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Autumn 2009 | Vol 13 No 1

Review

Wayne Skinner

Choice disordered: Addiction as a bookkeeping error

Gene Heyman’s new book on addiction has garnered an unusual amount of media attention. Not surprising, given its provocative subtitle – “a disorder of choice.” It is fascinating to see how quickly and easily Heyman’s ideas about choice were not just misunderstood, but appropriated to feed pop psychology’s appetite to see addiction as more about misguided free and bad decisions than as a real mental health issue.

However, this quick resort to reductive popular notions about volition misses the unconventional argument Heyman develops. First, he does not privilege choice as a uniquely human capacity, pointing out that all mammals behave in ways that are mostly voluntary. If you can halt a behaviour by changing the factors that shape decisions, it must be voluntary. Since drug use, like most other behaviours, is governed by its consequences, it can only be a matter of choice. Heyman quickly adds that does not mean voluntary behaviour is necessarily rational, or that “someone addicted to drugs can choose to quit.”

In Heyman’s model, choice depends on context. What makes addiction a disorder of choice is the way drug use draws the user into a pattern of decisions biased towards “local equilibrium” – choosing something because you will feel better now, rather that towards “global equilibrium” – choosing the better option for the long run. This undermines the “global bookkeeping” needed for healthy, rational functioning. Substances and behaviours are addictive because they are behaviourally toxic, poisoning the field and “making everything else relatively worse.” The rewards they provide are “specious,” mixing immediate benefits with hidden, deferred costs that keep the user thinking and acting “locally” – bound by the immediate situation, trying to get high and avoid withdrawal.

But since context shapes choice, when surroundings shift, people may choose to change. You couldn’t do that if what you had was a disease, argues Heyman. In fact, his choice theory leads him to ask, Why aren’t there more addicts? The theory predicts there should be more, but social factors come to the rescue. Having religious convictions, being married and having conventional social values protect people. By being good bookkeepers, we see that the costs and benefits of being addicts don’t add up. Addiction is thinking locally; prevention and recovery are about thinking and acting globally.

Heyman’s spirit of inquiry has an honest bent, and he tries to patch some of the holes in the model, but not quite adequately. For example, he reduces treatment to pharmacotherapy, contingency-oriented strategies and “AA and its offshoots.” To miss the wider array of therapies is to hurry through terrain that deserves fuller consideration.

Where Heyman does a better job is in his critique of other approaches to addiction. He shows that people who do not seek treatment differ from those who do. Those in treatment are more likely to have complex problems, causing us to lose sight of the fact that most people with addiction discontinue the behaviour by their 30s, often without formal help. He also offers narratives of people with addiction that illustrate how changing life circumstances led people to choose to stop using drugs. For Heyman, that sets addiction apart from diseases, where biological factors keep people ill in ways that volition cannot resolve.

While allowing that biology is integral to the nature of drug use, Heyman vigorously attacks the view that addiction is a chronic, relapsing brain disease. Yet even if his economics-informed psychology of choice enhances our understanding of addiction as a complex process, it too is insufficient. And if addiction is a disorder of choice, his argument leads away from failed volition and willpower and towards the ways social factors and biology shape physic space to make it easy or hard to engage in behaviours that lead into – and out of – addiction.

Addiction: A Disorder of Choice. Gene M. Heyman. Harvard University Press, Cambridge, 2009, 216 pp., $26.95US.

Wayne Skinner is deputy clinical director of the Addictions Program at the Centre for Addiction and Mental Health in Toronto.