'Addiction is a Choice,' Schaler Argues
by Ari Armstrong, October 1, 2003
If you think you "can't" stop smoking or drinking or using other drugs, Dr. Jeffrey Schaler offers a straight-forward diagnosis: you're lying to yourself.
"Conventional wisdom contradicts most of what I'm going to say," Schaler began, as the soft-mannered fellow grew into in authoritative voice at the microphone. Obviously battle-tested, Schaler nevertheless seemed somewhat weary as he anticipated the inevitable challenges to come.
Addiction is a Choice
The view that "addiction is a treatable disease" is a lie, Schaler said: "addiction is a behavior." Drugs are inanimate objects, he added, and "no drug can cause addiction." Drugs can be good or bad: "it all depends on how you use them." Put simply, "anyone can stop or moderate their use of addictive drugs anytime they want to."
Schaler began his talk by distinguishing the behavioral aspects of drug use from the chemistry. Early in the question-and-answer period, though, someone asked incredulously how Schaler could argue addiction is a choice, given what we know about the physiological impacts of drug use. Some people who quit using certain drugs suffer withdrawal symptoms, after all. Schaler said the questioner didn't get the point. "The chemical effects are not controversial... the controversy is how drugs get into the body," he said. He focuses on the "behavior of addiction," not "what drugs do to the brain." What happens once a person puts drugs into his or her body is irrelevant to the fact that the person still retains control over whether to take drugs.
"Addiction means you like to do something," he said. Thus, the key element of the addiction is the behavioral choice, not the object of the addiction.
Thus, people can be addicted to all sorts of things, including religion, sex, and eating. In all these things, the behavior is open to choice. "When we view behavior as caused, we dehumanize people," Schaler said. "Human beings are moral agents... choice is what distinguishes us."
The notion that behaviors can be blamed on chemicals leads to some strange conclusions, Schaler said. For instance, should we excuse rapists on the grounds that "genetics made him do it?" If something is involuntary, then it makes no sense to provide a punishment for it.
In fact, Schaler noted, many people who quit using drugs show no signs of withdrawal pains. When soldiers came back from Vietnam after using heroin heavily, he said, "87% gave up heroin like that [with] no withdrawal, and no treatment." He said the soldiers simply decided to stop using the drug once they got home. This case disproves the notion that physical changes force people to keep using drugs.
This raises an intriguing issue: are physical withdrawal pains more a result of one's psychological desire to continue in a particular activity? Schaler suggests such is the case. What is the most intense addiction known, Schaler asked, with the most pronounced withdrawal symptoms? These symptoms can include cravings and despair, headache, vomiting, insomnia, shakes, and even suicidal tendencies. What is the "cause" of all these symptoms? It is love.
Schaler offered another recent example. He was on the East Coast during the power outage. "It starts to bug you," he noted. People around him started to become irritable because the power was off, and in ways that couldn't be explained merely by the short-term inconveniences. People started to become depressed and restless. "We start craving electricity," he said. He asked people how they felt when the power came back on, and a typical response was, "What a rush!" Schaler concludes, "Addiction isn't a disease; it's a way of life." Drug use is not unique simply because it causes physiological changes. "Tell me something there's not physiological changes with," he said.
Since attending the lecture, I've noticed a number of other examples that illustrate Schaler's point. Writing for Entertainment Weekly, Stephen King wonders why people keep going to see sequels to horror films. "And why? Because the fear generated by a good horror picture is a drug, and as any junkie will tell you, you go on chasing the high long after the high is gone."
On his web page, successful science-fiction author Neal Stephenson writes, "[W]riting fiction every day seems to be an essential component in my sustaining good mental health. If I get blocked from writing fiction, I rapidly become depressed, and extremely unpleasant to be around. As long as I keep writing it, though, I am fit to be around other people."
The Politics of Addiction
If addiction is a choice, and if other sorts of addictions can be every bit as dangerous as the worst drug addictions, why does the U.S. have laws specifically against drug use? The most obvious answer is that hundreds of thousands of Americans have a direct economic incentive to keep those laws in place. But Schaler is interested in more fundamental cultural critiques.
"People embrace the therapeutic state," Schaler said. The "institutionalization of state-sanctioned psychiatry" is a serious threat to people's rights, he said. As Thomas Szasz argues, the therapeutic state has in many ways replaced the religious domination of politics from medieval times. Schaler noted that, under the Nazi regime, people had a "duty to be healthy." People's bodies literally belonged to the state. This is similar to the "therapeutic state today," Schaler argued. "Medicine and state should be separate," he said.
"Drug use and drug users are the major scapegoat today," Schaler added. Scapegoating attempts to "get rid of some problem by singling out a minority." Such practices give people a (false) sense of control over evil, and they often offer a sense of group identity. Scapegoating is "pervasive in history," Schaler said, citing as examples the oppression of racial minorities and homosexuals. Today, the drug war is "a form of religious persecution... that is done in the name of the state."
Not surprisingly, Schaler expressed a broadly libertarian outlook. He said the role of the state is to "protect us from each other, not ourselves."
The Treatment of Addiction
Schaler finds plenty of room for helping each other overcome harmful addictions, however. He calls for educational efforts to "teach accurate information about drugs." He said children today are often cynical about inaccurate anti-drug messages, because the evidence directly available to them opposes the rhetoric. With accurate information, people will be "more inclined to make an informed choice."
"I believe in psychiatry between consenting adults," Schaler said, and he has worked professionally with people to overcome harmful addictions. He said it's more helpful to address the underlying problems that people are trying to escape through harmful addictions. Assuming personal responsibility is important, which includes coming to terms with the ways we sometimes deceive ourselves.
Schaler is totally opposed to state-mandated treatment, however. Nor does he think much of popular treatment programs that, he says, claim addiction is an incurable disease and subvert personal responsibility.
I find Schaler's basic arguments about addiction quite persuasive. However, I think there still might be room for a more complete recognition of the physiological impacts of drug use that can impact behavior. To push this point, I asked Dr. Schaler about the usefulness of viewing the difficulties of choice as a continuum. For example, I said, surely the decision to drink a glass of water is much easier than the decision to stop smoking.
Schaler replied by pointing out that some people do stop smoking instantly, and they never look back or seem to suffer physical pains. People who claim they "can't stop" really just don't want to stop; it's not important to them to stop. At the same time, I considered later, there could be situations in which the decision to drink a glass of water could be quite difficult -- for example, if the behavior had some sort of religious significance. And, while I buy his basic point that the behaviors are fundamentally under our control, it still strikes me that some behaviors are physically harder to modify.
For example, even if most people can stop using drugs without withdrawal symptoms, it could be that some people are especially prone to severe physical reactions. While Schaler seemed to dismiss out of hand the notion that some people are genetically predisposed to become alcoholics, I'm confident alcohol does affect different people in different ways. To admit this is not to contest the point that the decision to drink is still up to the individual.
To take another example, the sex drive is hard-wired into us. While we can choose not to have sex, that choice has dramatic physiological impacts. Most people can't "just choose" not to have sex and expect everything else to remain normal. I am very interested in the notion that many physiological cravings are secondary to the psychological attachment (that is, our choices influence our cravings, not vice versa), but it strikes me as most likely that this is a two-way street.
Paying more attention to the physical difficulties some people have quitting an addictive behavior is compatible with viewing addiction as a choice and state-mandated treatment as wrong. At the same time, it might foster more effective programs of voluntary treatment.
If I'm right, Schaler's main points still stand, including his view of addiction. Whereas most people today seem to think of an "addiction" as a set of physical cravings caused by a particular item, Schaler's understanding of the term to describe choice and behavior is better grounded in reality.
Mental Disease and Religion
I now begin to stray from Schaler's discussion of drug use and addiction into the topics of mental illness. The reader interested only in drug use might wish to stop reading here. In my view, Schaler's beliefs about mental illness are more controversial, and they are (thankfully) separable from his beliefs about addiction and drug use. That is, even if you disagree with Schaler on the issues to come, that's no reason for you to dismiss his arguments about addiction and drug use.
So here it is. Schaler said, "There's no such thing as mental illness; your mind can't be sick." Brains get diseases, he quickly added, but not minds. Brain diseases can be observed during an autopsy; mental problems like depression cannot be. A physical disease might give rise to symptoms, but whether or not symptoms exist, tests can be run to discover whether a particular disease exists. For instance, a doctor might test your blood or scan you for heart defects or cancer. Alzheimer's disease can be observed in an autopsy. Schizophrenia, on the other hand, cannot be observed in an autopsy, and the only way it (allegedly) can be diagnosed is through its symptoms. It's true that brain scans are different for some schizophrenics, but it's also true that many healthy people have brain scans than look like those of schizophrenics, Schaler noted. Thus, some in his profession have taken to describing insanity or schizophrenia merely as "irrationality."
Thus, at one point Schaler drew a parallel between schizophrenia and religious belief. In one case, a person might claim to hear the voices of aliens through the fillings in his teeth. This person will be forcibly imprisoned at a place "called a mental hospital" (quoting Schaler). In the second case, a person might claim to commune with Jesus, who has entered his heart. This person will be respected as having a "valued religious experience."
And Schaler has a certain point here. If people can be forcibly imprisoned for making crazy, irrational claims, then surely a case could be made for locking away just about the entire population. I am not prepared to say the claim of hearing aliens through one's dental fillings especially qualifies a person for forcible imprisonment. On the other hand, threatening other people is inherently a crime, whether or not a person is schizophrenic, so that sort of behavior can be dealt with legally.
At the same time, it strikes me as obvious that Schaler is overstating his case. People who claim to talk to Jesus and live with the Holy Spirit inside them hold a fairly sophisticated theory about the supernatural that explains how a person can "talk to Jesus" without literally hearing voices inside one's head. On the other hand, the schizophrenic, as far as I can tell, actually "hears" voices, as if a real person were speaking. That's a much different sort of experience.
Yet I am not prepared to make a hard and fast distinction. Just as a desire to do something can manifest in physical reactions, so a belief in something can trigger physical states. For instance, I'm quite sure that many people professing a belief in a supernatural entity have experienced hallucinations they mistook for interaction with that entity. When most people say they "talk to Jesus," they mean that they communicate in a way that's analogous to talking. But some people really believe they've heard the voice of Jesus, speaking to them directly -- and many of these people never have been and never would be diagnosed as schizophrenic.
Probably most of us have had experiences that might be classified as hallucinations. Movies are full of references to people "seeing" others in the faces of complete strangers. Perhaps a romantic breakup will trigger these experiences of "seeing" one's former partner in the faces of others. I can remember going hunting as a boy, and every rock and stump looked at first glance remarkably like a big-game animal.
The common assumption seems to be that hallucinations trigger schizophrenia. But it's possible the causal connection may be the reverse of that. A person's very strong intellectual and emotional commitments to a particular idea might in fact trigger hallucinations involving that idea. If this is the case, then schizophrenia is at root a psychological problem, not a physiological one.
I think Schaler is mistaken in conflating schizophrenia with other sorts of irrational beliefs. Surely some forms of irrationality are much more serious and harmful than others. And I'm much more open to the idea that sometimes a problem like depression might require a physiological approach. At the same time, I agree with Schaler that treating schizophrenics as if they were animals with no rights is morally repugnant. We can reject the therapeutic state without rejecting medicinal psychiatry.
The Mind and the Brain
Schaler argues the mind is distinct from the brain. For everything that happens in the mind, there is a physical correspondence in the brain, but you don't find the "ego" when you conduct an autopsy. The "mind" is simply whatever it is we refer to with the pronoun "I," Schaler said, something we can talk about only with metaphors. The mind and the brain are different categories.
Schaler said some critics have accused him of Cartesian leanings. I agree with the critics. I think the "mind" and the "brain" are one and the same. The difference is merely one of perspective: when we are self-reflective, we are not aware of the brain; we are aware of our thoughts and feelings. Somebody looking at our brain would be able to observe our thoughts, but not experience them in a self-reflective way. There is not some kind of separate substance or stuff that is the "mind" in correspondence with the workings of the brain. There is no existential dualism; only a dualism of perspective. Minds are the only things in the universe that are self-reflective, that can contemplate themselves. But there aren't two planes of reality, one of the mind and one of the brain.
I think Schaler's belief that the mind is fundamentally different from the brain is behind many of his other beliefs. For instance, his tendency to create a radical separation between the physiological effects of a drug and the choice to use a drug is a consequence of his belief about the mind. We might use the term "pristine mind" to refer to this construct of the mind as unaffected by the merely physical. Likewise, Schaler's tendency to treat schizophrenia and religious belief as similar is rooted in the presumption of the "pristine mind." On the other hand, I believe in the unity of mind and brain, so I'm more willing to believe some choices are more difficult to make than others and that schizophrenia is quite different from other sorts of irrationality.
This gives rise to a paradox of intellectual history. How is it that I, who hold a naturalistic view of the mind, come to agree with most of Schaler's conclusions, while many who hold religious beliefs disagree vehemently with Schaler, who holds an essentially Christian-Cartesian view of the mind?
To review, I agree with Schaler that our behaviors are under our conscious control, that people should not be imprisoned for using particular drugs or holding particular irrational beliefs, that medicine and the state should be separate, and that the drug war is a horrible evil.
At the same time, many religious people profess a belief in free will, claim naturalists deny free will, yet argue the law should punish people for acting freely because certain substances are addictive.
But historically this is not so strange. The Inquisition involved punishing the flesh for the choices of the mind. Today's drug war is essentially a continuation of that practice, if somewhat less gruesome. It would seem a belief in free will does not entail a belief that individuals should be physically free to make their own decisions.
I think instead the key point is whether a person is an individualist. Both Schaler and I are individualists, which means we respect individual choices, we believe each individual is valuable in his or her own right, and we want the individual to retain physical freedom to make choices (except those that involve hurting others). That Schaler and I hold different theories about the mind influences some of our scientific conclusions but not most of our political and cultural ones.
At the same time, prohibition also joins together those with religious and naturalistic views of the mind. While alcohol prohibition was heavily influenced by religion, modern smoking bans are driven by Nanny State secularists. What unites the group is anti-individualism, or statism. That is, choices of the individual are to be subverted to the will of the state. Individuals are not the primary standard of moral value; the state is.
We can thus return to the opening topic: addiction is a choice. Schaler's main thesis is that individuals control their drug use, not the other way around. Thus, Schaler's individualism is robust: it recognizes that individuals are both worthy of making their own decisions and capable of doing so. Schaler's work promises to rescue those anemic individualists who favor prohibition on the grounds that (select) drugs disempower the individual. These weak-kneed individualists -- these panderers to biological determinism -- have formed a pact with the statists to impose prohibition. Once addiction is recognized as a choice, individualists can unite against prohibition.
But Schaler's thesis will not convince the statist. Indeed, I don't think most prohibitionists really believe their own rhetoric about (select) drugs overpowering the user. They want to punish drug use, precisely because it is a choice. It is a choice that individuals make over their own bodies. To allow such a choice is to affirm the principle of self-ownership and to deny the supremacy of the state. And that should wake up those libertarians who don't want to critique drug prohibition in public because it might make people uncomfortable.