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Book Review   |    
Addiction Is a Choice
Sally Satel, M.D.
Psychiatric Services 2001; doi: 10.1176/appi.ps.52.4.539
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by Jeffrey A. Schaler; Chicago, Open Court Publishers, 1999, 179 pages, $42.95 hardcover, $19.95 softcover

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Jeffrey A. Schaler, a psychologist, has written a pointed indictment of the prevailing concept of drug addiction as a disease—as opposed to, say, a behavioral condition. As the title indicates, Dr. Schaler views addiction as a choice, and he is very critical of treatments that "teach" patients that they are not in control of their behaviors. The author brings a libertarian sensibility to his understanding and treatment of addiction and to his policy recommendations; not surprisingly, he supports the decriminalization of all drugs, including heroin and cocaine. His treatment prescription involves getting addicts to unearth their underlying problems in life through cognitive techniques and thus help them make better choices.

Some of Schaler's criticisms should be taken seriously; they represent viewpoints rarely given a respectful hearing in our current climate of medicalization, in which addiction is considered a "brain disease." For example, Schaler claims, rightly in my view, that problems in living precede drug use. "Many of these problems in living arise because people will not muster up the courage to do what needs to be done." We often hear that people don't "choose" to be addicts, to mug their own grandmothers, get AIDS, live on the street, and so on. That is true. Few sane people would choose homelessness and alienation over a warm bed and a good family. Yet substance abusers make hundreds of conscious decisions and choices each day; over time these choices result in miserable consequences.

In other respects, however, Dr. Schaler is intemperate. He condemns doctors who prescribe medication as "legal drug dealers pushing Prozac." He calls Alcoholics Anonymous a "scam." Granted, the examples he uses to make the point that AA is little more than a cult and that its members are subjected to mind control are compelling. He writes of a young woman who wanted to attend a special public school for kids having trouble with drugs but who was rejected by the principal because the patient said she did not believe that addiction was a disease. I myself have seen counselors—recovered alcoholics—disparage patients who do not find AA helpful and who are not at ease with the "higher power" concept. On the other hand, I have seen many addicts take a less literal interpretation of the AA philosophy and use it as a constructive model for living. Schaler doesn't seem to want to acknowledge that this is possible and that AA has been life-saving for a great many people.

Nor does Schaler fully acknowledge that the universe of addicts and alcoholics likely contains biologically heterogeneous subgroups. "There is no need to dream up some far-fetched, scientifically worthless fantasy about 'physical addiction' to account for" the difficulty of quitting substances, he writes. Willpower remains within the reach of all, I agree, but it is very likely that some individuals do experience craving more intensely than others and that treatment strategies, including the use of pharmaceuticals, are useful for some. It is one thing to say that even some people who are dependent on alcohol may one day be able to drink in moderation, but another to gloss over the fact that many will not be able to manage. As clinicians and researchers, the important question for us is how we can predict who will not be able to drink controllably after a period of abstinence.

Furthermore, Schaler's flat-out insistence that treatment doesn't work is absurd. Admittedly, it works far less well than some of its proponents claim, but volumes of data show that drug use, criminal behavior, and health problems are abated during treatment, at the very least. We have seen relapse rates diminish with mechanisms such as drug testing sanctions and other forms of leverage.

I give a mixed rating to Addiction Is a Choice. It is useful for its review of studies that show convincingly that drug addicts can exercise free will, depending on the stakes. It also pokes some nice holes in what has become dogma—for example, that addiction is a chronic and relapsing condition, that all addicts require treatment, and that addiction is a disease just like diabetes is. But in refusing to acknowledge the shades of gray and certain clinical realities—for example, the limited effectiveness of treatment, individual differences in addiction physiology, and the fact that being addicted to crack cocaine is not like being "addicted" to chocolate—the book reads too much like a polemic, detracting from the profound points the author makes about the role of autonomy and choice in addiction.

Dr. Satel is staff psychiatrist at the Oasis Clinic in Washington, D.C., and lecturer in psychiatry at the Yale School of Medicine in New Haven, Connecticut.

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