By Daniel Hochman, MD
As a psychiatrist in the addiction field, I enjoy the endless thought-provoking discussions that come up both professionally and socially. People just can’t wrap their minds around human behavior – especially when it doesn’t seem to make sense. How much more confusing can it get, then, to wonder: Is addiction a choice? This question is not just an academic exercise. If you think about it, how one falls in their beliefs about it is what drives how we judge, punish, treat, help, and respond to anyone with an addiction. Let us look briefly at each layer necessary to begin to answer this question.
NOBODY WITH ADDICTION ENJOYS THE END RESULT
I will first say that I have yet to meet someone with a genuine addiction that enjoys the entire process. In recreational use, the person does enjoy the high. We can all enjoy the rush from everything addictive like sex, a win at poker, or cookies. But never does someone who is in the trappings of a true addiction enjoy their choice. They absolutely hate it. Please don’t get confused: they absolutely love the high, but they absolutely hate the fact they do that. They are highly self-critical, hopeless, and completely ashamed of their actions. So please dispel the idea that anyone truly chooses a life of addiction. At the very least, we are questioning whether one chooses the highs because nobody chooses to suffer despair and hopelessness. Even masochistic individuals might choose pain or unnecessary drama, but they do not choose dread.
It wouldn’t be fair to say that the question of whether addiction is a choice or not is simply a matter of semantics, or else we would be dodging important psychological questions. First, I would ask that we agree that in the end, we could all technically be held accountable for our actions and choices. Even if unknowingly or forced, it could be fair to say that anything we do is our own choice from an observational or superficial standpoint. If a prisoner of war is forced to walk somewhere, he may not seem to have a choice. But technically he still does maintain the choice of whether to be further beaten or oblige.
Here is where it gets a bit tricky. At this point I hear people say: “Exactly! We’re all responsible for our own decisions in the end…how can this not be the addict’s choice?!” Enter the concept of consciousness. Consciousness as we will discuss it is the mental state of being truly aware of one’s own internal state in relation to events going on around. We all actually “choose” to do things hundreds of times a day without being conscious of our choices. This is exactly what any marketing effort preys on through subliminal advertising (testing of different backgrounds, fonts, colors, voices – anything that can influence our behavior). We can easily have the illusion of choice. It might sound something like: “I chose to workout today instead of getting high. I made that choice because I thought about what would be best for me and I want to get fit and healthy.” But no. We could easily ask why that day and not the other days. That person also certainly already knew a workout is healthier than a hit. There are always more reasons we do what we do that are beyond our consciousness. You might think you relapsed because you made a bad choice, but how are you going to know what may have triggered that? Maybe you passed a billboard earlier that day that reminded you of an ex that cheated on you (that you never even visually registered). One can simply never fully know what is behind any choice. And that leads to the idea of a degree of consciousness.
DEGREES OF CONSCIOUSNESS
So if we can never be expected to fully know our decisions, what’s the difference between someone who is innocent, and someone who knows better? The answer lies in the degree, or amount of consciousness around what our choices are. The thumbs up gesture in the US means “up yours” in other places like Australia and much of the Middle-East. If you were traveling there and had no awareness of that, would you really say that person made a bad choice? If, on the other hand (pardon the pun), you did that with full awareness of the cultural meaning, you certainly made a much worse choice. Similarly, if you know that going to see a certain friend is going to trigger you to get high, that is clearly a conscious choice than being surprised by your craving and urge after you’re there. Anything we choose is always on this spectrum of choice at all times.
EMOTIONAL AND BEHAVIORAL CAPACITY
So how then can someone make such a bad choice if they clearly know better? This is where most people get tripped up. You can ask someone with daily heroin use what they know about the harms – and maybe even their triggers – and they will quickly respond with great awareness. Their awareness might even be greater than their doctor’s or therapist’s. But it is not simply a matter of fuller consciousness. Explaining the harms of addiction is nearly useless, and that is exactly what studies show. They must be given the chance to grow capacity. That means things like: learn distress tolerance and distraction techniques, practice grounding meditation, understand how to create relational boundaries, be appropriately assertive, find reward in kindness and gratitude, learn your sources of inspiration, etc. Addiction is not an intellectual choice, but a choice that feels like necessity. As my patients call it, the “fuck it” moment. They know full well what they’re getting into, and they do it anyway. We cannot expect anyone to act on their awareness without fostering the capacity to do so.
THE WAY FORWARD
So you can hopefully see that there is much more complexity to the question of whether addiction is a choice. Our thoughts and actions are only superficially our choices. But there is a spectrum of choice based on how conscious we are of ourselves, and we can only be expected to act on that consciousness based on the opportunities we have to grow capacity around that. This is the process of change, and should be the foundation for any addiction work: learn how the mind and human behavior works, grow consciousness of one’s self through deep reflection, and then set that person up to practice building capacity in a progressive fashion. That’s why in the addiction program I designed, people finally turn their lives around after years of rehabs and therapy…. because every single lesson and exercise is part of a methodical process to grow consciousness around important themes, and build the capacity to tolerate the difficulties of change. All treatments should involve this process, but the fact is most treatments are based on the false concept that the therapist’s advice will lead to better choices. Two things anyone can do on their own are:
- Learn just one more thing about yourself than you know right now.
- Find one skill or technique that can help you tolerate distress (or practice a skill you already have even more).
That is a process I can guarantee will create more free choices for you, but not fully free 😉
Dr. Daniel Hochman is a psychiatrist and creator of SelfRecovery.org, an online addiction program that takes people on a deep and systematic journey to understand themselves so fully that they can transform from the inside out. He developed this after working and consulting for several addiction facilities where he recognized the limitations in our current system. He serves as President of Texas Physicians for Social Responsibility and has a private practice in Austin, Texas with a focus on therapy and holistic care.