eudaimonia) requires the operation of our faculty of reason. It is reason that enables us to discriminate between different goods, and to recognize that the highest good is eudaimonia. To put it another way, we may enjoy all sorts of goods, including the ‘lower’ animal pleasures, but these must be subordinated to reason in the ‘ordered’ soul. Unless we ‘educate’ our desires, we will remain no better than the animals.

Since doing anything well involves excellence, it follows that living well requires some sort of ‘excellence’. The Greek word used here (aretê) was translated into Latin as virtus, from which we derive the English word ‘virtue’. Although Aristotle believed that human flourishing required the existence of goods that are not entirely under our control (e.g. health, wealth, friends and power), we do have some responsibility for acquiring and exercising the virtues. We grow into that responsibility, since as children we rely on adults to educate us.

Aristotle distinguishes between intellectual virtues and ethical virtues (virtues of character). The former are subdivided into virtues of theoretical reasoning and virtues of practical reasoning (phronêsis). The ethical virtues concern that part of the soul that does not reason, but which nevertheless is capable of following reason. Although we are all born with the ability to become wise (exercising phronêsis), and ethically virtuous, the process is a gradual one:

A low-grade form of ethical virtue emerges in us during childhood as we are repeatedly placed in situations that call for appropriate actions and emotions; but as we rely less on others and become capable of doing more of our own thinking, we learn to develop a larger picture of human life, our deliberative skills improve, and our emotional responses are perfected. Like anyone who has developed a skill in performing a complex and difficult activity, the virtuous person takes pleasure in exercising his intellectual skills. Furthermore, when he has decided what to do, he does not have to contend with internal pressures to act otherwise. He does not long to do something that he regards as shameful; and he is not greatly distressed at having to give up a pleasure that he realizes he should forego. (Richard Kraut, ‘Aristotle’s Ethics’, Stanford Encyclopedia of Philosophy, accessed 28 October 2017)

The foregoing represents an ideal scenario, of course, and in reality moral perfection is rare. Most of us fall short of the ideal, and have to contend with ‘internal pressures’ of one kind or another. Aristotle subdivides morally imperfect people into two main types: those who want to be virtuous, but are beset by counter-rational pressures; and those who don’t even want to be virtuous. The former group is further subdivided into those who are ‘continent’ (enkratês) – that is, able to resist such pressures; and those who are ‘incontinent’ (akratês) – that is, unable to resist such pressures. The continent person is not virtuous, because the virtuous person only desires the good, and is not beset by temptations. The continent person, however, generally behaves like the virtuous person, whereas the incontinent person does not.

Aristotle further distinguishes between two types of incontinence: impetuosity (propeteia) and weakness (astheneia). An impetuous person simply acts under the influence of a passion, without any deliberation. The weak person, by contrast, deliberates and makes a choice, but then fails to act in accordance with this choice, but rather under the influence of a passion. The former experiences no internal conflict at the time of action, but may later regret his action.

It is important to bear in mind that when Aristotle talks about impetuosity and weakness, he is discussing chronic conditions. The impetuous person is someone who acts emotionally and fails to deliberate not just once or twice but with some frequency; he makes this error more than most people do. Because of this pattern in his actions, we would be justified in saying of the impetuous person that had his passions not prevented him from doing so, he would have deliberated and chosen an action different from the one he did perform. (Kraut, ‘Aristotle’s Ethics’)

The ‘chronic’ nature of incontinence applies to Aristotle’s ethics more generally. A person’s character is not determined on the basis of a single act, or even several, but arises from a pattern of behaviour. This is why moral education is so important for Aristotle: it is largely a matter of acquiring good habits, of developing good character. In early childhood, this might involve suppressing certain desires, while at the same time cultivating others. In this way, the maturing child’s emotions are trained, so that he or she eventually desires what is best. This is much easier to achieve in a society that encourages virtue and discourages vice. For Aristotle, therefore, ethics is inseparable from politics.[8]

Aristotle assumes that when someone systematically makes bad decisions about how to live his life, his failures are caused by psychological forces that are less than fully rational. His desires for pleasure, power or some other external goal have become so strong that they make him care too little or not at all about acting ethically. To keep such destructive inner forces at bay, we need to develop the proper habits and emotional responses when we are children, and to reflect intelligently on our aims when we are adults. But some vulnerability to these disruptive forces is present even in more-or-less virtuous people; that is why even a good political community needs laws and the threat of punishment. Clear thinking about the best goals of human life and the proper way to put them into practice is a rare achievement, because the human psyche is not a hospitable environment for the development of these insights. (Kraut, ‘Aristotle’s Ethics’)

According to Aristotelian ethics, a virtue is a ‘disposition’ (hexis) to feel and act in a way that is conducive to human flourishing; in other words, it is a good habit. Defective dispositions are habits also, but they are not conducive to human flourishing: they are bad habits, or vices. Moreover, specific virtues and vices are related in the sense that a virtue can be conceived as existing at a midpoint (the so-called ‘golden mean’) between two vices that represent, on one side, a deficiency, and, on the other, an excess. A deficiency of the virtue of courage, for example, is cowardice; while an excess of courage is foolhardiness. Contrary to appearances, there is nothing mathematical about this mean. Knowing how to act in particular circumstances is a matter of practical wisdom, and this is acquired through experience, built on good education. It is not a rule-governed procedure. Certain circumstances may call for anger, but the degree and duration of the anger will depend on the particulars of the situation.

This is a far cry from the later search for universal principles in moral philosophy, be they consequentialist (e.g. utility) or non-consequentialist (e.g. duty). The virtuous person acts according to circumstances, although this may include taking consequences into account. Doing one’s duty may also, in certain circumstances, be the virtuous thing to do; while in others, it may not (Adolf Eichmann would not have been able to use ‘duty’ as a defence if he had been an Aristotelian rather than a Kantian). There is no set of rules in virtue ethics, although Aristotle did hold ‘certain emotions (spite, shamelessness, envy) and actions (adultery, theft, murder) [to be] always wrong, regardless of the circumstances’ (Kraut, ‘Aristotle’s Ethics’).

The translation of Aristotle’s surviving corpus into Latin was a gradual process, and only completed in the 13th century. His major medieval Christian interpreter was the Italian Dominican friar, Thomas Aquinas (1225–1274), who attempts to reconcile Aristotelian philosophy with Christianity in his Summa Theologiae. Aquinas accepts that pagan philosophers like Aristotle achieved a great deal using natural reason, but he holds that only through Christian faith can human nature be perfected, the exemplar being Jesus. My concern here, however, is with Aquinas’s development of Aristotle’s ethics, and only insofar as it relates to the task at hand. I shall accordingly ignore the notions of original sin, beatitude, and the specifically Christian virtues of faith, hope, and charity. Furthermore, it is not my purpose to defend Thomism, or scholasticism in general – such a defence is beyond the scope of this essay, and, in any case, others are better qualified to accomplish the task.

Like Aristotle, Aquinas takes reason to be the defining characteristic of human beings, and eudaimonia or human flourishing to consist in its proper exercise. The foundational principle for all practical reasoning is that good is to be done and evil is to be avoided. We possess a natural inclination to pursue those goods that contribute to our perfection, and avoid those evils that deter us from it. Some of the goods for which we have a natural inclination include life, the procreation and education of offspring, knowledge, and a civil social order. What distinguishes us from non-rational animals is the relationship between our intellect and our will: we can deliberate about our choices and form a judgment about how to act; our behaviour is not causally determined.

Things are, however, rarely that straightforward. We may always choose what we perceive to be good, but we are presented with different and often incompatible goods, and our apprehension of what is in our best interests is subject to distortion, due both to intellectual limitations (ignorance or ill-informed deliberation) and, especially, the clouding of our judgment by the passions.

Some goods provide immediate gratification but no long-term fulfillment. Other goods may precipitate hardship but eventually make us better people. Indeed, sometimes we must exercise considerable effort in ignoring superficial or petty pleasures while attending to more difficult yet enduring goods … This happens whenever we, through our own determination, direct our attention away from certain desirable objects and toward those we think are more choiceworthy. Of course, our character will often govern the goods we desire and ultimately choose. Even so, Aquinas does not think that our character wholly determines our choices, as evidenced by the fact that we sometimes make decisions that are contrary to our established habits. This is actually fortunate for us, for it suggests that even people disposed toward evil can manage to make good choices and perhaps begin to correct their more hardened and inordinate inclinations. (Shawn Floyd, ‘Thomas Aquinas: Moral Philosophy’, Internet Encyclopedia of Philosophy, accessed 16 December 2017)

It is because of our fallibility that we require virtues of mind and appetite, i.e. the intellectual and moral virtues. Moreover, like Aristotle, Aquinas believes that we need the right sort of upbringing in order to acquire them. He lists four ‘cardinal virtues’: prudence (Aristotle’s phronêsis), temperance, courage, and justice. Each of these subsumes a number of subsidiary virtues. For example, chastity, sobriety and abstinence (relating to sex, drink, and food, respectively) are subsumed under temperance.

Temperance does not eradicate our desire for bodily pleasure, and nor does Aquinas imply that such pleasure is deficient. He accepts that eating, drinking, and sex are natural operations of the body. He also recognizes, however, a common human propensity to sacrifice our well-being for the sake of these transient goods. The purpose of temperance, therefore, is to refine the way we enjoy bodily pleasures:

Specifically, it creates in the agent a proper sense of moderation with respect to what is pleasurable. For a person can more easily subordinate herself to reason when her passions are not excessive or deficient. On this view, bodily enjoyment can in fact be an integral part of a rational life. For the moderated enjoyment of bodily pleasure safeguards the good of reason and actually facilitates a more enduring kind of satisfaction. Thus Aquinas insists that “sensible and bodily goods … are not in opposition to reason, but are subject to it as instruments which reason employs in order to attain its proper end”. (Floyd, ‘Thomas Aquinas: Moral Philosophy’)

Without temperance we would be incapable of properly exercising prudence, as excessive passion interferes with the excellences required by prudence: memory, intelligence, docility, shrewdness, reason, foresight, circumspection, and caution.

Without these excellences, we may commit a number of cognitive errors that may prevent us from acting in a morally appropriate way. For example, we may reject the guidance of good counsel; make decisions precipitously; or act thoughtlessly by failing ‘to judge rightly through contempt or neglect of those things on which a right judgment depends’ … We may also act for the sake of goods that are contrary to our nature. This invariably happens when the passions cloud our judgment and make deficient objects of satisfaction look more choiceworthy than they really are. In order to make reliable judgments about what is really good, our passions need some measure of restraint so that they do not corrupt good judgment. (Floyd, ‘Thomas Aquinas: Moral Philosophy’)

We find in Aristotle and Aquinas some common themes. First, humans are distinguished from other creatures by our reason. Second, since reason is our ‘species difference’, our flourishing consists in its proper exercise. Third, although we are ‘rational animals’, our reason can be distorted. Fourth, we need to acquire the virtues as habits, or dispositions to act in the right way. Fifth, we accomplish this through the right sort of training, or upbringing, in society.

I have selected what I take to be the most relevant aspects of Aristotle’s and Aquinas’s ethics for the purpose of this review. Although those philosophers were exemplary in providing a particularly lucid analysis of the human condition, it is worth remembering that the sort of character development they extolled would have been common to all of the pre-Enlightenment societies with shared roots in Abrahamic religion and Greek philosophy. We would find similar emphases in other traditions, such as Buddhism, which stresses the importance of bringing the unruly mind under control.

Applying virtue ethics to addiction
We appear to be living at a time of extraordinary progress in the biological sciences, particularly genetics and neuroscience. The Biology of Desire benefits both from increased general awareness of such disciplines, as well as a heightened appetite for information concerning them. Moreover, if Thompson is right, and we are living in a time of unprecedented addiction, when social forces are pushing us towards greater consumption of addictive substances and processes[9], then the book also contributes to essential public debate concerning the dynamics of addiction, as well as offering hope and guidance to addicts themselves. It may encourage those with addictive tendencies to seek healthier ways of coping.

Using case histories, Lewis succeeds in putting a human face to the science, a recourse which also supports his argument against the medical model. By switching between levels of analysis – from the impersonal, objective, and universal language of science, to the personal, subjective, and individual language of biography – he demonstrates that a non-medical understanding of addiction is entirely compatible with a scientific account of what is happening in the brains of addicts.

I believe this ambitious approach can be credited for another reason. By connecting objective and subjective levels of analysis, Lewis makes it clear that a scientific understanding of the brain doesn’t necessarily entail determinism, and he thereby repudiates a prevailing tendency of modern science. Perhaps this is indicative of a paradigm-shift in biology, as new discoveries concerning epigenetics and brain plasticity point to a more complex and nuanced relationship between nature and nurture. As noted above, it also raises the philosophical question regarding free-will and determinism.

My detour through philosophical territory isn’t a criticism of Lewis for not writing a more philosophical book, but is intended, rather, to demonstrate that there is a long tradition of philosophical reflection on the sort of problems that his book grapples with, as well as applied wisdom in combatting them. Philosophers like Aristotle and Aquinas were dealing with human nature in general terms, rather than the extremes of addiction, but Lewis himself acknowledges that addiction lies along a continuum, based on the brain’s natural propensity for learning. So, although we might readily agree that our scientific knowledge has far surpassed that of ancient and medieval thinkers, and we may rightly regard some of their social views as unenlightened, we are not forced to conclude that their understanding of the fundamentals of human nature has been superseded.[10] They were also familiar with the notion of levels of analysis, as the above-quoted passage from Plato makes clear, along with Aristotle’s distinction between material, formal, efficient, and final causes.

I believe that Lewis’s switch from biology to biography also demonstrates this relevance, through his recourse to a more traditional and ordinary-language idiom. Terms like ‘habit’, ‘personality’, ‘will’, ‘effort’, ‘self-control’, ‘judgment’, ‘planning’, ‘perspective’ and ‘insight’ take the place of ‘neurons’, ‘synapses’, ‘dopamine’, ‘the dorsolateral prefrontal cortex’, and so on. Accounts of individual success in overcoming addiction involve having long-term goals such as ‘freedom from suffering, achievement of life projects, access to loving relationships, and the sense of coherence and self-love that can come with abstinence’ (p. 208).

Ancient and medieval philosophers didn’t debate free-will versus determinism in the way their modern academic counterparts do, but a nuanced understanding of human motivation is clearly to be found in Aristotle and Aquinas, as well as Stoicism and virtue ethics. According to the traditional account, the morally ideal person experiences no conflict between reason and emotion, because his emotions have been educated – he desires only that which is in keeping with his nature as a rational being, and, all else being equal, he has the best chance of achieving a state of flourishing. The continent person experiences conflict, but still acts according to reason. The incontinent person is swayed by passion and is least likely to achieve a state of flourishing. Implicit in this account is the idea that freedom is acting in accordance with one’s true nature as a rational being, and the further one departs from it – the more swayed by passion – the less free one is likely to become. Freedom, then, is not an all-or-nothing matter, but admits of degrees, and may even fluctuate over the course of a lifetime: one can become freer, or less free, depending on the choices one makes and the habits one develops.

The Biology of Desire appears to support such a take on freedom, and relates the psychological experience of choice and habit formation to the entrenching of neural pathways. As noted above, neuroplasticity can mean a vicious cycle of habit formation, but it can also mean a virtuous one: ‘what fires together wires together, and what fires apart wires apart’. One of Lewis’s definitions of addiction, quoted above, refers to it in terms of ‘a decrease in self-control’ (p. xiii). In each of his case histories, the process of becoming addicted is one of relinquishing autonomy; while overcoming addiction involves regaining it: ‘Most of the recovered addicts I’ve talked to would rather think of themselves as free – not cured, not in remission’ (p. 10). Also, as Lewis points out, personality is a constellation of intertwining habits: a pattern of emotional suffering leads to self-medication and temporary relief, followed by a desire for repeated relief, initiating a feedback loop and the entrenchment of the cycle; while other habits – such as stealing, lying, treating others as means to an end – become entwined with the core addictive behaviour. If we employ the jargon of neuroscience, we might say that the morally ideal person has a brain wired to be virtuous, through habitual training: she desires only what is good, what is in conformity with a flourishing human life. The addict, by contrast, and for one reason or another, has become incontinent to a marked degree: his lack of temperance means he can no longer exercise prudence, and strays further from the moral ideal, and consequently from a state of flourishing.

This leads us back to the tension in the book concerning the moral status of the addict. It can be construed as the tension between burdening someone with guilt, on the one hand, and depriving them of agency, on the other. It is not unique to addiction either: consider, for example, the problem of obesity. There may be sound practical reasons for not blaming the addict, since that can reinforce an undesirable pattern. The pragmatics of therapy, however, shouldn’t be confused with rigorous philosophical analysis (a parallel, perhaps, with Lewis’s claim that the pragmatics of the medical model shouldn’t be confused with good science). Lewis doesn’t resolve this philosophical issue. Indeed, I think he tries to have it both ways: not wanting to burden addicts with responsibility for their addiction, yet wanting to credit them with agency when they overcome it.

One of the complicating factors concerns the relationship between individual choice and precipitating individual and social factors. In Natalie’s case, there was a troubled childhood, followed later by a permissive (my word) peer group and the ‘mysterious’ influence of Steve:

A couple of months after she and Fred got together, she brought home another friend, Steve – tall and lanky, a marijuana leaf tattooed on his forearm and a country-boy accent. There was something about Steve she found mysterious and attractive … He seemed to bring out Natalie’s dark side, something vulnerable and spooky that didn’t match the rest of her. Something that seemed to break through the surface more and more as the months went by. (p. 48)

Then, two paragraphs later we are told:

Natalie had no particular moral compunctions about drugs, and she, Fred, and Steve experimented, like many of their friends, with whatever was going around. Magic mushrooms, even LSD once in a while – these were tickets to an exotic Disney World that you could visit without much planning or expense … And then there was Ecstasy, great for dancing at one of the two local rock cafes, where the DJ and the kids joined forces, coaxing great gouts of physical intimacy from the union of music and motion. These were ‘good’ drugs. They didn’t hurt you, nobody got addicted to them, they weren’t very expensive, and you could still function the next day – though perhaps not with utmost clarity. (pp. 48-9)

It was Steve who introduced Natalie to opioids, in the form of prescription painkillers like OxyContin, Percocet, and Dilaudid. Then he brought home two bags of heroin, which was to become Natalie’s downfall.

Morally speaking, what are we to make of this situation? How has it come about that Natalie is living in a society where drugs, both psychedelics and opioids, are so readily available, and experimentation with them has become acceptable, at least among certain groups? Did she really have to follow that path? Was it peer pressure, or was she a willing participant? Why was she so influenced by Steve, and could she have resisted that influence? Did her troubled personal history predispose her to addiction, as Lewis suggests? If that is so, why doesn’t everyone with a history of emotional suffering become an addict? Did her earlier choices make the later ones more likely? In other words, did she become less free, and, if so, how could she eventually have climbed out of the depths of her addiction? In a different society, would she have found a healthier way to solve her emotional problems?

Lewis’s mostly sidesteps such questions, although some of his comments are suggestive: ‘That’s how Natalie developed a serious habit. It’s not that she was forced to act on cue – but it became harder and harder to resist the temptation’ (p. 60). Thompson’s sociological approach, on the other hand, lends itself more naturally to them. He also has more to say about the broader reality of addiction, including ‘process’ addictions like shopping and gaming. If we combine Thompson and Lewis, we might say that social influences take advantage of normal (or, in evolutionary terms, ‘adaptive’) traits, such as delay discounting and ego fatigue. In a society where consumption and, by implication, the economy are ends in themselves, we can expect commercial interests to cultivate and exploit our desires, to take advantage of our weaknesses. Our consumer society is not conducive to educating desires in the Aristotelian sense. This affects most of us to some degree, and some of us – an increasing minority perhaps – will end up in the extreme situation of addiction.

I’m not suggesting that it is only consumerism that leads to addiction. Lewis’s predisposing factors include various types of emotional suffering and childhood trauma. I have no wish to downplay the complexities, which can include things like poverty, and physical and psychological abuse. People are subject to circumstances beyond their control. An exploration of such complexities would go beyond The Biology of Desire, and it could include the same sort of philosophical considerations presented above.

Virtue ethics offers another – and perhaps better – way of understanding the relationship between agency and addiction. According to this approach, the incontinent person is distinguished from the person who willingly chooses ‘evil’, but with the important qualification that incontinence interferes with the exercise of prudence, making poor moral choices ever more likely. It is not a single choice, but a pattern, that leads to incontinence. Virtue ethics also posits a strong association between the development of individual character and the social context in which individuals are raised and live, thereby combining the individual and the social dimensions of addiction (the foci of Lewis and Thompson respectively).[11]

One objection to the sort of evaluation I have carried out above is that it presupposes an ‘essentialist’ conception of human nature that has been out of fashion for some time, including in philosophy, where Existentialism famously declared that existence precedes essence (a declaration with roots in Enlightenment individualism). Even if some sort of evolutionary basis for morality were conceded, it wouldn’t necessarily be compatible with human nature as understood by Aristotle or Aquinas, i.e. with reason occupying the leading role. Certainly, Lewis seems to think that we are at least as irrational as we are rational. To repeat a passage quoted above:

So to say that addiction isn’t rational is just stating the obvious. The irrationality (including self-destructiveness) of addiction does not indicate that the brain is malfunctioning, as it would if diseased. It just shows that it’s a human brain. Thinkers from Homer to Dennett and writers from Shakespeare to Nabokov have made it abundantly clear that irrationality is an essential feature of being human. (p. 29)

For Aristotle, by contrast, rationality is the essential feature of human beings, distinguishing us from the other creatures, and, indeed, imbuing us with something ‘divine’ – it is our best part. Lewis’s position is perhaps closer to that of David Hume (1711–76), who stated in his Treatise on Human Nature: ‘Reason is, and ought only to be the slave of the passions, and can never pretend to any other office than to serve and obey them’. Of course, there’s a world of difference between saying that people are influenced by their passions, and saying that they ought to be slaves to them. It may be that we can be more-or-less rational, in the same way that we can be more-or-less free, and perhaps the two are related.[12]

The absence of an agreed conception of human nature makes consensus about an ideal society similarly elusive. According to Lewis, those who overcome addiction are often motivated to do so through discovery of a sense of purpose, but the philosophical question of purpose is beyond his scope. One is reminded, instead, of Holocaust-survivor Viktor Frankl’s ‘logotherapy’, as described in Man’s Search for Meaning. Those who survive horrific circumstances often do so through a sense of purpose, whether it be religious, vocational, a relationship, etc. It seems that in order to exercise their therapeutic function, such purposes have to express some core value, unlike a desire for revenge, for example! How one answers this question of human value and purpose will depend on one’s perspective.

Simon Kidd
Perth, Western Australia
January 2018

Notes

1. I am indebted to my good friend, B.A.J., who, in the course of many conversations, helped me clarify my thinking on this topic. I would also like to thank the following for feedback on Facebook: Marcus Holmes and Christopher Lee of the ‘Stoa Antipodea’ group, and Michael Francis Roach, Peter Hunter, and Mary B Moritz of the ‘Thomism Discussion Group’.

2. The tension is also evident in the following paragraph from an online article by Lewis: ‘Addiction isn’t about rationality or choice; it’s not about character defects or bad parenting, even though childhood adversity is clearly a risk factor. Addiction is about habit formation, brought on through recurring, self-reinforcing feedback loops. And although choice is not obliterated by addiction, it is much harder to break deep habits than shallow ones.’ (‘The addiction habit’, Aeon, 14 December 2016) This article is largely a synopsis of the book’s argument, although it introduces a concept (‘attractor’) that is not found in the latter, as far as I can remember (and it does not appear in the Index).

3. I have no desire to take sides in this dispute, wishing merely to allude to an age-old tension as it manifests in one medical specialization. An indication of its ongoing relevance may be gauged from a recent discussion on Australia’s Radio National (‘Does mental “illness” exist?’), in which Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool, argues against the tendency to medicalize mental distress. Kinderman would doubtless approve of Lewis’s criticism of the disease model: ‘The many addicts who end up quitting do so uniquely and inventively, through effort and insight. Thus quitting is best seen as further development, not “recovery” from a disease.’ (p. xiv)

4. Ironically perhaps, given the connotations of the word ‘tradition’, analytic philosophy has sometimes been characterized by a limiting ahistorical tendency, which may have blinded some exponents to the practical aspects of their subject’s archaic origins. Catholic philosophers appear to have avoided that pitfall, presumably due to the importance for them of medieval thinkers like Augustine of Hippo and Thomas Aquinas, who, in turn, were influenced by the Greeks. A rapprochement between these two philosophical ‘cultures’ has been described as ‘Analytical Thomism’ (see, for example, ‘Analytical Thomism and the Catholic Philosopher: An Interview with John Haldane’, The Leuven Philosophical Newsletter, Volume 14, 2005-2006, pp. 36-41).

5. Epicurus (341–271 BC), from whose school we derive the modern term for a person devoted to sensual enjoyment (epicurean), actually advocated the reduction of desire for the purpose of attaining tranquillity or happiness. See ‘Epicurus’ in the Internet Encyclopedia of Philosophy.

6. I am grateful to Marcus Holmes of ‘Stoa Antipodea’ for bringing this group to my attention, and also for recommending Musonius (see following paragraph) and the Mountain Stoic blog. Stoic resources on the Internet number in the tens of thousands, including blogs, podcasts, videos, discussion forums, social-media groups, and online journalism. Introductory articles include ‘How to Be a Stoic’ by Massimo Pigliucci, Professor of Philosophy, City College of New York (The New York Times, 2 February 2015); and ‘A timeless tonic for our modern malaise? Stoicism may be the way forward’ by Jane Goodall, Adjunct Professor, Writing and Society Research Centre, Western Sydney University. A more comprehensive article, with many links to other online resources, is ‘Stoicism 5.0: The unlikely 21st century reboot of an ancient philosophy’ (The Conversation, 6 November 2015) by Matthew Sharpe, Associate Professor in Philosophy, Deakin University, and author of the Internet Encyclopedia of Philosophy article on Pierre Hadot cited above (The Conversation, 13 July 2017).

Pigliucci’s book, How to Be a Stoic: Using Ancient Philosophy to Live a Modern Life was published in May 2017. In the first chapter, he describes how he came to Stoicism through his cultural inheritance, as well as his training in science and philosophy. He had already written Answers for Aristotle: How Science and Philosophy Can Lead Us to a More Meaningful Life, in which he attempted to blend scientific and philosophical perspectives: ‘The basic approach was to combine the ancient idea of virtue ethics, which focuses on character development and the pursuit of personal excellence as the pillars providing meaning to our lives, with the latest that the natural and social sciences tell us about human nature and how we work, fail, and learn.’ (p. 4)

A 2013 post by blogger Donald Robertson reveals an early influence of Stoicism on psychotherapy, in the form of Swiss neuropathologist Paul Dubois (1848-1918) and French-Swiss psychoanalyst Charles Baudouin (1893-1963): ‘He [Baudouin] concluded Stoicism was the school of ancient Western philosophy most-obviously relevant to the goals of personal improvement and selected it for special consideration because of the emphasis it placed upon self-discipline and the “education of the character” … He noted that both rational psychotherapy and Stoic practice rest upon “the law of habit, and the need for training”, prescribing exercises to be “assiduously practised, daily if possible” (‘Stoicism and Early 20th Century Psychotherapy’).

7. Zealous as Evans is, however, I find some of his emphases disconcerting, particularly his promotion of an ‘Esalen model – which combines intellectual and experimental research’ – ‘Where next for well-being policy?’, accessed 22 October 2017. The new-age Esalen Institute, based in California, with roots in the Human Potential Movement of the 1960s, has a disturbing history of ‘experimentation’ with mind-altering substances and unorthodox practices. Evans’ endorsement, coupled with his most recent publication, The Art of Losing Control: A Guide to Ecstatic Experience, makes me wonder to what extent he has departed from his troubled personal history of ‘amateur neuroscience’, as described in his 2013 TEDx talk, also available via the first link above. For a critical perspective on Esalen, see Kevin R. D. Shepherd, ‘Criticism of the New Age’, ‘Integral Studies’ and ‘Findhorn Foundation’, accessed 22 October 2017.

8. The ancient Greeks used the word paideia to cover the broad cultural formation of individuals. The extensive range of this concept can be gauged from the section on ‘Ancient Greece’ in the Stanford Encyclopedia of Philosophy article on ‘Civic Education’. For a detailed discussion of the refinement of desire and emotion as part of Aristotle’s conception of moral training, see ‘Shaping the Youth: Aristotle on the Education of Desire and Emotion’, a 2011 MA thesis by Jason DeRoche, submitted to Carleton University Ottawa, Ontario. See also the forthcoming Aristotle’s Way: How Ancient Wisdom Can Change Your Life by Edith Hall.

An interesting contemporary attempt to apply principles of virtue ethics in an educational context is The Jubilee Centre for Character and Virtues in the School of Education at the University of Birmingham. See, in particular, the publications of Professor Kristján Kristjánsson and Dr Tom Harrison.

Without any reference to philosophy, family physician and author Leonard Sax has written about the necessity for parents to educate their children’s desire, rather than simply allowing them to pursue happiness (see ‘“I Just Want Her To Be Happy”: The Collapse of American Parenting’, First Things, 5 May 2017).

9. I will post a review of Nicholas Carr’s The Shallows: What the Internet Is Doing to Our Brains in due course.

10. In providing feedback on the first draft of this paper, Michael Francis Roach of the Facebook ‘Thomism Discussion Group’ brought to my attention the work of Cambridge academic, Daniel De Haan. Two of his papers are of particular significance for this review: ‘Thomistic Hylomorphism, Self-Determination, Neuroplasticity, and Grace: The Case of Addiction’ (2012), and ‘The Ratio of Addiction within an Aristotelian Philosophical Anthropology: A Proposal’ (2014). It is gratifying to read these papers, for two reasons. First, they confirm my intuition that the Aristotelian-Thomistic tradition is relevant to addiction. Second, although De Haan is writing in an academic idiom, his basic conclusions do not contradict my own.

Another academic philosopher who has written about addiction from the perspective of Aristotelian-Thomistic virtue ethics is Kent J. Dunnington at Biola University in California. See his Addiction and Virtue: Beyond the Models of Disease and Choice.

11. See Christopher Caldwell, ‘American Carnage: The New Landscape of Opioid Addiction’, First Things, April 2017. Caldwell’s analysis of America’s current problem of opioid addiction provides both historical and political contexts, and includes the following interesting observations, as well as a reference to a book on the philosophy of addiction:

Calling addiction a disease usefully describes certain measurable aspects of the problem — particularly tolerance and withdrawal. It fails to capture what is special and dangerous about the way drugs bind with people’s minds. Almost every known disease is something people wish to be rid of. Addiction is different. Addicts resist known cures — even to the point of death. If you do not reckon with why addicts go to such lengths to continue suffering, you are unlikely to figure out how to treat them. This turns out to be an intensely personal matter.

Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, ‘heartless’ incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.

In 1993, Francis F. Seeburger, a professor of philosophy at the University of Denver, wrote a profound book on the thought processes of addicts called Addiction and Responsibility. We tend to focus on the damage addiction does. A cliché among empathetic therapists, eager to describe addiction as a standard-issue disease, is that ‘no one ever decides to become an addict.’ But that is not exactly true, Seeburger shows. ‘Something like an addiction to addiction plays a role in all addiction,’ he writes. ‘Addiction itself … is tempting; it has many attractive features.’ In an empty world, people have a need to need. Addiction supplies it. ‘Addiction involves the addict. It does not present itself as some externally imposed condition. Instead, it comes toward the addict as the addict’s very self.’ Addiction plays on our strengths, not just our failings. It simplifies things. It relieves us of certain responsibilities. It gives life a meaning. It is a ‘perversely clever copy of that transcendent peace of God.’

12. One book that attempts to explain morality in evolutionary terms is social psychologist Jonathan Haidt’s The Righteous Mind: Why Good People are Divided by Politics and Religion (Pantheon, 2012). I came across this book earlier this year, and still haven’t had a chance to read it, although I have read some of the reviews. Haidt believes the evidence supports an evolutionary basis for morality, as it serves to bind humans in non-related social groups. Morality is innate and intuitive, and elaborated culturally. The six core moral factors are defined in terms of binary oppositions: care/harm, liberty/oppression, fairness/cheating, loyalty/betrayal, authority/subversion, and sanctity/degradation. More significantly for the discussion of Lewis’s book, since moral decisions are intuitive, Haidt believes that we only use reason to justify our decisions after the fact: reason becomes rationalization. Of course, intuitions are not necessarily irrational, and it would be interesting to read Haidt’s book in the light of Aristotle’s conception of moral education. Does the product of that education, the ideally moral person, make decisions intuitively? Haidt is no stranger to traditional wisdom, having written The Happiness Hypothesis: Finding Modern Truth in Ancient Wisdom (Basic Books, 2006). Indeed, his research led him to the conclusion that modern secular Western morality is WEIRD, an acronym he borrows from cultural psychology: Western, educated, industrialized, rich, and democratic. WEIRD morality is a minority phenomenon, historically and globally, being associated with post-Enlightenment Western individualism. It narrowly places undue emphasis on the ‘harm principle’. By contrast, for most of our history, and in most of the world today, a sociocentric morality prevails, and it encompasses all of the core moral factors. Although this may be more congruent with ancient Greek and medieval European morality, Haidt would doubtless reject the teleological ‘natural law’ morality associated with Aristotle and Aquinas.

Addiction Unlimited

A review of

Damian Thompson

The Fix

How addiction is invading our lives

and taking over your world

(London: Collins, 2012)

the-fix-book-cover

Introductory comments
Given the seriousness of its subject matter, it might seem insensitive to joke that I couldn’t put this book down, but in truth The Fix is a highly readable account of the hydra-headed reality of contemporary addiction. Author Damian Thompson, a journalist with a PhD in sociology, and himself a former alcoholic, describes with disarming candour the ‘addictive desires’ to which he is subject, and which he believes are far more common than most of us would like to admit. Indeed, it is precisely the prevalence of such desires that makes them a target for those whose job it is to manipulate us into consumption of one form or another, and this is really what The Fix is about.

The science of addiction
The book doesn’t present any groundbreaking research. The perspective is more sociological than neuroscientific, although brain chemistry is central to the story, and Thompson’s exposition of it is lucid and interesting. He points out that the scientific jury is still out on the precise causes of addiction. Although the role of neurotransmitters – such as dopamine and the opioid system – in reinforcing certain behaviours is well understood, there is less certainty about what causes some people to cross the line into debilitating addiction, while others evade this outcome. One thing that Thompson is adamant about, however, is that addiction is not a disease.

As an alcoholic, Thompson attended the AA 12-step program and is open about the benefits he received from it, but he attributes the success of the method to the ‘remarkable power of peer-group moral support’ (p. 34), despite – rather than because of – its adoption of the ‘disease model’ of addiction. For Thompson, the disease model is pernicious, because it removes ‘will’ from the picture. Not that his tone is moralising – he recognises the adverse circumstances that can lead to some forms of addiction – but he favours an account, more traditional in my view, that sees addiction in terms of habit formation. In this context, he approvingly cites psychologist Dr Stanton Peele, who ‘argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction’ (p. 44). Thompson finds the jargon of addiction specialists to be fuzzy and superficial: ‘They’ll use a term like “compulsion” without exploring the philosophical questions it raises about free will’ (p. 43); and he accuses them of a circular logic: ‘heavy drinkers who give up alcohol of their own accord … cannot have had the disease and were therefore never alcoholics in the first place ‘(pp. 35–36). The problem, of course, is that there is no diagnostic test for the ‘disease’ of addiction, unlike cancer or tuberculosis.

Countering the disease model, Thompson presents both anecdotal evidence and the results of large-scale research. In the former category is his account of Robin and James, friends from similar backgrounds who both drifted from alcohol to hard drugs. But while Robin gradually turned his life around with great effort, James committed suicide. Thompson points out that if Robin had died during his addiction phase, as nearly happened, the specialists would have felt vindicated in attributing his fate to a disease. Since he recovered through his own efforts, however, the conclusion must instead be that he never had the disease.

The disease model is not supported at an epidemiological level either, as extensive US government research conducted with Vietnam veterans demonstrates. Fearing a massive public-order problem caused by thousands of heroin-addicted GIs returning to American cities, the government commissioned a study of 400 users who described themselves as addicted. What they found, however, was that 88% of the subjects kicked the habit once they returned to civilian life. It seems very likely that it was the extreme circumstances in Vietnam, coupled with availability and peer behaviour, that was the cause of the addiction. Once the circumstances changed, for most of the soldiers the addiction was overcome. For Thompson, this identifies a key factor in addiction, which he describes as the ‘availability hypothesis’. Following Professor Michael Gossop, a leading researcher at the National Addiction Centre, King’s College, London, he describes different ‘dimensions of availability’: physical, psychological, economic, and social. The Vietnam GIs ticked all of the boxes.

Chapter 3 takes a closer look at the science of addiction. The role of dopamine is discussed, as is the opioid system, which contains the brain’s morphine-like compounds (endorphins). The former seems to have more to do with desire (wanting), and the latter with pleasure (liking). The surprising fact for me was that the former is stronger than the latter – our bodies reward wanting more than liking, although the latter plays a role in the former. Grafted onto this schema is what Thompson calls the Go and Stop impulses. The Go impulse is very primitive and we share it with animals. Dopamine is central to this urge. The Stop impulse is associated with the frontal lobes and is highly developed only in adult humans – it helps us to manage the Go impulse by reasoning about the consequences of immediate reward. I might observe that, if we leave out the technical vocabulary, none of this would have been news to the philosophers of the ancient world, who developed reasoning about desire to a high degree.

The point about the brain chemistry is that the same chemicals are involved in any form of addiction, be it ‘substance’ or ‘process’ addiction. The effects of different ‘recreational’ drugs on the brain may vary, and can be observed in addict behaviour (pp. 60–63), but ‘dopamine is still the master drug’ (p. 63). It plays a role in fastening onto ‘cues’, and here Thompson links the rarer experience of addicts to our everyday experience. The physiological effect of cues has been understood at least since Pavlov, but the point here is the continuity of the experience – ‘ordinary’ and ‘addictive’ represent different points on the same spectrum, and that is significant to the case that Thompson is making: ‘the brain’s reward circuits don’t necessarily distinguish between supposedly innocent and supposedly dangerous pursuits … addictive behaviours are accompanied by physical changes in the brain – whether or not they involve drugs’ (p. 65).

This brings us to the heart of the argument about brain chemistry and addiction, and it recalls what was said earlier about the will and habit formation. The following key passage is worth quoting in full:

Why does science have such a hard time getting to grips with the phenomenon of addiction? In a nutshell, because human brains, as opposed to animal ones, can instruct the body to perform an almost infinite number of voluntary (and therefore unpredictable) actions. And, contrary to the beliefs of disease-model advocates and the huge therapeutic industry, addictive behaviour is essentially voluntary. Addicts may be influenced by their disordered brain chemistry to make bad choices, but they are choices nonetheless. (p. 67)

For Thompson, addiction is a disorder describing how ‘people choose to do things that are not in their best interests … addicts are those who consistently seek damaging short-term rewards’ (p. 70). He doesn’t rule out an inherited predisposition, since, for example, alcoholism is known to run in families, but unlike a genetically inherited disease, no one has isolated a specific gene for alcoholism, and Thompson isn’t sanguine about the prospects of finding one: ‘since addiction consists of complex sequences of voluntary acts, such neurological reductionism is a waste of time’ (p. 70). Here he anticipates much of the theme for the remainder of his book. Hard drugs are not physically, psychologically, economically, or socially available to most of us, but there are many other substances, objects, and processes that are, and the producers of such things have a very strong interest in getting – and keeping – us hooked on them.

The chapter concludes with some semantic considerations that emerge from the science. First, ‘the old distinction between “psychological” and “physical” addiction is misleading’ (p. 72). We can be physically addicted to something, meaning that its consumption or repetition is reinforced by changes in the brain, but it is nonetheless reversible if the behaviour changes. Second, ‘dependence’ can mean different things. A diabetic may be dependent on insulin, meaning that he will die without it; but a heroin addict will not die without heroin. Thompson urges that ‘wanting’ and ‘liking’, though not scientific terms, ‘can be used unambiguously because they correspond to discrete urges governed by different brain mechanisms … [and] we can say with some confidence that, increasingly, our wanting urge is overwhelming our liking urge’ (p. 72). He argues that corporations have become very adept at manipulating our environment ‘to make us as greedy as possible’ (p. 73).

The business of addiction
Chapter 4 links what has already been said about brain chemistry and the availability hypothesis, with what we know about evolutionary biology, and applies this knowledge to our contemporary world, with some historical examples that lend support to the argument. A key paragraph is the following:

In evolutionary terms, we essentially have the brains and bodies of hunter-gatherers. Our biochemistry has changed a bit in response to our dramatically altered surroundings, but not nearly enough for us to be able to adjust to them without damaging ourselves. Most people don’t reach the point of becoming addicts; but this mismatch between our bodies and our environment is the fundamental problem of addiction, and it is common to all humanity. (p. 76)

The biological goal of evolution is survival, and the mechanism that drives it is pleasure. Pleasure rewards the behaviour that increases our chances of survival. The problem is that our brain chemistry keeps pushing us towards those pleasurable experiences after our biological needs have been met: ‘We have no way of switching off the hunter-gatherer instincts inherited from the mammals that preceded us, which have developed over hundreds of thousands of years’ (p. 79).

Technology plays a central role in the struggle for survival. Thompson defines technology as ‘an infinite number of tools, crafts and techniques that, thanks to scientific discoveries, have the potential to make life more bearable for us’ (p. 80). Technology ‘allows us to achieve greater rewards for less effort … [it] pushes the work-to-reward ratio in the direction of rewards – and usually short-term rewards at that’ (pp. 80–81).

Problems begin when – due to urbanization, industrialization, and capitalism – we arrive at a situation of unlimited availability. The well-known example of sugar is given: useful in the form of occasional fruit for hunter-gatherers, but positively dangerous in the quantities that we are now consuming it. This brings us to the concept of ‘addictive epidemics’ (p. 87). Heroin addiction among Vietnam GIs was an example of this, and Thompson provides others, such as the eighteenth-century ‘Gin Craze’ in London – the ‘first recorded epidemic of drunkenness in history’ (pp. 84–7); and, in the same century, the epidemic of opium smoking in China (pp. 89–92). In both cases, the epidemics involved a combination of technological developments and other social factors, leading to ‘availability’ in the senses discussed earlier.

Moving on from heroin, alcohol, and opium, Thompson points out that addictive urges needn’t involve ‘substances’ at all, and he gives the examples of casinos and strip clubs, both being cases where the thrill-seeker ‘is endlessly teased with cues that signify sudden wealth or a glorious sexual encounter’ (p. 93). It’s not important that the customer knows deep-down that these expectations are unrealistic, since his brain chemistry leads him to ignore the long-term consequences in favour of a ‘short-term buzz of excitement’ (p. 93).

For Thompson, there is no tidy explanation of what tips people over into self-destructive behaviours, but he asks us to step back and remind ourselves of the big picture:

The only things limiting our ability to stimulate ourselves to the point of frenzy are our fragile biology and our common sense. Western society has moved beyond the point where addictive epidemics can easily be distinguished from everyday behaviour; the dynamics of addiction and the dynamics of the free market simply have too much in common. (p. 94)

Dramatically illustrating this point is the example of the German pharmaceutical company, Bayer, which commercialized the drug diamorphine in 1898, marketing it as a syrup for ‘coughs, colds and “irritation”’ (p. 95). It was trademarked as Heroin, ‘to indicate its “heroic” properties’ (p. 95). (Diamorphine had first been synthesized by an English chemist in 1874, but Bayer led commercialization after Felix Hoffmann independently re-synthesized it.) Although they had been searching for a less addictive form of morphine, they ended up producing a substance that was more addictive, and then making it readily available with dreadful consequences. We now know that once demand has been created, limiting supply becomes ineffective, because addicts will switch to other substances, and even to non-substance forms of addiction:

Addictive behaviours aren’t necessarily locked on to specific things: in a world where there are practically limitless pleasurable experiences on offer, obsessive behaviour becomes promiscuous: it can grab hold of any object or activity that promises us a hit. (p. 98)

Most of the rest of the book applies this argument to various modern forms of addiction. Chapter 5 is devoted to sugar, which Thompson points out shares some of the psychoactive properties of ‘recreational’ drugs. Lab tests at Princeton University indicate that sugar induces cocaine-like reactions in rodents (pp. 107–8). Beyond the substance itself, however, is all of the daily behaviour that surrounds it, and which surrounds our consumption (and over-consumption) of food in general: ‘the food industry not only engineers food that exploits our natural preference for sugar, fat and salt, but also grabs our attention when we’re not eating, employing cues that awaken our wanting instinct’ (p. 123).

Chapter 6 considers the social phenomenon of binge drinking. Public drunkenness has become more prevalent, even among women, and its effects are graphically portrayed not just in the traditional media but on social-media platforms like YouTube. The ‘narrowing of the alcohol gender gap … [means that] women are now exposed to changes in brain chemistry that had previously been restricted to men’ (pp. 134–5). A large part of this chapter is autobiographical, but Thompson draws out the implications, describing himself as ‘a fairly typical casualty of an environment saturated with my drug of choice’ (p. 141). He goes on to link the social change in drinking patterns to the related ingestion of recreational drugs, which are being synthesized at an increasing rate, and often available at low cost on the Internet. The acceleration of the process makes it virtually impossible for the authorities to keep up. The conclusion is a pessimistic one:

Government scientists are scrambling desperately to classify these drugs and warn young people of the dangers of taking them. But the underground laboratories, and their new digital sales departments, are too far ahead. It’s a lost cause. (p. 150)

Chapter 7 takes a look at the converging problem of prescription medication. Drugs like Adderall and Ritalin, designed to treat ADD and ADHD (controversial diagnoses in their own right), have become widely prescribed, particularly in the US. These stimulants have been adopted as cognitive-enhancing drugs, particularly by students who are under pressure to perform, and they are traded accordingly. The social pressure on students to drink, at parties or in clubs, has resulted in widespread self-medication, often involving carefully-planned sequences of alcohol, amphetamines (legal and illegal), painkillers (e.g. codeine), and tranquilizers.

What we’re confronting here goes further than a blurring of the boundary between legal and illegal drugs. Also evaporating are the distinctions between the legal, inappropriate and unlawful use of medicines, plus the difference between medication and self-medication. (p. 159)

The pattern doesn’t necessarily end with graduation either, but can be carried over into a high-pressure workplace. Research indicates, however, not only that the drugs are damaging, but that they deliver no long-term cognitive enhancement. In the case of such self-medicating high achievers, Thompson suggests that ‘it might be worth checking on the state of their brain chemistry in a few years’ time’ (p. 171).

The next two chapters take us beyond substance abuse to forms of non-substance addiction, such as ‘gaming’ (Chapter 8) and pornography (Chapter 9), both being areas where computer technology has created unheard-of forms of addiction.

The title of Chapter 8 (‘Gaming, the new gambling’) is a succinct summary of its content. A watershed event was the passing of a law in the US in 2006, making online betting illegal and preventing any company from providing it there. People who had been addicted to online gambling switched instead to online gaming, and gaming companies recruited programmers from the now-illegal industry. The switch would have been relatively smooth for them because, as Thompson points out, the two activities employ similar ‘reward dynamics’ (p. 174). He describes them with an evocative phrase: ‘brain-hijackers with transferable skills’ (p. 180). Supporting this claim is a statement from an anonymous Silicon Valley gaming company CEO:

We design an environment in which losses are insignificant and there are regular reassurance mechanisms. Then we make modifications to that environment and monitor which combinations of punishment and encouragement keep users playing for longer. We engineer the game very precisely to keep players enjoying it for the longest possible time, and we use complex software to help us monitor what the entire installed user base of players is doing with their copy of the game. (p. 181)

Who are these players? Thompson points out that ‘it isn’t just children who are getting trapped in cyberspace’ (p. 176). There are adults who spend hours in front of a screen tweaking their online personas (avatars), purchasing virtual real estate, furniture, and clothing, and interacting with other avatars in an immersive virtual world (e.g. Second Life). Corporations take male and female preferences into account and tailor their games accordingly. Furthermore, not only has the ‘traditional’ gaming market mushroomed, but a host of other software applications has been ‘gamified’ (p. 177), including email, Twitter and Facebook. That such applications are now installed on multiple platforms (smartphones, tablets, laptops and desktop computers) means that we are increasingly bombarded with visible and audible notifications that give us a buzz of excitement.

Although games and social media technologies might appear trivial by comparison with some forms of addiction, Thompson believes we are facing ‘yet another social epidemic, born out of the marriage of marketing and reward-responsive brain chemistry’ (p. 183). He numbers ‘300 internet addiction clinics in China alone, catering to some of the estimated 17 million game and internet addicts in that country’ (p. 188).

A troubling implication of this burgeoning online interaction is that ‘relationships in the real world will resemble those in the digital one: transitory, accelerated, pragmatic associations that provide a hit of narcissistic reassurance rather than lasting bonds between close friends’ (p. 194). If this sounds far-fetched to some, Thompson concludes, consider that ‘by the end of 2011, Facebook was being cited in a third of divorce cases in the UK’ (p. 195).

Chapter 9 tells a similar story, but this time it is digital pornography that is of concern. Men are more prone to this addiction, but women are affected. It is a difficult area to research, but the available data ‘suggests that the sexual appetites of countless millions of people are being manipulated in ways for which there is no historical precedent’ (p. 196). Of all the addictions that Thompson describes in the book, ‘it’s the one that comes closest to panicking the experts’ (p. 198).

By contrast with the pre-digital version, digital porn has become increasingly explicit, in response to the jaded appetites of consumers. This includes a ‘drift towards violence and cruelty’ (p. 204). Furthermore, although porn has always taken advantage of new technologies, the Internet has made it available on an unprecedented scale, frequently without cost, and to children as well as adults.

Thompson cites psychiatrist Norman Doidge, whose 2007 book, The Brain that Changes Itself, has made popular the idea of ‘neuroplasticity’. For Doidge, ‘internet porn is addictive in roughly the same way as drugs’ (p. 211). In the mid- to late-1990s, he noticed that some of his male patients complained of problems with normal sexual performance, and he ascribed this to brain rewiring, brought on by repeated bursts of dopamine in response to explicit pornographic images. The business side of porn may not be as systematic as online gaming, but the effects on the brain are just as pernicious, if not more so.

The examples provided by Thompson demonstrate that this problem is affecting males of all ages and backgrounds, with publicised cases revealing the collection of hundreds of thousands of illegal images. This is one of the instances where addiction reveals obsessive-compulsive traits. Like other forms of addiction, internet porn exploits loneliness, and masquerades as an antidote to it. It is a case of the progressive replacement of people by things, in this instance by increasingly hard-core images.

The title of the final chapter (‘Deliver us from temptation’) has religious overtones, perhaps reflecting Thompson’s academic and professional background – his PhD was in the sociology of religion, and he has been religious affairs correspondent of The Daily Telegraph and editor-in-chief of the Catholic Herald.

In this chapter, we return to the big picture, to get some sense of what we are confronting. Regarding legalisation of drugs, Thompson points out that the resulting changes to lines of supply would not provide any remedy for addiction. Furthermore, technological changes mean that the boundary between legal and illegal drugs has become blurred, and, in any case, many abused drugs are already easy to get hold of (e.g. Adderall, Ritalin, codeine).

As a way of understanding addiction in the 21st century, Thompson adopts the pyramidal model proposed by Dr Adi Jaffe, a former addict and dealer turned academic psychologist. According to this model, the pyramid is divided into thirds: the bottom third represents ordinary people whose addictive impulses are ‘difficult, but not impossible, to excite’; the middle layer consists of ‘vulnerable individuals whose natural reaction to stress is to search for a fix’; at the top are those we consider addicts in the real sense, ‘with their wide-open “wanting” pathways who are capable of developing an all-consuming obsession with anything from candy bars to sadomasochistic sex acts’ (p. 237). In the light of the preceding chapters of his book, Thompson proposes that we are witnessing an upward trend within this pyramid:

More of us find ourselves in the category of addict or the intermediary layer of vulnerable consumer. More of us are at risk than ever before of developing crippling addictive behaviours. Ignoring potentially harmful temptations involves significantly more willpower than it once did. (p. 238)

If, as Thompson argues, addiction is not caused by brain malfunction, but rather the opposite – ‘addictive behaviour, influenced above all by the available supply of addictive substances and experiences, can sometimes cause brain abnormalities’ (p. 238) – then the social implications are enormous.

Thompson refers to ‘the sudden disappearance of political and cultural obstacles that limited the geographical spread of particular addictive products and practices’ (pp. 240–41). These include the fall of the Berlin Wall, hi-tech globalization, migration, organized crime, and long-haul travel (which ‘has changed the attitude of students and young professionals towards mind-altering drugs, which they have seen consumed in developing countries as part of the natural rhythm of life – or so they like to think, in their romantic way’, pp. 244–5). The changes are too rapid to be described as ‘generational’ and they place a huge burden on our psyches:

One way or another, everybody in the Western world has to confront the quickening of desire. It’s true that many people can’t afford to pursue more than a few of those desires. Most of us, however, face an intensity of temptation that we can only intermittently resist. Managing those temptations draws deeply on our psychological resources: it can dominate our thoughts and swallow up our time. (p. 246)

The modern consumer society only exacerbates this burden, since it is ‘partly fashioned around our inability to exercise willpower’. Indeed, our livelihoods often depend on ‘other people’s vulnerability to temptation’, which implies that we are all implicated: ‘The multiplication of choice, the expansion of the free market and the stimulation of greed are so tightly interwoven as to be almost indistinguishable from each other’ (p. 258). The result is that the ‘addictive personality … is fast becoming the default personal style of disoriented modern citizens’ (p. 259).

The medical model may appear to lighten the burden by making us think that ‘addictions are not so much the product of our actions as something we are unlucky enough to have acquired’ (p. 247), which Thompson describes as ‘a recipe for learned helplessness’ (p. 249), but it will not help us in the long term. In the final analysis, he believes that ‘addiction is a disorder of choice, and we’re not doomed to carry on making bad choices to the point of helplessness’ (p. 259):

Perhaps we need to rediscover the vigilance that protected our hunter-gatherer ancestors. The quicker we are to spot the technological tricks that manipulate our “wanting” impulse, the greater will be our chance of resisting them. That’s if we want to, of course. (p. 260)

Concluding comments
The Fix is written for a general audience, although the influence of Thompson’s background in sociology is detectable. With minimal use of scientific jargon, he makes a plausible case for the continuity between extreme forms of addiction, which we might all recognise, and the more mundane experience of giving in to temptation, whether the object of our desire be food, prescribed medication, or digital distractions. Furthermore, he suggests that our contemporary way of life is pushing us into addictive-type behaviours.

A recurring theme in the book is that addiction involves the progressive replacement of people by things. This is particularly evident where addiction intersects with obsessive collecting (a form of OCD), but it is not limited to such cases. Even the people in an addict’s life often become a means to the object of his addiction. And addicts often end up alone in their bedroom or sitting room, whether they are addicted to alcohol or gaming.

Describing himself as a former addict, he refuses to accept the ‘medical model’ that claims addiction is an incurable disease. Although he acknowledges the role of ‘situation and context’, and agrees with Malcolm Gladwell (The Tipping Point, 2000) that we tend to ‘overestimate the importance of character traits’ (p. 88), his description of addiction as a ‘disorder of choice’ is entirely compatible with traditional accounts of habit formation.

We know from their writings that ancient philosophers like Plato and Aristotle well understood the human psyche to be a battleground between competing influences. Notwithstanding the power of irrational forces, they regarded rationality as the defining characteristic of human beings, and they claimed that the ordered psyche was one in which the irrational was submitted to the rational. Ancient philosophical schools, such as the Epicureans and the Stoics, developed a sophisticated understanding of desire and emotion, including a hierarchy of different kinds of pleasure, and they elaborated exercises to help students strengthen the will against temptation. Their goal was eudaimonia, often translated as ‘flourishing’, in the sense of a fulfilling human life. They were concerned with ‘normal’ desire, rather than the extreme of addiction, though doubtless they would have seen the two lying along a spectrum, with the latter being the developmental endpoint of a dissolute life, one in which there was no attempt to subjugate the lower desires.

Thompson, perhaps judiciously, doesn’t bring such historical considerations into his account, which is generally factual and descriptive rather than moralizing. I believe it is significant, however, that he leaves open the door to what the ancients have to teach us. Although no stranger to addictive desires himself, he refuses to shirk responsibility for his own poor choices in the past. Rather, he returns, like the escaped prisoner in Plato’s cave allegory, to help liberate his erstwhile fellow captives, and warn against complacency in a world increasingly governed by desire.

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