Abstract
While some form of loss of control is often assumed to be a common feature of the diverse manifestations of addiction, it is far from clear how loss of control should be understood. In this paper, I put forward a concept of decrease in control in addiction that aims to fill this gap and thus provide a general framework for thinking about addictive behavior. The development of this account involves two main steps. First, I present a view of degrees of control as the degree to which an agent would be responsive to potential or counterfactual sufficient reasons to do otherwise. Second, I sketch an account of the relevant control-undermining factors in addiction that is consonant with my proposed view of degrees of control. Being a high-level functional property, reasons-responsiveness is particularly well suited to frame an account of control-undermining factors that is doubly pluralistic: it encompasses the contribution of factors both internal and external to the agent, and it is consistent with various proposals as to the precise nature of the anomaly taking place in the psychology of addiction.
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Notes
Even though I will restrict the scope of ‘addiction’ to substance use for the purposes of the present discussion, the view I put forward here may be relevant to other sorts of addictions as well if there were any. As for the term ‘drugs’, I will use it liberally to refer to whatever substances may be the target of addictive behavior, thus including alcohol, tobacco and other substances not commonly referred to as drugs in everyday discourse. In ordinary discourse the labelling of a person as an addict often involves a negative appraisal of her behavior or her character, it is frequently meant as a stigmatizing characterization and it is often interpreted as picking out an essential trait of the agent. I wish to imply none of these things. The appropriateness of labelling addiction a ‘disease’ or a ‘disorder’ will not be part of the present discussion.
This is paradigmatically the approach of the Diagnostic and Statistical Manual of the APA (2013). The DSM-V renders the “essential feature” of ‘substance-use disorders’ as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (p. 483). As usual in the DSM, the definition is operationalized in a set of diagnostic criteria. The ten criteria provided for substance-use disorder are divided into four categories: impaired control, social impairment, risky use of the substance and pharmacological criteria. See APA (2013), pp. 483–484.
Besides the already quoted definition in the DSM-V, other definitions that make a reference to negative or harmful consequences include World Health Organization (2014); National Institute on Drug Abuse (2014); Heather (1998); Sinnott-Armstrong & Pickard (2013). A dissenting voice is found in Watson (1999: 13).
Loewenstein (1999) and Levy (2010) may be cited as examples of a view of this kind. It is also frequently the assumed view of addiction in the literature on free will and moral responsibility. Frankfurt (1971) and Watson (1977) come to mind as two paradigmatic examples.
Compulsion views are also widely held in the medical and mind sciences, with a plausible claim to being the mainstream view of addiction in those fields. The reference to “compulsive drug-taking” is incorporated in the DSM-V’s characterization of severe substance-use disorder (APA 2013, p. 485), which is colloquially identified as addiction. It is also the view of addiction held by the National Institute for Drug Addiction (NIDA), which defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use” (NIDA 2014, p. 5). Though the claim regarding compulsion is widely held and has a long history, it has of late been particularly associated with the ‘Brain Disease’ model of addiction (Kalivas & Volkow, 2005; Volkow, Koob, & McLellan, 2016). A concern may arise, however, regarding what exactly is meant by compulsion-talk in the medical literature, where this is typically left underspecified.
See Gene Heyman (2009). Some statements by Hanna Pickard (2012, 2017, 2018, 2020) suggest a view along these lines, though in other passages she acknowledges that control may be compromised in addiction to some extent. Some versions of Self-Medication (Khantzian, 2003) and of Learning models of addiction (Lewis, 2017) also have affinities with this kind of view.
I am not the first to argue that we should move past the Compulsion/Choice dichotomy and look for intermediate alternatives. Others include Wallace (1999); Watson (1999); Holton (2009); Holton & Berridge (2013); Flanagan (2013); Sinnott-Armstrong (2013); Sinnott-Armstrong & Pickard (2013); Henden (2018).
As noted in the text, ‘Pure’ Compulsion and ‘Pure’ Choice views are meant as theoretical poles, serving as reference points to present the concept of a decrease in control. However, proponents of both Compulsion and Choice views do appear at times to approximate these more extreme variations of their positions. For instance, Carl Elliot depicts the addict as someone who “must go where her addiction leads her, because the addiction holds the leash” (2002: 48); and Louis Charland describes the condition of someone diagnosed with drug (heroin) dependence as someone whose “decisions that relate directly to heroin use are susceptible to powerful physiological and psychological compulsions that usually nullify any semblance of voluntary choice” (2002: 41; emphasis added); and Nora Volkow speaks of addiction as a condition under which “a person’s brain is no longer able to produce something needed for our functioning and that healthy people take for granted, free will” (from her blog post ‘Addiction is a Disease of Free Will’, based on her inaugural address as Director of the National Institute on Drug Abuse, retrieved from: https://archives.drugabuse.gov/about-nida/noras-blog/2015/06/addiction-disease-free-will on march 4th 2021). Proponents of Choice views also occasionally state their claims in ways that suggest more extreme views than the authors’ own considered judgements would allow. For instance, Hanna Pickard at times articulates her view by saying that “addicts use drugs and alcohol purposively (…). Consumption is a chosen means to desired ends. If the ends are no longer as pressing, or alternative ways of achieving them are available, it is possible to choose differently” (2012: 41) and that “drug choice in addiction is voluntary and value-based” (2020: 8). As noted before, however, in other passages Pickard gives a more nuanced statement of her view, acknowledging that control may be compromised in addiction to some extent.
For both kinds of first-person reports from addicts, see Hänninen & Koski-Jännes (1999). Another interesting source of first-person stories of addiction is the Crackdown podcast, available at https://crackdownpod.com/.
Of course, this observation falls short of an argument that such a challenge cannot be met. For instance, a Pure Compulsion theorist could claim that formerly compulsive, irresistible desires lose that quality and become resistible during the process of recovery. Or she could argue that people who are able to recover were not true addicts to begin with or not the kind of addicts that the account is meant to apply to. For present purposes, it suffices to note that a Pure Compulsion view would be required to come up with a convincing reply to the puzzle of recovery.
As the text implies, that interpretation may be open to dispute. Sinnott-Armstrong (2013: 132–133) discusses possible grounds for scepticism about Heyman’s interpretation.
Another way to frame this worry is in terms of the distinction between a general and a specific sense of ability (Clarke, 2009; Whittle, 2010). That is, when we wonder how much control an addicted agent enjoys over her drug-related behavior we are not asking whether she retains the general ability to control her behavior but whether she is presently able to exercise that ability in the actual circumstances she finds herself in.
This view is meant to be compatible with a fairly deflationary account of reasons and need not entail any particular ontological commitments in this regard. It is not implied either that the capacities underlying reasons-responsiveness do not involve an affective dimension. Further, following Fischer and Ravizza’s account (1998: 77), what constitutes a sufficient reason to do otherwise may be deferred to the considered judgements in wide reflective equilibrium of the relevant community. Finally, a stipulation should be added to the effect that the agent’s reaction to the presence of the relevant reasons be appropriately connected to her appreciation of what those reasons are.
Fischer and Ravizza’s (1998) account of reasons-responsiveness construes it as a property of the ‘mechanism’ or the set of sub-personal processes that lead to action rather than as a personal-level property of agents. Other reasons-responsiveness theories (e.g., Brink & Nelkin 2013; McKenna, 2013; Nelkin, 2011; Vargas, 2013) opt instead for an agent-based approach. The decision to favor one sort of approach over the other turns on some potentially tricky issues, including different ways of responding to Frankfurt-type scenarios and the difficulties involved in providing an account of mechanism individuation (for discussion, see McKenna, 2013). For present purposes, I shall remain neutral between these different ways of specifying the reasons-responsiveness account. Even if, for ease of exposition, I refrain from explicitly re-stating both possibilities with each reference to reasons-responsiveness, I intend to be interpreted in terms of this neutral stance.
Fischer and Ravizza impose asymmetrical requirements on receptivity and reactivity as a result of their claim that “reactivity is all of a piece” (1998: 73). ‘Regular’ receptivity is meant to exclude patterns of response that would look haphazard or strange by the lights of a third party. Thus, it reflects the requirement that there be an appropriate connection between the relevant reasons and the agent’s responses.
I do not mean to imply that there are no other regards in which the decision-making processes of addicted agents may be somehow anomalous (Verdejo-Garcia, 2018). Whether this is the case, what kinds of processes are compromised and to what extent, are all questions to be settled in the light of appropriate evidence.
In accordance with the way the DSM works, the different degrees of severity are equated with the presence of different quantities of the relevant symptoms —2 or 3 for the mild, 4 or 5 for the moderate and 6 or more for the severe. Thus, the DSM points to a gradient of differences of a scalar nature, even though this is not captured in a very precise way by the characteristic quantity-of-symptoms approach of the manual. Nevertheless, insofar as the DSM implies that there is a need to think of addiction as something that someone may suffer to different degrees, the present account in terms of degrees of reasons-responsiveness provides a tool for thinking about degrees of severity that could be useful in practice.
As noted before, the rationale for this is that under the present account control is understood in terms of the exercise of certain rational and volitional capacities. If the premise is granted that situational and environmental factors of the kind cited here may in some cases have an impact over the agent’s relevant capacities, then that amounts to their having an impact over the agent’s control. The key thought is that the opportunities that the present situation affords to the agent are an integral part of the explanation of what the agent is presently able or not able to do. A full discussion of this point, however, would lead to some tricky issues concerning the interpretation of capacity-talk that are beyond the scope of this paper. For discussion of the relevant notion of capacity, see Clarke (2009) and Vargas (2013), chapter 7.
By ‘anomaly’ I mean simply that there is something in the way these processes are working that is peculiar or distinctive. Moreover, it is something that makes it the case that there is a difference between how these processes are working in addiction and how they ordinarily work, both for non-addicted agents and possibly for addicted agents too when it comes to matters not related to drug use. As I mentioned before (note 1), I remain neutral on the issue of whether it is appropriate to label addiction a ‘disease’ or a ‘disorder’, as this raises further questions about the concept of a disease that are beyond the scope of this essay.
The pluralistic stance regarding the precise nature of the psychological underpinnings of tiltedness may give a reason to prefer a mechanism-based over an agent-based account of reasons-responsiveness (see note 13 above). The concept of a ‘mechanism’ is not easily defined and gives rise to some difficult questions regarding mechanisms’ individuation and demarcation. Still, it is probably safe to assume that different mechanisms are involved in the production of action. Moreover, it is likely as well that the anomaly that results in the overall tiltedness of the process leading to action may be traced back to the operation of different mechanisms in different cases. That sort of picture would also be able to explain elegantly why the same agent may appear to be differently responsive to reasons in different occasions. I thank an anonymous referee for pointing out this possibility.
Another way to frame what is anomalous in cases of belief-oscillation and hyperbolic discounting is by noting the strange pattern of responsiveness that they embody. To say that an agent is responding to reasons does not mean simply that there are reasons to behave in some way and that the agent in fact acts in accordance with those reasons. It requires, moreover, that the agent’s behavior is mediated by an appreciation of what the relevant reasons are (see note 12 above). As Fischer and Ravizza argued, if we heard of an agent who would desist from buying a ticket to a basketball game if the ticket were priced at 1000 dollars, and yet would go on to purchase the ticket if its price were 1001 dollars, we would naturally question whether the agent’s response to the 1000 dollars-ticket scenario was in fact a reflection of reasons-responsiveness on her part. Instead, we would likely interpret the counterfactual test as evidence of anomalous, erratic behavior. What we expect to find in an agent who is actually being receptive and reactive to reasons is a sufficiently coherent pattern of responsiveness across different potential or counterfactual scenarios (Fischer and Ravizza 1998: 65 and ff.). This is something we arguably do not find, or find to a lesser degree, in an agent who undergoes the envisaged kinds of judgement or preference shift in cases of belief-oscillation and hyperbolic discounting.
I thank an anonymous referee for bringing this problem to my attention.
Notice that effortfulness and difficulty or costliness for the agent may come apart in important ways. In particular, many self-regulation strategies available to people struggling to overcome addiction—for instance, distancing themselves from certain kinds of situations, places, and relations —may be difficult to pursue and result in significant costs for the agent, without involving in a prominent way the phenomenology of mental effort that usually goes with exertions of willpower. Moreover, there are reasons to think that strategies of the former sort may be more effective than relying in willpower to directly inhibit wayward desires (Snoek et al. 2016).
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Acknowledgements
I thank Santiago Amaya, Emily Bingeman, Cami Koepke, Dana Nelkin, Diana Pérez, Fernando Rudy Hiller, Manuel Vargas and two anonymous referees for their comments on previous drafts of this paper. This publication was made possible through the support of a grant from the John Templeton Foundation, grant #61,255 project name ‘LATAM Free Will, Agency and Responsibility’. The opinions expressed in this publication are those of the author and do not necessarily reflect the views of the John Templeton Foundation.
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Burdman, F. A pluralistic account of degrees of control in addiction. Philos Stud 179, 197–221 (2022). https://doi.org/10.1007/s11098-021-01656-7
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DOI: https://doi.org/10.1007/s11098-021-01656-7