The Good, the Bad and the Addicted: Addiction and Normality
Addictive behavior is a pretty good social adhesive until it is not.
Posted May 06, 2012
Every Tuesday and Thursday, rain or shine, Stevie L., long widowed and living alone, gets up at 6:30am to catch the 9:00 o’clock Lucky Streak greyhound bus to Atlantic City. There, in the company of ten other women, also regulars on the bus, she works her way along the long rows of flashing slot machines, stopping only to eat lunch, exchange brief stories about the escapades of children and grandchildren or celebrate a win with one of her traveling companions. Stevie never plays anything other than the slots and though she usually loses more than she wins, she never loses more than she can afford; primarily because she instinctively knows that excessive wagering would be frowned upon by the members of her de facto social club. In short, the reinforcement, the pleasure that Stevie derives from her gambling behavior, comes not solely from the infrequent but always exhilarating rush of the clanking, flashing lights signifying a winning pull of the machine’s lever, but also from the knowledge that when she wins, she does so in accordance with the implicit norms of her subculture of ten.
Stevie sees her biweekly visits to Atlantic City as critical to her hedonic economy. On the rare occasions when she has been unable to make the trip due to illness, the weather or a conflicting engagement, she finds herself thinking about what she may have missed and pining for her next visit to AC. She also feels diminished when the usual group of ten is not at full strength, remarking that the experience feels somewhat less rewarding when the number of friends to share it with becomes smaller.
Is Stevie an addict? I would like to think that reasonable people would conclude that she is not; at least not by any conventional meaning of the word. After all, there seems to be no negative consequences associated with her twice a week indulgences. And while she may feel unhappy when prevented from participating, there is no evidence that she could not stop if she wanted to. But I would like to further contend that most reasonable people would also make one or both of the following observations about Stevie’s weekly routine. First, I suspect that they would agree that although Stevie is not an addict, it is not that difficult to conceive of a line (albeit a lengthy line) connecting Stevie’s currently benign and controlled brand of gambling activity to a more pernicious version in which she feels compelled to make the AC trips in lieu of a critical doctor appointment or keeping her promise to attend her granddaughter’s birthday party.
The other observation that could be made is that the weekly AC trips may actually be making Stevie’s life better than would otherwise be the case. In a way, the AC social group regulates not only Stevie’s gambling behavior but actually her entire experience by ensuring that her hedonic pursuits mesh seamlessly with the norms of the group, as well as the norms of the larger culture.
The first of these observations bleeds inexorably into the broader question of whether the so called behavioral addictions (such as compulsive gambling) are or are not qualitatively distinct from the chemical addictions like nicotine addiction or alcoholism. Although a more thorough discussion of this debate will have to wait for a later posting to this blog, suffice to say that the disorder of compulsive gambling is set to enter the addictive disorders section of the soon to be released DSM 5 (APA 2012; due 2013). And while this does not automatically lead to a confirmation of the more expansive claim that practically any human activity or routine that results in positive reinforcement (a subjectively pleasurable outcome) has the potential to be “addictive”, there can be little dispute with the collateral claim that such activities in certain patterns and doses can and do interfere with the performance of important social roles and responsibilities. From the young mother so consumed with a role playing video game that she frequently forgets to feed her infant son, to the compulsive baseball card collector who eventually bankrupts himself, there are countless examples of so-called hobbies and habitual recreational pursuits where individuals have crossed the line into something resembling addiction.
Negative consequences are therefore part and parcel of the risk we take in pursuing pleasurable activities, especially in complex social communities. But that is not to say that we always agree on what we mean by the term “negative consequences”. Indeed one of the other defining characteristics of an addiction is the often great disparity between the addict’s appraisal of the severity of the attendant negative consequences and the judgments of almost everyone else who cares. In other words: denial. There can also be little disagreement with the notion that the presence of negative consequences is a highly fungible standard that is very much dependent on time and place. Consider, for example, the 44 percent cigarette smoking rate in the 1950’s compared with the 24% rate of today (Saad, 2008). Although I have no direct evidence to support this conjecture, it is difficult to conduct a fair reading of the history of anti-smoking efforts over the last fifty years and not suspect that it was not until the 70’s and 80’s, by virtue of the shifting of social expectations of non-smokers (precipitated largely by the Surgeon General’s anti-smoking campaign) that sizable numbers of smokers actually began to feel that they wanted to stop smoking. In other words, social communities constrain our choices by informing us not only about what we should do and should not do, but also more fundamentally by shaping our subjective sense of what we want to do. This distinction between being merely aware of a community’s insistence that you change your behavior and one’s internalization of the motivation to do so, is a critical one, as the former can be experienced as oppressive and the latter as a willful expression of self determination and freedom of choice. Accordingly, the recovering addict’s constant struggle to maintain self control in the face of temptation is also paradoxically, a struggle for a resumption of social regulation or stated differently, regulation by a “higher power”.
That brings us to the second observation that we can make about Stevie’s AC habit, which is the notion that it may actually be good for her and for her traveling companions. But how so, one might ask? Well consider the obvious fact that Stevie “enjoys” her Tuesday/Thursday visits to AC. It is, after all, an activity that is reliable in its hedonic payoff; and by that I don’t mean her winnings at the slot machines. Rather, it is the total experience, the gambling and the social context in which it is embedded that she finds rewarding. In a way, the social context has become an integral part of the delivery system for her gambling behavior in that it limits (regulates) the psychoactive properties of the experience by ensuring that it is administered in manageable, controlled doses. And just as important, the gambling behavior binds Stevie to the social fabric through the pursuit of a common purpose and the creation of an implicit social contract that effectively demands that she do her part in regulating the behavior of her traveling companions, just as they do for her.
These types of reciprocal expectations regarding the synchronized pursuit of hedonic experiences are pervasive in modern societies. Starting in childhood, all societies expect its members to pursue a preferred slate of reinforcing experiences (i.e., pleasurable activities) in doses and on schedules that contribute to social cohesion, or, at the very least, do not interfere with or degrade existing social bonds. Stevie’s gambling is merely one example of an endless list of possible hedonic pursuits that populate our personal calendars of daily activity. Many of those activities, like television watching, attending Star Trek conventions or fly fishing, barely register, if at all, as addiction risks. Yet how much time and resources we are willing to spend on these activities and, indeed, the extent to which we subjectively want to pursue them at all is very much a product of our implicit agreement with the members of our community that they will play their part in regulating and controlling our hedonic pursuits and we will do the same for them. This reciprocal regulatory compact in the service of hedonic pursuits, I would contend, is a grossly underappreciated force for social cohesion that enhances the intrinsically reinforcing properties of social affiliation.
In a sense, by sharing an individually reinforcing but normative experience within the context of a social group we are afforded an additive reinforcement effect by combining the intrinsically rewarding properties of social affiliation with the reinforcement of the hedonic activity itself. Consequently, social bonds and relationships are experienced as more rewarding than would otherwise be the case, while at the same time the potency of hedonic activity is subjectively enhanced. The enhancement of the hedonic experience by social forces is probably best illustrated by studies on the “expectancy effect” in which the subjective responses to psychoactive and inert substances are manipulated based on what subjects are socially induced to believe they are receiving (i.e.., a drug or a placebo). For example, in a well known study by Marlatt and Rohsenow (1980), the researchers found that light and moderate drinkers who were convinced by confederates that they had received alcohol but were actually given a placebo, exhibited many of the cognitive and affective effects associated with actual alcohol consumption.
On the other hand, the reciprocal effect, the positive influence of a hedonic activity on social cohesion and bonding, is amply illustrated by the existence of special drinking places (taverns and bars) in almost every culture that are specifically designed to promote social bonding through alcohol-centered rituals of sharing and reciprocity (Heath, 1995). In echoing this sentiment, Takeshi Tanigawa, a professor of public health at Ehime University Graduate School of Medicine, was recently cited as making the following observation about Japanese culture: “…Alcohol consumption can be used to maintain human relationships between father and son, senior and junior, community to community… these socializing customs may help to create a stress-free space for those persons surrounded by dozens of stresses, especially in the workplace." (Science Daily 2009).
In evolutionary terms this kind of reciprocal arrangement between social cohesion and individual hedonic activity makes sense. If social cooperation is usually more effective in securing primary reinforcers such as food (i.e., through nomadic hunter-gathering activity or agriculture) for the members of the group than purely individual industry, why should the same logic not be applied to other classes of reinforcing activities, including ordinary recreational pursuits? It may be the case that as social animals we are predisposed to pursue hedonic activities as part of a group, and that the frequent sharing of hedonic pursuits at a group level ensures that social ties are constantly refreshed, updated and strengthened. Indeed, at a time in history when the citizens of modern, wealthy societies are spending progressively less time in subsistence related activities, it may well be the case that the cohesion of those societies will become increasingly dependent on the extent to which leisure time remains a shared activity. Literally, the community that plays together will stay together.
And what does this adaptive advantage look like in concrete terms? Well, it would not be unreasonable to assume that the sharing of reinforcing experiences in a normative group should ensure, among other things, that (1) the individual’s intoxication/success/reinforcement as a consequence of the drug or activity (e.g., Stevie winning at the casino) can be amplified or otherwise moderated by affirmation and other responses from the group; (2) the amount of resources (time, money etc..) invested in obtaining the reinforcing experience can be contained or pooled, thus regulating risk for both the group and the individual; and (3) provided the individual has complied with the group’s implicit norms, the negative consequences that can result from a particular hedonic activity can be diluted, if not concretely (e.g., by the willingness of others to share their winnings), at least psychologically, through positive reinforcement from the group.
This view of addictions as the product of failed social compacts regarding the mutual regulation of hedonic pursuits is consistent with the fact that almost all “addictions” begin as activities that are pursued in the company of, or at least with the knowledge and tacit approval of a particular social group or community. In the case of drugs, it is the stage of use that is often referred to as being a period of “experimentation”. Less obvious, however, is the possibility that the proposed model is also consistent with one of the major insights that have emerged over the last 50 years from the study of the brain activity underlying drug addiction. I am referring to the claim that the so-called “addictive” drugs tend to “hijack” processes in a region of the brain called the “reward pathway”; a patchwork of neural connections extending from the pre-frontal areas to the midbrain that have evolved over millions of years for the sole purpose detecting and repeating behaviors that result in reinforcement (i.e., fitness improvement signaled by subjective pleasure). It is assumed that this hijacking occurs because technology has made reinforcement available and accessible at rates, quantities and potencies (e.g., refined sugars, fast food, drugs, and so on) that far exceed the design specs of our relatively primitive reward pathway (Neese & Berridge, 1997).
This of course sounds right, but missing from this neuro-centric formulation are the social structures and processes that give addictive experiences meaning. You will recall that Stevie was aware of the fact that her hedonic experience was diminished when her social circle was reduced in size, suggesting that she understood, at least on an intuitive level, that it was NOT just the gambling per se that gave her the buzz that she so looks forward to every week. But what if one day Stevie suddenly came to the conclusion that the real source of her happiness on Tuesdays and Thursdays came from her relationship with the slot machines, and that alone. Given this premise, she might then decide, quite reasonably, that there is no good reason why she could not visit the casino more often and by herself. Moreover, with increasingly less of a reason to make sure that she gets up early enough to make it on to the Tuesday-Thursday 9:00am bus to AC, one could imagine Stevie becoming progressively more estranged from, and increasingly less regulated by, the group. What would follow next is probably familiar to anyone with an addiction history: increased risky decisions, larger and more severe negative consequences, loss of social supports and rapidly diminishing hedonic returns. However, the point here is that Stevie’s reward pathway could not in that situation be said to have been hijacked by a drug, since she is a gambler, not a drug user. But if we are to take seriously the proposition that on a neuro-psychological level a gambling addiction is fundamentally no different from drug addiction (remember it will say so in the shiny pages of the new DSM 5), there should at least be some evidence of a common mechanism that could account for the alleged “hijacking”.
I would like to propose a possible candidate for this mystery mechanism. I would like to suggest that the alleged hijacking of the nervous system occurs through the promotion of what is referred to as a fundamental attribution error. That is to say, individuals who become addicted to a drug or activity have ceased to correctly attribute or perceive a causal role for their social relationships in their hedonic response to the drug or activity. Instead, it is attributed exclusively to the effects of the drug or activity. That fateful decision inevitably disqualifies the individual as both a pliant object of social control and as a reliable contributor to the regulation of others in the group, thus initiating the ever familiar vicious cycle that eventually leads to a mostly solitary pursuit of the hedonic activity. But it does not stop there. As every addict knows, social control is eventually reinstated, but in the form of an invidious sort in which the individual’s hedonic activity becomes emeshed in a social network that is dedicated almost exclusively to the transactions necessary for maintenance of the now deviant but preferred level of hedonic activity. So in the case of drugs, it is the dealer, it is the people that you lie to in order to persuade them to lend you the money for the drugs you need, is it is people with similar patterns of use, it is the people who frequent the places where the drugs are likely to be sold and used, and so on. Importantly, however, even in this new state of homeostasis, the typical addict is still blind to the fact that their total hedonic experience is not due to the drugs alone but rather to the drugs + the totality of the social relationships and transactions that make the drug use possible. It is merely a new social contract with considerably more liberal regulatory rules, but ultimately with the same objectives as the original social compacts that supported the initial experimentation with the drug.
A reasonable question to ask of course is why is it believed to be so difficult for someone in recovery to successfully re-submit to the regulatory control of their pre-addictive social groups? And as a corollary, why do so many recovering addicts seem to need the specialized regulatory control of abstinence-based self help groups like AA in order to remain functional? The answer to these questions I believe is actually two fold. First, it may be case that these claims are simply not true. There is a substantial body of research that suggests that natural recovery without treatment is quite common among at least middle class addicts, and in fact may be the norm. In fact, some estimates range as high as 80% for some types of alcoholics (Sobell et al, 1992). This means that for a large proportion of the clinically addicted it is probably possible to reinstate normative social control, especially if the individual has not been formally labeled an “addict” or “alcoholic” by an institutional authority such as a treatment facility. The second reason, and one for which I admittedly have considerably less evidence, is the possibility that individuals who cannot easily readapt to normative social control constitute a minority of individuals who are particularly prone to making attribution errors regarding the sources of their hedonic experiences. It is also possible that they are less susceptible to social regulation, which is consistent with the well documented relationship between psychopathic traits and an increased risk for developing substance use problems. Both of these latter possibilities, which are not mutually exclusive, are consistent with the recent finding from researchers at Vanderbilt University that suggest that impulsive-antisocial personality traits are linked to a hypersensitive brain reward system (Buckholtz et al, 2010). Importantly, these individuals would be equally hopeless at fulfilling their end of the regulatory compact in a normative group. Not only would their peers be frequently frustrated in their attempts to exert regulatory control over them, but they would be equally disappointed by the individual’s inability to contribute to the effective regulation of others in the group. Indeed, the reason why most of us are not considered addicts by our social peers is because like Stevie, we remain convinced that our hedonic pursuits are inseparable from the social relationships in which they are embedded. As a consequence, we are constantly striving to regulate the hedonic strivings of others in our social group in an effort to maintain the integrity of those relationships. Non addicts, as active participants in the maintenance of regulatory control in their social relationships, crave the stability of their social relationships as much as they crave a particular drug or hedonic activity.
As a final comment, the argument that has been put forward also has some unavoidable implications for the highly popularized concept of co-dependence. Over the last several decades the concept of co-dependence has assumed a supremely negative connotation, especially in non-academic circles. The co-dependent individual is cast as a spineless enabler who contributes toward maintaining the alcoholic’s pattern of drinking behavior for the sake of establishing some sort of homeostasis in the home. But if there is any truth to what has been said above, co-dependency is part of the normal human condition, and we are all charged with the responsibility of regulating the hedonic pursuits of others, not only in our families but also more broadly, in our communities as well. Alcohol abuse and dependence in the family is not maintained by a co-dependent relationship. On the contrary, it is enabled by an array of inadequate co-dependent relationships.
American Psychiatric Association (2012) DSM 5 Development: Substance Use and Addictive Disorders. http://www.dsm5.org/proposedrevision/pages/substanceuseandaddictivedisor...
Heath, D.B. (ed.). (1995) International Handbook on Alcohol and Culture. Westport,Conn.: Greenwood.
Marlatt, G.A., & Rohsenow, D.J. (1980) Cognitive processes in alcohol use: Expectancy and the balanced placebo design. In N.K. Mello (Ed), Advances in substance abuse: Behavioral and biological research (pp. 159-199) Greenwich., CT:JAI
Neese, R., & Berridge, K. (1997). Psychoactive drug use in evolutionary perspective. Science, 278, 63-65
Saad, L. (2008) US smoking rates still coming down. Gallup Wellbeing. http://www.gallup.com/poll/109048/us-smoking-rate-still-coming-down.aspx
ScienceDaily (2009). Light to moderate drinking and socialization are jointly good for cardiovascular health, study finds. http://www.sciencedaily.com /releases/2009/03/090319161456.htm
Sobell, L.C., Sobell, M.D., & Toneatto, T. (1992). Recovery from alcohol problems without treatment. In Heather, S., Miller, W.R., & Greeley, J,. (Eds). Self-Control and Addictive Behaviours, New York: MacMillian, pp. 198-242.