Psychiatrists, like the rest of America, continue to have trouble with alcoholic and other addicted patients. We are comfortable when patients want to get better, tell us the truth and come to treatment of their own free will, but alcoholics often don't fit this profile. We respond angrily when patients manipulate us. We are surprised when their sincere desire for help evaporates after we suggest a plan that will bring about real change. We may agree that the drinking is a response to stress and, therefore, be tempted to think that a reduction in stress will bring about improvement in the drinking problem. We find ourselves feeling anger and some shame when the patient continues to drink and gets into further trouble under our well-meaning care.
It is no longer news that neurophysiological reinforcement mechanisms are implicated in addiction, but the clinical relevance of this information needs better integration into policy and practice. The astounding new fact of the 1980s was the discovery that essentially all drugs of abuse have one thing in common: they stimulate dopamine secretion in the human equivalent of the nucleus accumbens septi. Furthermore, the neural structures and pathways involved seemed to be the ones responsible for pleasure and reinforcement of behavior. The obvious interpretation is that alcohol and drugs make a person feel better and make them want to do more, but the implications run much deeper. The key is free will.
As a society, our anger at alcoholics is common, as if their destructive acts were the result of free choice. We also hear echoes of the opposite view, of the alcoholic as a helpless victim. As each new pharmacological discovery comes along, we hear statements that a "cure" for alcoholism has been found. At last we will be able to give the (passive) patient a drug and the illness will be cured. With each discovery, those who work with addicts in clinical settings remind us that these treatments don't work without enlisting the patient in a recovery process. Nevertheless, hope springs eternal that the next cure won't demand active involvement of the patient.
Alcoholics' Free Will Compromised
The key to understanding the behavior of alcoholics is to think of free will as an organ that, like any other organ, can be compromised. Compromised free will may lead individuals to make choices that are not in their best interest, and to resist change. There are degrees of compromise. Some addicts have an easier time than others in being honest with themselves and accepting help. The techniques of employee assistance counselors and interventionists, honed by clinical experience, all require some degree of willing cooperation from the alcoholic. At the same time, these techniques assume major limitations in free will requiring external incentives and consequences. Treatment is designed to leverage a small amount of healthy free will into a long-term process of healing.
Free Will Can Heal Over Time
Significantly, the degree of compromise can be seen to clinically improve over time as the recovery process goes on. The experience of operating an abstinence-oriented, intensive, outpatient treatment program has provided insight into the phenomenology of free will. Our structured treatment program was divided into phases that roughly added up to one year. The counselors understood intuitively that during the first phase of treatment, when patients announced their desire to go on vacation, it was usually "the disease talking," and the vacation plans represented a royal route back to active drinking. On the other hand, in the second phase of treatment, some patients were able to benefit from vacation. We developed a policy in which patients in the second phase of treatment were expected to discuss their vacation plans with other patients and with their sponsor, and to follow the advice they were given. Clinical reality steered us to a system that recognized an increasing degree of healthy free will. The patient could be trusted enough to recognize that others' views of the vacation would be more objective than his or her own. At the same time, the group could be trusted at that point to exercise some objectivity about their peer's condition. The policy worked quite well and allowed us to give recognition to the growing level of health in our patients.
In the third phase of treatment, patients were expected to exercise their own judgment about vacations. Of course, this implied an expectation of sober behavior in sharing the plan in advance with others. Patients who acted impulsively or in isolation were subject to confrontation by peers who, by this time, could be trusted to identify unhealthy decision making and speak up.
Thus, clinical experience led us to a set of policies that took into account not only the principle of variable degrees of compromise of free will, but a typical timetable for its healing. Not surprisingly, Alcoholics Anonymous (AA) recognizes the same timetable: Members are told that they should not make major life decisions during the first year of their recovery.
Holding Onto Their Addictions
A little speculation about the function of the brain reward system helps to make sense of the extreme difficulty of initiation of abstinence in the first place. If the purpose of the brain reward system is the perpetuation of the species, then it is not a surprise that we are active and tenacious in choosing behaviors that keep us alive and reproducing. It is a short step, therefore, to conceptualize addiction as a transformation of systems designed for survival to a new goal, namely the continuation of the addiction. It is not that survival is no longer important, but rather that the right to "get high" has become synonymous with survival. Consistent with this picture, alcoholics have been known to abstain for weeks at a time just to prove their control so they can maintain the ultimate right to drink.
Clinically, the theory fits the data. Alcoholics and addicts not yet in recovery behave as if they were fighting to preserve life itself. They act as if they are citizens in a malevolent society where operatives are using every technique including authoritarian force, manipulation and seduction to attack their existence. They valiantly resist all efforts to effect change. They may not like to lie, but they will if necessary. They use specialized psychological defenses including denial, minimization, rationalization, blaming, intimidation and proclaiming the right to make their own decisions in life. Like victims of oppression, they go underground in their attempts to protect their freedom. Their defenses become habitual and function smoothly even when cognitive faculties begin to fail.
Alcoholics Anonymous (1976), 3rd ed. New York: Alcoholics Anonymous World Services Inc., pp 58-59.
Vaillant GE, Milofsky ES (1982), Natural history of male alcoholism IV. Paths to recovery. Arch Gen Psychiatry 39(2):127-13