Anke Snoek

Pleasure and Addiction

What is the role and value of pleasure in addiction? Foddy and Savulescu (1) have claimed that substance use is just pleasure-oriented behavior. They describe addiction as “strong appetites toward pleasure” and argue that addicts suffer in significant part because of strong social and moral disapproval of lives dominated by pleasure seeking. But such lives, they claim, can be autonomous and rational. The view they offer is largely in line with the choice model and opposed to a disease model of addiction. Foddy and Savulescu are sceptical of self-reports that emphasize the ill effects of addiction such as loss of family and possessions, or that claim an absence of pleasure after tolerance sets in. Such reports they think are shaped by social stigma which makes available a limited set of socially approved addiction narratives. We will not question the claim that a life devoted to pleasure can be autonomously chosen. Nor do we question the claim that the social stigma attached to the use of certain drugs increases the harm suffered by the user. However our interviews with addicts (as philosophers rather than health professionals or peers) reveal a genuinely ambivalent and complex relationship between addiction, value, and pleasure. Our subjects did not shy away from discussing pleasure and its role in use. But though they usually valued the pleasurable properties of substances, and this played that did not mean that they valued an addictive life. Our interviews distinguished changing attitudes towards drug related pleasures across the course of substance use, including diminishing pleasure from use over time and increasing resentment at the effects of substance use on other valued activities. In this paper we consider the implications of what drug users say about pleasure and value over the course of addiction for models of addiction.

How to recover from a brain disease: is addiction a disease, or is there a disease-like stage in addiction?

People struggling with addiction are neither powerless over their addiction, nor are they fully in control. Lewis vigorously objects to the brain disease model of addiction (BDMA), because it makes people lose belief in their self-efficacy, and hence hinders their recovery. Although he acknowledges that there is a compulsive state in addiction, he objects to the claim that this compulsion is carved in stone. Lewis argues that the BDMA underestimates the agency of addicted people, and hence hinder their recovery. Lewis’s work offers us a very much to be welcomed neurobiology of recovery. It offers addicted people a hopeful and respectful narrative for their recovery that treats them as agents rather than as damaged brains. However, I argue that overestimating people’s agency can also result in people losing belief in their self-efficacy. Lewis’s strong focus on the agency of addicted people might not match their experiences of struggle, hence reinforcing their feelings of guilt when they fail to control their use. I propose to replace the notion of addiction as a disease with a notion of a disease-like stage in addiction. I call this stage the duress stage in addiction, in which the addictive behaviour is largely impervious to the agent’s values and to available techniques of self-control. However, the agent can overcome this stage by developing new techniques of self-control, by building on their self-concept and belief in self-efficacy, by changing their environments and habits, and by engaging in projects that are meaningful to the agent.

Stigma and self-stigma in addiction

Addictions are commonly accompanied by a sense of shame or self-stigmatization. Self-stigmatization results from public stigmatization in a process leading to the internalization of the social opprobrium attaching to the negative stereotypes associated with addiction. We offer an account of how this process works in terms of a range of looping effects, and this leads to our main claim that for a significant range of cases public stigma figures in the social construction of addiction. This rests on a social constructivist account in which those affected by public stigmatization internalize its norms. Stigma figures as part-constituent of the dynamic process in which addiction is formed. Our thesis is partly theoretical, partly empirical, as we source our claims about the process of internalization from interviews with people in treatment for substance use problems.

The Importance of the Self for Autonomous Behavior

Neuroscientific findings have often been argued to undermine notions of free will and to require far-reaching changes of our political and legal systems. Making a difference between the metaphysical notion of free will and the political notion of autonomy, Dubljević (2013) argues this switchover to be mistaken. While we appreciate attention to the social limits of neuroscientific findings, we also have a twofold concern with his proposal. The first covers the nontransparent way in which he either rejects or embraces certain scientific findings, which renders the background and motivation of his argument unclear. The second revolves around his idea of a “rational life-plan,” which, while it covers a person’s capacity to conform to social and external factors, misses out what it means to act for a reason or be the source of one’s actions. Revisiting the example of former addict Tommy McHugh and invoking the example of a resigned addict, we present the idea of an “autonomous life-plan,” which is metaphysically sound and practically relevant.

Introduction: Testing and Refining Marc Lewis’s Critique of the Brain Disease Model of Addiction

In this introduction we set out some salient themes that will help structure understanding of a complex set of intersecting issues discussed in this special issue on the work of Marc Lewis: (1) conceptual foundations of the disease model, (2) tolerating the disease model given socio-political environments, and (3) A third wave: refining conceptualization of addiction in the light of Lewis’s model.

Strong-willed but not successful: The importance of strategies in recovery from addiction

Introduction Philosophers, cognitive and social psychologists and laypeople often subscribe to the view that willpower is central to recovery from addiction. But there are reasons to suspect that willpower is much less important to explaining recovery than this view suggests. Methods Here we report findings from a qualitative longitudinal study on how substance dependent people see their agency and self-control, and how their self-control develops over time. 69 opioid, alcohol and methamphetamine dependent people were interviewed over a 3 year period. Results Most of the participants described themselves as strong willed; in fact, as very strong willed. However, there seemed no correlation between having a (self-assessed) strong will and recovery status. Rather, the number of strategies cited by participants distinguished those in stable recovery from those who were not. Participants in recovery were also more enthusiastic about strategies than those who have not succeeded in controlling substance use. Willpower remained important, but was itself used strategically. Conclusions People with addiction seem not to be short on willpower; rather, recovery is dependent on developing strategies to preserve willpower by controlling the environment.

Lessons in Biopolitics and Agency: Agamben on Addiction

The concepts of ‘biopolitics’ and ‘naked life’ have become increasingly relevant in the debate on substance dependency due to the growing prominence of neuroscience in defining the nature of addiction1 and its threat to agency. However, these concepts are not necessarily well understood, and therefore may lead to oversight rather than insight. In this article we review the literature on Italian philosopher Giorgio Agamben, whose founding works on both concepts shed a different light on addiction. We argue that the current debate is missing a key insight from Agambens work: the idea of agency past the subject, of agency past identity. We will illustrate how this can be an important form of agency against the stigmatization of users, making use of empirical data from our ongoing work on addiction and agency.

Beyond Dualism: A Plea for an Extended Taxonomy of Agency Impairment in Addiction

Pickard (2012) claims that the neurobiological or disease model of addiction hinders the recovery of people because it undermines their feeling of self-efficacy and agency. Substance users are “not aided by being treated as victims of a neurobiological disease, as opposed to agents of their own recovery” (40). Although Pickard acknowledges that claims of powerlessness or loss of agency can have a functional role in the self-narratives of substance users in excusing them from blame, she primarily focuses on the negative effects of the disease model on the recovery of substance users. Preliminary evidence from in-depth interviews with heroin-dependent participants in our current cohort study on addiction and moral identity supports Pickard’s claims in part: Substance users describe grades of control, psychological distress, and loss of options, and an ambivalent attitude toward their belief in self-efficacy. However the interviews also provide points of critique. While Pickard is right to dismiss the more extreme claims of proponents of the disease model—namely, that drug use in addicts is literally compelled—user responses suggest that an understanding of the neurobiology of addiction might in some respects support rather than undermine a sense of agency. Moreover, there is reason to suppose that the relation between substance use and psychological distress is not as straightforward as Pickard claims. In this respect we believe the debate must become more nuanced and move beyond a simple opposition between the disease model and the rational choice model endorsed by Pickard.

Ethical issues in research on substance-dependent parents: The risk of implicit normative judgements by researchers

Abstract When doing research among vulnerable populations, researchers are obliged to protect their subjects from harm. We will argue that traditional ethical guidelines are not sufficient to do this, since they mainly focus on direct harms that can occur: for example, issues around informed consent, fair recruitment and risk/harm analysis. However, research also entails indirect harms that remain largely unnoticed by research ethical committees and the research community. Indirect harms do not occur during data collection, but in the analysis of the data, and how the data is presented to the scientific and wider societal community. Highly stigmatized research subjects, like substance‐dependent parents, are especially at risk of encountering indirect harm, because the prejudice against them is so persistent. In this paper we discuss two forms of indirect harm. First, researchers have to be aware how their results will be preceived by society. Even when subjects are presented in an objective way, further, out of porportion stigmatization can occur. Researchers sometimes try to counteract this by whitewashing their results, at the risk of downplaying their respondents’ problems. The second risk researchers face is that their own normative judgements influence how they question such parents, report results and interpret statements. Researchers’ own normative judgements may influence the way they present their subjects. This article reviews a broad range of research that exhibits such indirect harms, discussing how and why indirect harms occur and formulating corresponding recommendations on how to prevent them.

Does DBS Alienate Identity or Does It Simply Fail to Restore Identity Already Eroded by Illness

Qualitative studies on new treatments give us important insights into how patients experience a treatment, and how the treatment either improves or disrupts their lives. Gilbert and colleagues’ study (Gilbert et al. 2017) is a valuable contribution to the phenomenological literature on how deep brain stimulation (DBS) as a treatment for Parkinson’s disease (PD) can influence people’s self-concept. However, there is insufficient detail about the lives of their respondents in this fascinating study. This context is needed to better interpret the authors’ results, and will clarify some of the methodological and theoretical issues they outline. The first issue that arises is how we should understand self-estrangement in the context of DBS. Although the authors provocatively title their article “I Miss Being Me,” suggesting that DBS induces self-estrangement, the authors outline that this link is only weakly supported. To start with, less than half (47%) of their respondents experienced some sort of self-estrangement. These eight respondents also described how their symptoms of PD devastated their existence. Before their DBS they already experienced self-estrangement. Thus, it seems less likely that DBS induces self-estrangement, but instead that DBS fails to restore an identity already eroded by illness. Other studies on identity change in PD support this conclusion (Nijhof 2002; Roger and Medved 2010; Platt 2004). Four respondents stated that PD enhanced their lives; these four also experienced identity continuity after DBS. However, very few details are given about this group. Why did they experience PD as enhancing their lives? Did the PD result in a much-wanted early retirement? Apart from some basic details like gender, age, and some treatment history, we know nothing about the respondents. How did PD influence their lives, their projects, their relationships? What in their lives did they hope that DBS would change? Answering these questions is essential for interpreting the authors’ category of “restorative self-estrangement.” An interesting finding of the article is that even if DBS restores the capacities destroyed by PD, the patients can still experience self-estrangement. This self-estrangement is due to a side effect of the DBS, which the respondents call “emotional incontinence.” Gilbert and colleagues do not explore why this emotional incontinence is so estranging for the respondents. However, Baumeister and colleagues have shown that emotions play a very important role in our decision making (Tice, Bratslavsky, and Baumeister 2001). Gilbert and colleagues cite Mackenzie and Walker (2015), stating, “The question is not whether DBS intervention threatens identity, but whether the intervention impairs autonomy competence (e.g., volitional/emotional/motivational/imaginative skills)” (102). But they explain very little about the respondents capacities: Which capacities are restored? Which of the capacities that are eroded by PD fail to be restored by DBS? Which previously intact capacities are impaired by DBS? I find the category “restorative estrangement” somewhat misleading because the estrangement does not come from the restoration of capacity, but from the destruction of other capacities.