Personal Autonomy, Addiction and Mental Disorder

In science, normative thinking about addiction has traditionally been divided between, on the one hand, a medical model which sees addiction as a disease characterized by compulsive and relapsing drug use over which the addict has little or no control and, on the other, a moral model which sees addiction as a choice characterized by voluntary behaviour under the control of the addict. Proponents of the former appeal to evidence showing that regular consumption of drugs causes persistent changes in the brain structures and functions known to be involved in the motivation of behavior. On this evidence, it is often concluded that becoming addicted involves a transition from voluntary, chosen drug use to non-voluntary, compulsive and irrational drug use. Against this view, proponents of the moral model provide evidence that addictive drug use involves voluntary chosen behaviour that can be viewed as a perfectly rational response to harmful social or psychologically circumstances. A general difficulty for both these models of addiction is that the criteria used to determine ?voluntariness?, ?compulsion? and ?autonomy? are themselves deeply normative as well as controversial, and that no simple inference therefore can be made from the empirical evidence to any of these models. To provide adequate support for one or another of these models it is therefore necessary to examine not only the empirical evidence, but also the normative notions they rely on. The overarching aim in this project has been to do exactly that. We have conducted a systematic investigation of how addiction impacts on normatively relevant properties of addicts such as capacities for voluntary choice, rationality and personal autonomy, in order to assess the (often implicit) normative assumptions about addiction current in the scientific literature. The results of this investigation have been published in a series of articles in high-ranking international journals in philosophy, psychology and psychiatry, as well as in several book chapters. In these works, a new philosophical analysis of some of the relevant normative notions have been developed and applied (in combination with recent findings in addiction neuroscience) to argue for a different normative conception of addiction, one that neither rules out the view of addictive drug use as compulsive, nor that it involves voluntary chosen behaviour (thus breaking down the traditional divide between the medical and the moral model). In addition to this conceptual and philosophical work needed to assess addicts? normative capacities, the project has conducted two empirical surveys on normative conceptions of addiction in the population. In the largest of these, we investigated normative beliefs about nine addictions in five European countries (Poland, Norway, Germany, Finland, and Sweden). This investigation was conducted by postal or telephone surveys or a web panel, directed at largely representative population samples (total N= 4843). Aspects covered by the surveys were the perceived severity of various addictive problems as societal problems, in themselves and compared to other societal concerns, as well as the perceived addictiveness (the risk to ?get hooked on?) of various substances or activities. In addition, respondents were asked to rate to what extent they thought that the onset of various addictive problems should be blamed on the individual addict or on other circumstances, and to what extent the individual should be held responsible for solving the problem. Finally, the surveys raised the question of the perceived likelihood of recovery from various addictions, with and without formal treatment. The results pointed to interesting differences between the five countries. The project has also generated work on various practical implications for treatment and policies in the addiction field. In ?Constructing a Theory and Evidence-Based Approach to Promote and Evaluate Autonomy in Addiction? (Inquiry), Johansen (with Farnad & Franzen) use theory and empirical evidence to synthesize a model for the analysis of autonomy in people with addictions. They present three main factors involved in autonomy in addiction (mentalizing, positive self-concept, and stigma), and illustrate their model by examining variations on these parameters in two case studies of heroin addicts. They conclude that a growth perspective is needed to assess functioning in populations believed to be ?addicted? and make suggestions for assessment. In ?Drug Policy, Values and the Public Health approach?, Røgeberg argues that a public health approach to analysing drug policies, as currently practised, fails to capture several concerns seen as important by recent drug policy reform movements.

The normative thinking about addiction has traditionally been divided between, on the one hand, a medical model which sees addiction as a mental disorder characterized by compulsive and relapsing drug use over which the addict has little or no control and , on the other, a moral model which sees it as a moral weakness characterized by (wrongful) intentional behavior largely under the control of the addict. Although there are different views of, precisely, what make some condition a mental disorder, one com mon feature of many of these views is the claim that a necessary requirement is that the condition is characterized by a certain sort of impairment of "normal" autonomy. In this project our aim is to examine how addiction impacts on the autonomous agency and mental health of addicts. Our hypothesis is that drug addiction is characterized by an impairment of normal autonomy and that it should be counted a mental disorder. However, we believe it is time to break down the divide between the medical and mora l thinking about addiction: even if addiction is a disorder that involves compulsive patterns of behavior, this does not mean that addicts have little or no control over their addictive drug use. Using philosophical analysis in combination with data from our own empirical study, as well as other sources of evidence, we wish to develop a new conceptual model to study autonomous agency and the effects addiction has on such agency. Our working hypothesis is that personal autonomy includes a capacity for rela tedness, to form close personal relationships, understanding others feelings and responding to normative pressures placed on one by other persons, where a necessary condition for this capacity is a certain sort of reciprocal interaction of one's own behav ior, environments responsiveness to one's behavior, and self-appraisal of one's performance. We want to investigate whether the involuntary impairment of such capacity might be what diminishes addicts' autonomy.