In addiction discussion, don't dismiss the importance of choices


The recent difficulties occasioned by the abuse of "prescription medication" on the part of radio talk-show host Rush Limbaugh and Democratic Rep. Patrick J. Kennedy of Rhode Island have again raised the issue of the disease model of addiction vs. the concepts of legal and personal responsibility.

It has been said that "truth is a matter of emphasis." To understand this concept clinically, consider the struggle we have in dealing with the tension between biological predisposition and volitional behavior. This is a continual problem in addictions and in psychiatry.

A common example is our evolving conception of alcoholism. Because a vulnerability to the effects of alcohol is clearly genetically determined, and because unchecked drinking produces organic changes, notably cirrhosis of the liver, it has become an article of faith among mental health professionals that alcoholism is an illness. You can, after all, die from it.

This appears to represent a commendable effort by the medical community to destigmatize a condition that for centuries has been treated as a moral lapse, a failure of will, a deficit of character so deplorable that those who manifested it were discouraged from getting help. If we label it an illness, the reasoning goes, people will treat it like any other sickness and seek treatment.

This treatment, directed at abstinence, does involve an act of will, albeit with group support. The problem, of course, is relapse. How do we deal with the tendency of substance abusers to resume drinking or drugging after a period of not doing so?

We don't condemn people with asthma or heart disease when they relapse. These are understood to be chronic illnesses. Theoretically, we should adopt a similarly nonjudgmental attitude toward those with addictions. They can't help it. Or can they?

What can we reasonably expect from a drinking alcoholic? This is not a theoretical question for a family member who is coping with the ruinous secondary effects of alcoholism. What they observe looks to them like voluntary behavior: the person they love and depend on insists on taking a drink. Followed by another drink. And so on.

Yet the family has been told that their loved one has a chronic, relapsing illness. So how can they be angry with the alcoholic for simply displaying the symptoms of this illness? Where is the truth? Where is the line between the helplessness that most of us feel in the face of our genetic heritage and our obligation to control our destructive impulses?

Beware of psychiatric diagnoses, the primary purpose of which is to relieve people of responsibility. If someone claims that he is not guilty because his body is inhabited by multiple personalities and that it was his evil alter ego that committed the crime, I would notice the similarity between this plea and the assertion that "the devil made me do it."

Even as we attach medical diagnoses to human behavior, we are confronted with the essential questions of how to discern what it is that we are responsible for and what we must accommodate. One analogy is to heart disease.

Clearly, there are things that predispose us to suffer coronary events over which we have no control - our gender and genetic backgrounds, for example.

If your family history is one of early death from heart attacks, it is a good idea to refrain from smoking, watch your diet and exercise regularly. But you still stand a good chance of suffering a myocardial infarction. So does it make sense to say "the heck with it" and eat, drink and smoke as you please for as long as you can? That, of course, is a personal decision.

And so it is that we must live our lives in the gray area between the extremes of biological determinism and individual responsibility. What can we choose and what are we helpless to control? If we err, it probably ought to be in the direction of emphasizing the importance of choices.

Gordon Livingston, a psychiatrist who lives in Columbia, is the author of "And Never Stop Dancing." His e-mail is

Columnist Clarence Page will return Tuesday.

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