Wednesday 4 September 2019

From pleasure to vice to addiction

I’ve been reading quite a bit of fiction and non-fiction about substance use and ‘addiction’ lately, and some of the latest things have sparked me to wonder if we think carefully enough, or fundamentally enough about the issues.

I’m going to focus here on David Courtwright’s new book The Age of Addiction: How Bad Habits Became Big Business, but the points apply equally across a lot of the debate currently.  Although this reads a bit like a review, I’m trying to make a broader point that we’re sometimes not as clear as we could be about what the problem is and how we’re trying to solve it – and this is important if we’re going to develop effective public policy.

Courtwright’s book is a whistle-stop tour through the history of substance use, from prehistory and the development of agriculture through to the industrial revolution and more recent developments such as digital technology and online markets and interactions.  Although not mentioned in the title of the book, the argument hangs on a couple of key concepts.  He’s concerned with ‘vices’ and how something he calls ‘limbic capitalism’ has made us more vulnerable to developing these.

Courtwright argues that there are parallels in the ways we can get into trouble with different substances, whether we understand them as ‘drugs’ or not, and behaviours like sex and gambling.  What start off as being ‘pleasures’ can transform into ‘vices’ and eventually ‘addictions’.  In this way, the book is about sugary food and drink as well as gambling as much as more familiar issues grouped under the banner of ‘addiction’ like alcohol and other drugs.

Courtwright suggests that with industrial capitalism certain pleasures became more attractive and available, as urbanisation fostered psychological as well as geographical disruption.  For example, drink was more available in cities, you could indulge in pleasures with less fear of judgement as there are more anonymous spaces, and you had more reason to as there was less social connection and the work and living conditions were less stable and rewarding.  So the industrial age was one of vices, not mere pleasures.

But Courtwright’s warning is that we have moved beyond this form of capitalism and its associated vices to a new form – ‘limbic’ capitalism – and the issues emerging deserve the label of addiction, not just ‘vice’.  The word ‘limbic’ refers to the ‘limbic’ system, an idea Courtwright takes from the work of people like  Daniel Kahneman.  The idea is that humans have two ways of acting: through rational deliberation, making use of their ‘head’; and through more automatic mechanisms, often labelled as a ‘gut’ reaction.  It’s the ‘limbic’ system that’s responsible for the latter.  (Incidentally, I think Dan Gardner is more relevant in this context.)

Thinking about these two systems is one way of understanding the paradox at the heart of the concept of addiction: that we can knowingly act against our best interests.  When we employ our ‘head’ to think about things, we know a particular course of action is unwise, and we want to avoid it; but when, in the heat of the moment, we rely on our ‘gut’, we make a mistake – or a ‘lapse’.

Courtwright’s contention is that capitalism today is increasingly efficient at mobilising the ‘gut’ at the expense of the ‘head’, meaning that ‘addiction’ is more common.  Examples include the formulation and marketing of unhealthy food and drink and the design and delivery of computer games and social media through the internet and mobile devices.

The elegance of the this argument makes it attractive, though I would take issue with some of the claims.  I don’t want this to be a comprehensive book review, so I won’t go into detail here, but I worry that this view idealises the past and misrepresents the nature of addiction.

Prehistoric and agricultural societies were not innocent worlds where ‘pleasures’ never transformed into ‘vices’ – and although that isn’t what Courtwright is saying, there’s something about the argument that suggests there was some golden age where we had our ‘guts’ and ‘heads’ in balance.

Crucially, the ‘gut’ and ‘head’ are not entirely separate and we can’t quite explain ‘addictive’ behaviour in this way.  Representing two systems like this risks reproducing a Cartesian mind/body dualism, which has been critiqued to death.  While a Cognitive Behavioural Therapy (CBT) approach to issues around substance use might take the approach of getting people to actively reflect using reason, that isn’t quite the philosophy behind other approaches that many people rely on, including Alcoholics Anonymous (AA).  These approaches to recovery aren’t simply about prioritising the ‘head’ over the ‘gut’; they’re about re-training your ‘gut’.  Just as genetics and early experiences help determine what ‘pleasures’ we are most vulnerable too, so we can ‘re-train’ ourselves to form different tastes and habits.  The reflective can become automatic – so much so that the reformed smoker or meat-eater can find the smell of cigarettes or frying bacon viscerally disgusting.

But in a sense that’s by the by for Courtwright’s argument.  It could still be claimed that this is prioritising the ‘head’ in order to understand what is genuinely in our best interests, and then we can use the ‘head’ to slowly turn round the ‘gut’.  (I’m not quite convinced by this; encouragement to fake it till you make it and just keep attending meetings don’t feel exactly ‘rational’, or something the ‘head’ can entirely justify.)

But more important than these details are the issues of language and concepts.  Courtwright isn’t exactly clinical in defining what makes an erstwhile pleasure a ‘vice’ or ‘addiction’.  I suppose he would say that a vice is an indulgence in a perhaps fleeting pleasure where, at least in the long run, either you or someone else around you is harmed, and this can be understood as an ‘addiction’ where there is some sense of compulsion.

And perhaps this lack of clarity is forgivable in what is essentially a book outlining a grand narrative.  At some level my frustration with this is simply a matter of personal style and preference.  The sort of books and authors Courtwright is drawing on don’t do a lot for me – Kahneman, Steven Pinker, Yuval Noah Harari, Thaler and Sunstein and so on.  For me, too much gets lost in the grand sweep of the arguments, and they often include errors or oversights.

But it’s also a question about the purpose of these discussions (and these kinds of books).  Courtwright is writing because he’s concerned about trends in behaviour, and the economic and political forces that are moulding these.  The book ends for a call for us to avoid ‘excess’, both in enjoying pleasures and in our politics.  (I’m sure some members of the Drinking Studies Network would have plenty to say on this.)

Maybe it’s my personal baggage, but it all feels a bit ‘centrist dad’, like a cry for us to grow up and become ‘rational’ adults.  I felt like I was being told to drink less, go to bed earlier, and probably vote Lib Dem.

The thing is, that isn’t necessarily ‘rational’ for everyone.  One person’s pleasure is another’s vice.  The key question is how to define and police the boundaries between these categories of pleasure/vice/addiction.  Can we?  Should we?

If this is a call for a return to classical liberalism, we can’t be sure how we should regulate pleasure.  A reliance on single word like ‘excess’ cannot resolve the fundamental tensions in liberal thought, even if we could all agree to call ourselves ‘liberals’.  Think of TH Green and JS Mill arguing in the nineteenth century about what the truly liberal position on alcohol was.  When, where and how can lines be drawn defining competence, capacity, freedom and harm?  You might think I drink too much, but who can genuinely judge that apart from me?  What if I know the risks and I think what you might consider ‘excessive’ is actually perfectly balanced?

This might sound a bit abstract and overblown, but I want to illustrate that these are real, live and important issues for practice and policy at the moment.

First, let’s look at some of the things Courtwright seems to define as vices.  For example, he seems to worry about young people having no-strings-attached sex in the gap between high school and college (p.203), which, in itself, I can see little problem with.  The devil is, of course, in the detail of safety and consent – but that’s more complicated than condemning this kind of experience in itself.

Oddly he worries: ‘Me-not-them remains a popular game.  Try vaping instead of smoking.  Try cannabis for pain instead of opioids … Disney lobbied to keep casinos from competing for tourist dollars in its Florida backyard.  Yet it hired sommeliers to recommend wines in its restaurants’ (p.231).  None of these particularly worries me.  They sound like reasonable, pragmatic approaches that could well lead to more positive outcomes.  I’m not unquestioningly in favour, but I’d need a bit more persuasion from Courtwright to understand why each of them is a bad idea.

Courtwright even seems to suggest that banning e-cigarettes can be considered an ‘achievement’; a statement that itself would worry many public health professionals, let alone liberals.

Behind each of these statements are fundamental questions about what ‘the good life’ looks like.  Courtwright, for example, praises ‘mercantile and industrial capitalism’ for fostering ‘self-discipline, future orientation, and efficient time management’ (p.210) as if these are all unquestionable virtues.  As if they don’t exist on the same kind of spectrum as pleasure/vice/addiction.  Surely not all those writing during the industrial revolution would have agreed with the claim that ‘Innovation and competition, however fair and orderly, tend to make the social consequences of improved production worse, not better’ (p.226).

He therefore also seems to dodge the implicit question about the ethics of ‘nudging’ people into different behaviours, uncritically noting that certain environments ‘work for us instead of against us’ (p.228).  Who decides what’s ‘for’ us and what’s ‘against’?  How?

At root, we have a view that emphasises the value of rationality.  But there are two key problems with that.  First, there is no single definition of a ‘rational’ decision.  For example, Courtwright states that when Zadie Smith gave up Facebook to help her concentrate on writing a novel ‘She was wise to do so’ (p.209).  Perhaps, but how can we know?  And would we all be wise to do so?  There are plenty of people who have been inspired or supported by Facebook; even supported to give up their ‘addictions’.  How can we develop a general policy position on a medium like Facebook?

Second, constant rationality is not always productive – either for individuals or societies.  There is a reason that feasts and holidays were endorsed by rulers and ruled alike.

Is it that ‘vices’ hold real risks, or are they somehow imagined?  It seems to me that ‘self-control’ is valued not because the consequences of uncontrolled behaviour are risky, but simply because they are (in some people’s eyes at least) somehow irrational.  Well indeed, that is precisely the point.

Perhaps it could be argued that so long as not too much harm is involved, then activities could still be classed as ‘pleasures’ (or perhaps ‘vices’) rather than ‘addictions’.  And yet if they are not rational, how can they still be classified in this way?  How can we then draw appropriate lines between them?

If this still sounds like an abstract and indulgent academic argument, think of how we regulate e-cigarettes, the night-time economy or alcohol more broadly.  If vaping is somehow seen as a vice, not to be encouraged, this has serious implications for public health and smoking cessation  policy.

If we are not able to define clearer boundaries between ‘vice’ and ‘addiction’, then we will struggle to support people who have issues with heavy drinking.  As health professionals wrestle with the issue of why such a small percentage of people who drink heavily access support, there are plenty of people suggesting that we need a more nuanced approach to ideas of mental capacity and consent, arguing that, at a certain stage, we can define heavy drinkers as acting so irrationally against their best interests that they cannot sensibly be said to have mental capacity to make informed, rational decisions about their own welfare.

Without clearer thinking and writing, we won’t get closer to resolving these questions and developing policy solutions.  David Courtwright has offered an interesting and engaging contribution to the discussion, but for me he raised more questions than he answered.