Guest Post: Gene Heyman on addiction and choice

Last week, Tom spoke with Gene Heyman, a research psychologist at McLean Hospital and lecturer at Harvard Medical School, about his new book, “Addiction: A Disorder of Choice.” It's a controversial topic, to be sure, and we heard pushback on the air from our two other guests — Marvin Seppala of the Hazelden Foundation, a nonprofit alcohol and drug addiction treatment center, and Nora Volkow, director of the National Institute on Drug Abuse (NIDA) — and from many of our callers. The hour also provoked a big response online.

Gene Heyman sent us the following note, as a followup to the discussion. We think it's worth sharing here, and we hope you'll continue the conversation.

I would again like to thank On Point for the opportunity to describe some of the research and ideas that my new book summarizes. What I will add here are a few words about the book’s approach or method and some reflections on the meaning of voluntary and involuntary behavior.

The book emphasizes research results. This is because I wanted readers to be able to decide for themselves whether addiction is a chronic condition and whether it should be called a disease. Instead of relying on interpretations of research findings, the book provides many of the basic research findings themselves. It includes the results of every major epidemiological survey of psychiatric disorders, a collection of autobiographical accounts of drug use, laboratory studies of drug effects, and historical trends in drug use and its understanding. Surprisingly, the clergy not physicians introduced the idea that addiction is a disease, and they did so in the early 17th century, before the emergence of science-based medicine. Like many of my colleagues, my initial impetus in studying addiction was to discover how voluntary drug use became involuntary drug use. The book describes some of the highlights of what I have learned.

The issue of what we mean by voluntary and involuntary behavior is one of those age-old problems that philosophers and scientists have discussed in countless books and articles. I look to everyday usage and social practices for the answer. We distinguish between those activities that can be influenced by expectations and consequences and those that are little influenced by expectations and consequences.

For example, activities differ in the degree to which they are influenced by monetary gain, what others think, cultural values, personal values, and the various other factors that influence our decisions. When expectations and consequences have little influence on an activity, we say it is involuntary, when expectations and consequences have lots of influence, we say it is voluntary. Think of the difference between winks and (reflexive) blinks, or, as I said on air, think of the difference between spitting and sneezing. Of course there is a continuum. Most activities are composed of both voluntary and involuntary elements. Hence, we can influence adult diabetes by exercise and diet, but not enough to consider it voluntary. Also expectations and consequences affect exercise and diet, not the key symptom of diabetes, which is insulin insensitivity. In contrast, expectations and consequences can directly decrease drug use in addicts, and drug use is the key symptom of addiction. Of course not everyone is the same so that the same set of costs and benefits do not work the same for every addict. Similarly, not everyone who has the flu responds positively to treatments that usually work for the flu. Just as we may not find the right treatment for everyone with a particular disease, we will not necessarily find the right intervention for everyone who keeps making self-destructive choices.

This discussion and the book reveal that voluntary and involuntary behavior share much in common. Both are influenced by factors that are outside of a person’s control (e.g., we do not choose our parents). Both have a biological basis and are thus influenced by genes and drugs. And both are mediated by the brain. However, the brain circuits that mediate voluntary behavior have strong connections with areas of the brain that mediate memory and forethought, whereas those that mediate involuntary behavior do not. (However, as I have discussed in other publications, there is also a social component to what we mean by involuntary. For example, we usually do not punish people for true accidents or for acts committed at the point of a gun.)

Why does the difference between voluntary and involuntary behavior matter? We can’t understand the behavior of others if we do not have a good sense of whether their actions are voluntary or involuntary, and we can’t properly design good social policy if we do not understand if a pattern of socially relevant behavior, such as drug use, is voluntary or not. There may be no more fundamental behavioral distinction. For example, consider the fact that pre-scientific cultures distinguished between “medicine men” and “wise men.” The “wise men” attended to voluntary acts, and the “medicine men” attended to involuntary phenomena, including mental illness.

What is unfortunate is that many people think that punishment is the only way to respond to voluntary destructive behavior. If you think about your social relations, particularly with your friends and/or children, you will see that this is a limited and often counter-productive view. Put another way, I take the view that addicts and those affected by them will be best served if we understand correctly the nature of addiction.
-Gene Heyman