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.
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.
Jumping From a Burning Building
Looking deeper yet, we can discern more subtle aspects of the functioning of free will and self/species-preserving systems. Under desperate conditions, humans do things they could not imagine under normal conditions. Members of the Donner party commited acts of cannibalism. People regularly jump out of high windows to escape fire. Under crisis conditions, we are able to make rapid calculations as to the most likely path for survival. My work with adults who were subjected to extreme abuse as children has indicated that this capacity for prioritizing between terrible choices is available at an early age.
Applying this observation to the phenomenology of alcoholism elucidates more about the process of "hitting bottom." In a study of 400 inner-city men, researchers found that alcoholics who become sober do so suddenly under the influence of some crisis situation (Vaillant and Milofsky, 1982). Employee assistance programs and professional assistance programs employ a strategy that frames a crisis such that the alcoholic must choose between loss of job and recovery. Faced with such a choice, alcoholics and addicts will choose the first steps toward recovery, even if it is in the hope of soon returning to "normal."
If alcoholics can see what is best for them, then why do they continue to drink in the face of obvious negative consequences? The defensive bulwark that their self-preservative systems erect against all influences for change is sufficient under most conditions to maintain the addiction, but it can be breached. Alcoholics sometimes experience a sudden spontaneous awakening. For instance, one patient found himself in a gutter outside a bar and was struck by the gap between his self-concept and the reality of his behavior. A mother hit rock bottom one day when she realized that she would be too drunk to get help for her child if her daughter became ill in the night.
The technique of planned intervention makes use of both force of numbers and surprise to maximize the chances of breaching defenses. The number of concerned people confronting the alcoholic seems to increase its effectiveness. The surprise of the intervention itself is further enhanced as the subject does not face the "attack" that they expect. Instead, those assembled express their personal experiences with, and feelings and concerns for, the alcoholic. The technique is aimed to create optimum conditions for habitual defenses to be breached.
The desired outcome of the intervention or hitting bottom experience can then be reached: The addict becomes at least outwardly willing to do whatever is necessary to achieve abstinence. To understand the whole phenomenon, we need to take into account both the element of choosing the lesser evil in a crisis, and the breaching of habitual defenses. Interestingly, the greater the element of crisis, the less of an impediment are the defenses, though the relative proportions vary widely between individuals.
Obsession and Insanity
A final observation about the behavioral control system that we call free will comes from anyone who has attempted a diet. After initial success in dieting, the strength and flexibility of the self-preservative system is revealed. When the brain is told it doesn't need more food, its reaction is more sophisticated than simply creating an increased desire for food. Soon, there is a tendency to obsess over food. The more the deprivation continues, the more obsessed we become.
Next, we find ourselves subject to alterations in our rational thinking. The jagged edge of a cake, which was not troublesome before, is now intolerable. We must recut the edge, but this time the cut is at the wrong angle and requires further correction. Soon comes the shameful realization that the cake has been completely finished. What happened? The self-preservative system was able to override good judgment and make some quite implausible thoughts seem rational.
Let us consider the possible species-preservative nature of these sophisticated mechanisms. The hunter-gatherer, who is weak from hunger and lacks the strength to venture out, must possess means of motivation to perform acts beyond endurance. While speculative, it seems quite reasonable to infer that the need for self-preservative systems is capable of creating obsessive goal-directed thinking and overriding reason when necessary. When these characteristics are applied to a system that is no longer serving the best interests of the individual, the result is, as described in The Big Book of Alcoholics Anonymous, "Cunning, baffling and powerful" (Alcoholics Anonymous, 1976).
Acknowledging that alcoholics have compromised their free will helps in working with them, both before and after initiation of recovery. Professionals working in the addiction field know that alcoholics do not need to come into treatment on a strictly voluntary basis in order to be successful. In fact, patients who present voluntarily for treatment are often more likely to leave treatment under the influence of their compromised free will.
Treatment offered in lieu of negative consequences may be a necessary counterbalance to the power of a compromised free will. Unnecessary coercion is usually destructive, but insufficient use of leverage is even less responsible, as it overestimates patients' ability to exercise free will in their own best interest. As the slogans of recovery so forcefully remind us, an alcoholic who tries to do it "on his own" is in serious danger.
The stress of realizing that one has lost control over one's own life (AA calls this unmanageability), along with the loss of the substance, creates an intense neediness that favors group bonding. The substitution of people for substances allows alcoholics to shore up their compromised free will with the power of the group. Over time, the result is a gradual healing of the free will as described above, until the influence of the addiction is at a minimum and the alcoholic's will is almost fully free.
Question of Complete Abstinence
Does this way of looking at alcoholism contribute to the debate about whether complete abstinence is necessary? For most people who have experienced the terrible loss of control over alcohol and their lives, the answer is rather simple. Within the powerful magnetic field of addiction, it is much harder to maintain clear thinking with shades of gray. If alcoholics give themselves permission to drink "a little," then the once-compromised behavioral control system will have a very hard time avoiding corruption by some seemingly rational idea that really represents the tug of the addiction. Similarly, the well-meaning physician's prescription of an addictive substance, especially members of the pharmacological class of sedative hypnotics (including ethanol, benzodiazepines, barbiturates and meprobamate, among others), is experienced by the alcoholic as a tease, opening the doors to uncontrolled use.
Not Guilty but Responsible
It is clear that after initial resistance, alcoholics do respond positively to being held responsible for their actions and, in contrast, get worse when they are relieved of responsibility. At the same time, the concept of guilt should not be applied to a condition characterized by compromised free will. Thus, returning to the issue of policy, clinical observation and the notion of compromised free will would suggest the need for a new category: Not guilty but responsible.
Inherent in this view is the idea that we are seeing self/species-preservative systems functioning normally, but with abnormal inputs. Viewing an alcoholic in trouble in this way puts the behavior in perspective and avoid the understandable but unhelpful reactions of anger, ridicule and well-meaning enabling.
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