Addiction and Self-Control: Perspectives from Philosophy, Psychology and Neuroscience

The interrogative looms large in every chapter of this fascinating book. Its approach of argument, counter-argument and the continuity of key themes avoids some of the difficulties associated with thematically constructed edited books. Do individuals who have an addiction – or “pathological decision making” according to Walton and Nasrallah’s chapter – have self-control? If so: always, never, sometimes? And if sometimes, why does it occur in one situation and not another? The answer to these questions has enormous implications for the practice of therapy, delivery of services, legal frameworks, social and economic policy.

The book’s 12 chapters cover Aristotelian team reasoning, legal and policy implications of the addicted brain, responsibility and self-control, addiction and akrasia, addiction, compulsion and choice, addiction and blameworthiness, philosophical lessons from a personality disorder clinic and the epistemic authority of AA.

George Ainslie’s opening chapter on hyperbolic discounting – essentially a time delay method of judging which alternate activities are worth pursuing – notes “We now regard deprivation states as making appetites possible; appetites are what makes possible reward in general and satisfaction in particular”. He shows that in terms of rational choice theory the gambler “seeks wealth despite the likelihood of actually losing this same wealth” and “an expected payoff lower than zero”. The gambler does this because of habituation to the reward, hyperbolic discounting and many cognitive distortions that persist in the face of correction. Whilst money is the “ostensible target of pursuit […] its real role is to structure the pursuit”. Ainslie’s solution is to restrict the availability of rewards so that we do not habituate to them and refresh our appetites by placing obstacles to their attainment through a form of self-deception.

Responding, Don Ross suggests that this so called “picoeconomic” account of addiction to gambling ignores brain chemistry and intermittent reinforcement structures and suggests a “considerable cognitive sophistication to subcognitive processes”. Ross argues for both hyperbolic discounting and neurocognitive processes, not simply either/or.

Owen Flanagan’s Phenomenal Authority: The Epistemic Authority of Alcoholics Anonymous suggests that AA works not because it is right or correct in its core principles but rather because it is a repository of collective wisdom about self-control and recovery. “It works. But this doesn’t mean that it deserves […] […] the phenomenal authority it has about the nature and causes of alcoholism”. If one were to strip away its phenomenal authority and explanatory framework there would be no intellectual or meaning structure around which to congregate, and probably no consensus about what to put in its place.

Hanna Pickard and Steve Pearce write about addiction in the context of a personality disorder clinic. Their central thesis is that clients are able to regulate their consumption of drugs, thus questioning the idea that drug use is a compulsive act. They argue that addicts can respond to “ordinary incentives” provided that comorbid psychiatric problems and dysfunctional backgrounds are also targeted. They identify five areas for clinical intervention: strength of desire and habit; willpower; motivation; functional role; decision and resolve. By targeting these factors, enhanced choice, improved control and augmented agency should follow. “We cannot help addicts unless we treat them as agents, capable of choice and control, and responsible for their behaviour”.

Levy brings together a range of academics and clinicians who pose a number of fundamental questions concerning the role of self-control in the experience of addiction, resulting in a mixture of philosophical argument and incisive comment which is genuinely stimulating for a clinician. I have noted a number of ideas and propositions relevant to my own practice, including an understanding of procrastination as a pervasive form of regretted choice.

This book is full of ideas and propositions that make one think about what one thinks one knows and some of the paradoxes facing those working with or trying to change their addicted states.