By Candice L. Shelby Palgrave Macmillan, 2016 Review by Susanne Uusitalo, Ph.D. on Aug 23rd 2016
Candice L Shelby's monograph provides a new, empirically informed, philosophical account of addiction that sheds light to the lives of addicted individuals and their treatment in the society. The approach is unique, as it draws on various fields of theoretical philosophy in light of empirical research on addiction. She argues that seeing addiction either as a disease or a choice is a false dichotomy and offers her account of addiction as an emergent process of a set of complex processes.
Shelby's task is ambitious as the perspective touches upon highly theoretical issues in philosophy of mind and language, metaphysics, and philosophy of science, and it further tries to tie them with empirical data and literature on addiction. However, the number of pages (177 + notes and references) hardly does justice to explicating the amount of theory with empirical data. Shelby's attempt is admirable though occasionally her enterprise seems wanting. Instead of a fully convincing new theory, her account can be seen as a tactic to shake up the current addiction research and policy, and in this she excels in parts.
In addition to the academic endeavor, the book can be seen as a personal project. In fact, Shelby declares her personal interest in understanding and explaining addiction already in the acknowledgements. The personal touch further motivates and justifies her attempt along the way to seek better ways of treatment and policy regarding addiction. In what follows, I will introduce the book chapter by chapter, providing the main themes in each and pointing out some of the aspects that I found myself pondering on.
In Introduction: Dismantling the Catch Phrase, the book begins with an illustration of current view of addiction as a biochemical disorder. Shelby introduces the biochemical disorder with a healthy criticism of the potential of (neuro)science in exhaustively explaining addiction. As she critically reviews the kind of accounts that rely heavily on biochemistry, she highlights the characteristics she finds to be of relevance in addiction. She joins the force to highlight the complexity of the phenomenon and its explanations. In her view, addiction is a process rather than a state, and the process accommodates at least two temporal aspects, namely the agents' plans to use and their desires of refraining from use, and development and dissipation of addiction. She argues that the biochemical explanation of addiction falls short, as there cannot be addiction without self-consciousness and human social experience. (p. 2)
She points out a practical problem of having different sets of necessary and sufficient conditions in distinguishing addicted individuals from non-addicted individuals. (p.3.)These sets can roughly be divided into two sets: the disease view that Shelby sees as the received view, and the choice view. Both of the theories have their own strengths and challenges, but Shelby suggests that an entirely new perspective needs to be employed. This new perspective culminates in understanding that "addiction, rather than being one thing, whether a way of thinking or a physiological condition, is a set of interacting physical, mental, and social patterns that develops, persists, and dissipates as the patterns from which it emerges and with witch it interacts undergo changes". (p.6) This new framework rests on a specific metaphysical position and the analyses of addiction take places on many levels. (p.7) The subsequent chapters follow this agenda; as the framework has now been introduced, different levels of addiction are analyzed.
The second chapter Some Philosophical Questions and a New Theory begins with challenges of diagnosing addiction. This highlights the importance of understanding the nature of addiction and distinguishing addicted individuals from non-addicted individuals. Shelby explores the biological aspect of addiction and its nature–whether it is a disease, and what kind of a disease if it is. She rejects the view that addiction is merely a case of weakness of will–however it is understood and points out that accounts of weakness of will leave open the question why people act against their better judgement. By rejecting the weakness of will view, she is not accepting the view in which addiction is characterized by compulsive behavior driven by particular entities in the brain, either.
In fact, with these discussions she is highlighting the insufficiency of dualistic or reductionist metaphysics. According to Shelby, choice theory presumes mind/body dualism. Unfortunately due to the brevity of Shelby's discussion of the choice theory, the theory seems to gain elements of a strawman. "This [choice] view has more in common with the spiritual disease model than it does with the physical disease model because both the choice view and the spiritual disease view suggest that mind (or spirit) is separate from body, and that it is free choices that are responsible for the havoc that addiction wreaks" (p.4). The disease view, in turn, is taken to be a representative of reductionist metaphysics. By showing their problems, Shelby further suggests that in order to understand addiction, we need to embrace "more functional process metaphysics" (p.27) and defy reductionism (and dualism) in favor of emergentism. In her view, addiction "involves physiological, psychological, and higher and lower orders of complexity" (p. 33) and she elaborates that "[a]ddiction is a multifaceted process emerging from both lower-scale and higher-scale interacting dynamic patterns, open ended and at most only relatively stable." This sound plausible enough and it may well be true about addiction, and all other kinds of phenomena in human life. How much does it then explain is left for the following chapters, i.e. the analyses of addiction on different "levels and their interactions".
In Chapter 3, the first level is introduced and it focuses on the individual. Shelby again sets off with the psychological disease model in order to eventually make sense of the relation between the physiological and psychological elements of addiction without reductionism or dualism. Shelby introduces different accounts of addiction that emphasize different aspects such as hedonism, incentive salience and habits. As a side point to this and some other parts of the book, the subchapters could be titled in a more signposting way that would help the reader to understand the overall structure as well as the subchapters' relations to each other (p. 37-45).
However, having presented criticism about the structure, Shelby helpfully contextualizes the view in a specific time and place in history and gives provides a contextual description of the methods employed in the research behind the view. This is important not only for her enterprise but also to the reader to understand the limitations of utilizing different kinds of research data. It also contributes how the false dichotomy, in Shelby's terms, between the disease view and the choice view has evolved. Representatives of the choice view e.g. picoenomics are briefly dealt with in the end of the chapter. Having discussed both views in more or less detail, she concludes the chapter by noting that both fall short of providing us an explanation why some people become addicted (more easily) and why (some) people struggle with transition out of addictive patterns.
The chapter The Ecology of Addiction takes a person-centered perspective to the ways in which how the environment affects the development of addiction. Shelby states that "[a]ddiction in this sense is a pattern embedded in a person's thinking and feeling that emerges from the rhythms of her biological organism interacting with those of her external environments, both physical and social" (p. 61). She explores the role of stress affecting human development and behavior. However, as stress is part of everyday life, she rejects it as a single identifiable factor as cause for addiction. Yet, on the basis of various empirical research, stress appears a powerful factor expose to vulnerability to addiction. She then introduces trauma studies focusing on childhood development and argues that people who have experienced traumatic experiences seem to correlate to a great extent with those people developing addiction in later life. The effects of stress are further argued to be supported with animal studies. The reader could hope a little more critical discussion on the relevance and importance of animal studies (in addiction research and more generally), especially when the nature of addiction is argued to be irreducible to biological functioning (in an environment). However, Shelby's discussion of the animal studies succeeds in showing that mere focus on drugs is insufficient so the rejection of the drug-centered view is justified. (p. 70) Rather, it is about the individual and the drug (in an environment).
Shelby brings up the discussion about human agency and the role of genetic influence by utilizing adoption and twin studies (p. 72). The overall motivation behind the chapter is to show that there is reason to "seek contributing causes and correlations to addiction from molecular level to the organismic level to interactive levels with parents and the society" as long as endeavor is not reduced to single causes. The analysis would benefit from a more detailed explication of our conception of human agency in general. This would help to understand the special nature of the addictive process in relation to human agency and action in general. This hope also reoccurs in the following chapters.
In chapter The Culture of Addiction, Shelby sketches the next level of analysis by historical features of economic and political forces that have influenced and shaped the access and consumption of different substances. The sketch is not meant to cover the global history of each individual substance, but rather to illustrate that different substances have different stories in different societies. The cultural variation of different substances brings out the tension between the objective and subjective categorization of addiction. What I mean by this is that Shelby raises the question of the extent of which the society wishes to categorize deviant substance-related behavior as addiction and to what extent addiction is something else, a subjectively felt phenomenon that cannot be understood merely by observing the agent's behavior from the outside.
She is also interested in exploring "to what extent is addiction brought about by social circumstances themselves" when addiction is a set of enlivened processes (p. 82). The story Shelby provides is dominantly American-based and I feel it maybe too broad and rough to be helpful for her analysis, occasionally conflating drug use, drug abuse, and agendas of different societal agents ranging from the state to economic and treatment-related stakeholders. Maybe a detailed case study of a specific substance, its culture within a culture involving policies for research, governance, and treatment would have been more convincing and provided grounds to understand the socially constructed phenomenon as an emergent process. Also a skeptical question arises whether there is such a process of addiction that emerges from shared characteristic process in different cultures at all. As far as I know, this topic has been raised in the philosophy of psychiatry, but Shelby does not contextualize her account to this philosophical discussion. Rather, she gives more of a sociological or similar field analysis of the topic. Had she discussed and criticized the existing philosophical views on addiction on this and all the levels, the reader would have been better equipped to consider her suggested perspective.
Shelby aptly illustrates that social inequalities and other societal factors seem to play an important role in explaining which conditions seem to contribute to the vulnerability of certain people to become addicted. She also does a good job in highlighting that drug-related problems do not always refer to illegal drugs but also to prescription drugs. However, it would also be good to point out that talking about drug overdoses does not have to be connected to addiction in any way. Nevertheless, the chapter nicely shows how different substances and behavior maintain different statuses (typically stigma).
The length of the review on this chapter is indicative of the amount of issues involved in the chapter and one could only hope that the discussion of these issues continues beyond this volume. Shelby's agenda is to wake the reader up to the relativity of the "set of phenomena that we call addiction" and in this way to further motivate her next move to introduce a specific account of meaning to her perspective. (p. 100)
The chapter Addiction and Meaning is motivated by describing the alleged discrepancy between addicted individuals and nonaddicted individuals. She argues that this should be understood as an issue concerning meaning: "The meaning of that substance or activity to her spouse, friends, children, or parents, although completely different from what it is for the addicted person, is a driving force in their lives"(p. 101). According to Shelby, this failure in communication is one of the important problems and she offers a theory of meaning to explain what is in fact going on. Another reason for bringing up the issue of meaning is to explain "concrete world shifts that can take place within addict's own experience" (p. 102). This is interesting and unique approach to understanding addiction, but of course it has its own limitations, which could have been dealt in more detail.
Furthermore, it is not entirely clear what exactly is the role of the theory of meaning here, since it seems to be very closely connected to understanding and explaining how people act. In any case, the relation between meanings and action is not really spelled out in detail. In the end of the chapter Shelby merely states that "addicts are people moved to action by the values inherent in the world constructed by them, in interaction with their environments, both local and global" (p. 121). Is she perhaps committed to strong motivational internalism? What kind of action guiding principles are in play in her account? To repeat an earlier point: it would have been nice to have a chapter on action and agency in this respect in the book to further clarify her position and help the reader to better see the how the pieces of the puzzle fit together.
The next chapter The Phenomenology ofAddiction turns to the experience of addicted individuals. Shelby heavily draws on autobiographical literature on addiction and recovery as well and by doing so succeeds in illustrating how all the mentioned theories, e.g. the dual systems understanding and other theories, fall short in taking the experience into account in a sufficient way. In the end of the chapter, Shelby summarizes her agenda again, and claims that since "there is no essence of addiction" (p. 141), we cannot even expect to find a single theory. I am sympathetic to her effort and agree that most theories only cover some aspects, but I wonder how many of those theorists would actually be ready to refute and dismiss the experiences of addicted individuals that do not fit their theories in absolute terms.
The chapter Possibilities for Change offers a discussion about treatment and recovery, touching upon an array of different approaches. With this chapter, Shelby highlights the fact that the field is huge and there are all kinds of approaches. At times, it seems that Shelby accepts the idea that abstinence or sobriety is necessary for getting rid of addiction, but at least in light of some empirical data, this is not the case. Therefore, it could have been beneficial for the project to address this question too and at least discuss the plausibility of the conception of abstinence as a necessary for recovery in more detail than a brief reflection on treating heroin-addicted individuals with methadone (p. 147).
As the title of the book suggests, it is a perspective, not an account by which we explain addiction (with linear causality) though it conforms to the certain principles of causality: "none of the higher levels can contradict lower levels" (p .172). Rather, the book provides a different kinds of lenses through which we can make sense of addiction in a more holistic manner and utilizes the notion of probability. As these issues have been underlying and surfaced throughout the book, they would have deserved a more detailed discussion in terms of the nature of theories and their function in science than the brief discussion in Conclusion.
All in all, the reader is expected to hold a quite extensive knowledge of different fields of philosophy, ranging from philosophy of science (p. 26) to meaning theory (p. 103). One is left wondering at whom is the book first and foremost targeted. The book provides a philosophical perspective, yet, some (or most) of current discussion about addiction in philosophy (of action, agency, moral psychology, applied ethics, philosophy of science…) is left without proper discussion and even reference. This is unfortunate, as it undermines the plausibility of the proposed new perspective: if it leaves out or poorly describes its opponents, how can it be then expected to convince readers who are familiar with the current literature about addiction in philosophy?
Finally I want to raise attention to the poor editing of the volume. There are problems with numbering the chapters: references in the main body of text seem to refer to wrong chapters. For instance in the very end of Chapter 3, Shelby writes "Adoption and twin studies – that we will discuss in Chapter 3 -- " (p.58). These discussions actually take place in Chapter 4. In the beginning these references were simply confusing, that is, before it was established that it is a consistent mistake. The references have not been checked; for instance there are several places in which there is a reference to Neil Levy's work, either his own work or a volume he has edited. Some of them involve recurrent typo "Levey" and in the index he has been categorized on the basis of his first name. Also a critical remark to the layout is in order. My initial browsing through the book finished with a finding of a surprisingly short reference list, especially when the back cover blurbs praise the nuanced understanding of recent research in science and medicine. Once the reading began this surprise ceased, as most of the references actually occur in the end notes. This, however, is hardly reader-friendly, as it requires the reader to go through the end notes when she wants to check whether the author has used some articles or another, for instance. These are in some sense minor flaws but give a sour flavor to the reading experience which itself is far from deprived of insightful and intriguing points and observations. The focus of this review may have been more on the shortcomings and challenges of Shelby's account, but it should be noted that the book does a great job in fleshing out the complexities and varieties of addiction as a set of phenomena as well as providing an overview of some of the current empirical research on the issue.