Sally Satel reviews Gene Heyman's recent book, Addiction: A Disorder of Choice, in the New Republic. Here's a sample:
In a most impressive display of brain technology, scientists have used scanning technology to observe metabolic activity of the brain in action. In a typical demonstration, addicts are shown drug-related videos that depict people handling a crack pipe or needle. Brain scans capture the viewer’s reaction to these provocative images and represent it as glowing technicolor splotches of color that represent activation in drug-sensitized brain regions. (Videos of neutral content, such as landscapes, induce no such response.) Even in users who quit several months ago, neuronal alterations may persist, leaving them vulnerable to sudden, strong urges to use. But addiction is not a brain state, it is a behavior. As philosopher Daniel Shapiro of West Virginia University puts it, “You can examine pictures of brains all day, but you’d never call anyone an addict unless he acted like one.”
Furthermore, as Heyman says, much of the public, and a dismaying number of psychiatrists, psychologists, and neuroscientists, mistakenly believe that if a behavior is influenced by genes or mediated by the brain then the actor cannot choose his actions. While every behavior has a biological correlate (and a genetic contribution) and every experience that changes behavior does so by changing the brain, the critical question, Heyman wisely says, is not whether brain changes occur (they do) but whether these changes block the influence of the factors that support self-control.
. . .
Heyman’s answer is that "voluntary activities vary systematically as a function of their consequences, where the consequences include benefits, costs, and values.” Take, for example, the case of addicted physicians and pilots. When they are reported to their oversight boards they are monitored closely for several long years; if they don’t fly right, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. Via entities called drug courts, the criminal justice system applies swift and certain sanctions to drug offenders who fail drug tests—the threat of jail time if tests are repeatedly failed is the stick—while the carrot is that charges are expunged if the program is completed. Participants in drug courts tend to fare significantly better than their counterparts who have been adjudicated as usual. In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.
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