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Theory of AddictionReview - Theory of Addiction
by Robert West
Blackwell, 2006
Review by George Graham, Ph.D.
May 29th 2007 (Volume 11, Issue 22)

West's book does not look like the book that it is.  To read the table of contents is to get the impression that this book is a catalogue of theories of addiction with commentary and is perhaps meant as a survey text for graduate courses on addiction.  Some of that might be true.  But that's not the story. That's not this book.

Texts often are long.  But this is short (about 200 pages).   Texts often fail to identify the strengths and weaknesses of theories that they canvass.  But this book assesses, evaluates, and judges the theories it considers.  Texts often are devoid of novel ideas.  But this book contributes an original theory viz. West's own account of addiction.  He describes it as a synthetic theory.  It aims to selectively incorporate elements of other theories and tries to answer the main questions that, according to West, should be answered by a theory of addiction.  Why do we need a concept of addiction?  What is addiction?  Why are some substances more addictive than others?  Why do most addicts have periods in which they successfully refrain from the substance that they consume, addictively, but then relapse, despite avowals of regret, expressions of shame, and prior efforts to the contrary?

West names his theory PRIME.  That's an acronym, of course.  But it aptly identifies the elements of his proposal.  The main idea behind PRIME, whose letters refer to plans, responses, impulses/inhibitions, motives, and evaluations, is that the motivational economy operative in addiction is, in most general terms, not unique to addiction.  Two kinds of forces help to produce all human purposeful behavior.  Impulses and inhibitory forces.  Each is entrained within motives and is checked, balanced, and regulated by executive higher-order activities of planning and evaluating.  The behavioral plans we propose for ourselves and the evaluations we make of our behavior help to give it stability, identity, and purpose.  So, for example, if I recognize myself to be addicted to cigarette smoking, but I evaluate my smoking behavior as risking damage to my somatic health, I then may formulate a plan, perhaps a pattern of displacement behavior, to refrain.  I may relapse, though, in spite of this plan, if nicotine ingested during my history as a smoker has set up classically conditioned impulses to smoke.  The initial autonomic stages of such impulses may lie beneath the threshold of my awareness.  The impulse to smoke may surface only in a conscious representation of cigarettes.  So, if left to initial plans, and remaining in ignorance of non-conscious forces within me, I may not be able to inhibit them.  When I relapse again, fresh expressions of remorse may signal additional negative evaluation.  Perhaps some self-blame.  If so, it's time to refine the plan or to develop a new one.  Or, alternatively, my disavowals may be insincere expressions of disapproval.  I may not wish to admit it, but I am a habitual and frequent smoker in spite of its sullen somatic consequences.  I care enough about myself to read West, but Turn East when nicotine is in the smoke-filled eastern air.

PRIME, as noted, is not a theory specifically of addiction.  It is a general theory (a better word would be 'template' for a general theory) of human motivation applied to addiction.  Just what is to be said in PRIME's favor as a general theory is hard to assess without examining other sorts of applications.  West does not provide them.  PRIME is stocked with a lot of concepts and sub-hypotheses, including an account of associative learning and of the roles of mental representation in behavior.  Here I have mentioned only a few.  Intuitively, however, although conceptually bulky and offered with but the one detailed application (to addiction), West's theory is quite plausible.  William James brush-stroked a somewhat similar portrait of human motivation in his Gifford Lectures on religious experience: "'Yes! yes!', say the impulses; 'No! no!, say the inhibitions."  And a great deal of human behavior follows in their train, James added, as these influences mold us with their pressures (James [1901/2] 2002: 287).  Human behavior abounds with potential applications for PRIME.  Whether West will offer more is not obvious from the book.  He sticks to addiction and its variants.

West's command of the approximately three dozen theories of addiction offered before proposing his own is singularly impressive and draws in part, no doubt, upon his position as the editor-in-chief of the journal Addiction and from the sort of familiarity with relevant literature that such a prominent role may play in someone's scholarship. Each theory is described in 2 or 3 pages, examined in light of how it answers the main questions asked of addiction, and then, insofar as these answers may be incomplete or unsatisfactory, another theory is offered, described and put to the test. All this is done with full citations and useful references.

West's tour of theory after theory is quite nuanced.  At first, I feared it would be insufficiently dialectical, but it's not.  It is mapped as an interconnected series of short studies, beginning with the proposition that addiction is a type of rational choice (rational choice theories), through the proposition that addiction is choice plus impairment (bias theories), through the proposition that addiction is under sub-personal neurochemical control (of dopamine, for example) of wayward instrumental learning, all the way to considering the role of social networks and cultural dynamics in addiction.

One of the most useful theories on the tour, to this reader, who has a long-standing interest in the phenomenon of self-knowledge and its role in mental disorder, is known as Incentive Sensitization Theory and is due to Kent Berridge and Terry Robinson of the University of Michigan (see also Berridge and Robinson 1995).  Berridge and Robinson's theory contains a distinction that may answer one of the main and most vexing questions about addiction.

Here is the question: Why do some addicts relapse even when they sincerely claim that they do not like the substance to which they are addicted?  Here is the Berridge and Robinson answer.  Liking something is a hedonic process and is associated with its own neural substrate.  Liking may explain why addicts initially take and persist in taking drugs (for the pleasure this produces, and to avoid the displeasure of withdrawal).  Addicts, however, may re-take drugs after a period of refraining, long after the displeasures associated with withdrawal are past, and for no anticipated pleasure.  This is because the neural systems that are sensitized to drug taking are connected with wanting or desiring.  These are dopamine systems and they are not the same substrates as those for liking.  Addicts may want drugs or be motivated to take them even if they rightly believe that they don't like them, and therein are both unawares of wanting them and unprepared to inhibit the impulse to seek them.

One clinical lesson of the distinction is that persons should continue to exercise watchful restraint over stimuli for addictive behavior even if, or perhaps just because, they feel no need to restrain themselves since the drug is no longer liked. So says the theory. That's a potentially potent idea, I believe, for, if sound, it applies to a lot of human behavior that is imprudent and disordered even if not specifically addictive.  Consider, for example, obsessive-compulsive behavior, whose subject may claim that they receive no relief at all from washing their hands, and dislike the chore, but persist in the behavior and become anxious when stymied.  West utilizes the idea in PRIME.  Cigarette smoking may feel so disliked that an individual feels inhibited from lighting up.  But beware. The impulse to smoke and motivation to renew one's engagement with cigarettes may abide.

In addition to his own theory of addiction and assessments of other theories, there is a lot of just plain useful information about addiction that West shares in this book.  Did you know that it is rare for efforts to overcome addiction to be successful the first time?  Did you know that adults who engage in one type of addictive behavior often (albeit not universally) engage in others?

This is an impressive book.  It draws from a number of different disciplines (the psychology of learning and motivation, neuroscience, and social psychology, foremost).  It is rich in scholarship and extraordinarily informative.  For anyone who is interested in the nature, significance and therapeutic treatment of addiction, Theory of Addiction is essential reading.

 

References

Berridge, K. and Robinson, T. (1995). The mind of an addicted brain: neural sensitization of wanting versus liking. Current Directions in Psychological Science, 4, 71-76.

James, W. (2002). The Varieties of Religious Experience: A Study in Human Nature.   New York: Modern Library/Random House.

 

 

George Graham is A.C. Reid Professor of Philosophy at Wake Forest University in Winston-Salem, North Carolina, U.S.A.  He has helped to produce Reconceiving Schizophrenia, which has just been published by Oxford University Press.

 

 


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