How Do Addicts Make Decisions?
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How Do Addicts Make Decisions?
Most, if not all, addicts and alcoholics struggle with quitting and staying sober. And many have an equally hard time understanding why. What if would-be recovering addicts and alcoholics knew more about what goes into the making decisions—and how setting and achieving goals, and putting value on rewards, goes wrong in addiction? Learning about the economics of decision-making will not only make life in recovery easier, but it could mean the difference between relapse and long-term sobriety.
The concept of temporal discounting is not new. In fact, it can be traced back to the earliest philosophers. In temporal discounting, people put less value on more distant rewards. “A bird in hand is better than two in the bush,” as the saying goes—the distant, seemingly-uncertain reward, even while greater, appears less valuable than the more immediate, certain one.
Many studies have shown that addicted people show higher temporal discount rates. And that’s at the crux of a substance use disorder. If all the reward from using heroin, let’s say, came 20 years down the road, and the problems with relationships, or the law, came immediately, addiction wouldn’t exist in the same form as it does now. “The immediacy [of the reward] is integral to the problem of addiction,” says Dr. John Monterosso, a professor at the University of Southern California and author of an intriguing article with Dr. George Ainslie on the behavioral economics of will in recovery.
While temporal discounting is a tendency to give greater value to rewards that are closer in time to the present—despite being of an actual lesser or equal value—there’s something else that happens. Animals, including humans, are not necessarily rational when it comes to decision-making. Dr. Ainslie was the first to show that preferences do not follow a curve that would produce consistent choices over time—both humans and animals alike follow a hyperbolic curve. In hyperbolic discounting, the value of a reward is not necessarily a function of time. In other words, people are not consistent in the value they place on near and distant rewards. For example, if given the choice between $50 now or $100 a year from now, many people would choose the $50. However, if offered $50 in five years or $100 in six years, many would choose the $100—even though it’s the same time difference of one year.
Likewise, most people would be OK with staying sober for 91 days instead of 90, but not for eight instead of seven. Generally speaking, impatience subjectively decreases with increases in time.
Why are addicts more apt to be unable to wait for the delayed reward? They could be predisposed to do so—genetics have made them more impulsive, or more neurotic. Studies have shown that addiction itself can cause changes in these areas. “Delayed gratification may have some genetic component, but it has been shown that responsive parents who are sensitive to their children’s needs foster better skills in their children for waiting longer to get rewards,” Dr. Ibrahim Senay, an assistant professor of psychology at Istanbul Sehir University, says. Dr. Senay co-authored a paper several years ago showing that people were more apt to succeed in achieving their goals if they asked themselves, “Will I?” instead of telling themselves, “I will.”
He believes impulsivity is a personality trait that comes into play in decision-making. Impulsivity increases with addiction, and this will affect temporal discount rates. “The personality trait that may be negatively associated with impulsivity is very much likely to be conscientiousness, the ability to plan ahead in working toward goals,” he says. Another personality characteristic that may be negatively associated with delayed gratification is neuroticism, which, he says, is characterized by moodiness, anxiety, and guilt. “There is evidence, I think, showing that neurotic people are more likely to have psychopathic tendencies and show self-centering thinking,” he says. “In other words, they are less likely to have future goals and cannot tolerate waiting.”
Of two minds
Temporal discounting can be viewed as a battle between the present self and the future self, or, in layman’s terms, the good angel and the bad angel. However, decades of research by USC’s Dr. Antoine Bechara has shown that there might be more than meets the eye to the “two brains” theory. Dr. Bechara, who created the Iowa gambling task while a professor at the University of Iowa, has led groundbreaking work discovering that our emotions are involved in decision-making—in opposition to our frontal cortex, or more reflexive brain.
In earlier work dating back to the 1990s, Dr. Bechara, alongside Dr. Antonio Damasio another leading neuroscientist and now also at USC, showed that damage to either the frontal cortex or the amygdala impairs decision-making (8,9). In a paper published in Nature Neuroscience in 2005, Dr. Bechara found that the amygdala, the emotional center of the brain, could override the frontal cortex in decision-making. This resulted in loss of willpower, or the ability to set and work toward long-term goals. “Addicted people become unable to make drug-use choices on the basis of long-term outcome, and I [proposed] a neural framework that explains this myopia for future consequences,” he says of that work. “The newer conceptualization of addiction that was proposed in that paper is that addiction resembles an imbalance between the 'accelerator' in the car—this would be the impulsive system—and the brake system of the car—the reflective system: The tendency for the car to keep speeding and you cannot stop it comes from an excessive push on the accelerator, a malfunctioning brake system to stop the car, or a combination of both.”
When it comes to integrating emotional and reflexive behavior, self-control might boil down to simple fatigue. In the 1990s, Roy Baumeister at Florida State University did research on self-control, showing that mental challenges deplete the energy required to rein in our habitual but not necessarily healthy behaviors. So, any task or activity requiring focus or concentration will weaken an individual’s self-control. “People are generally able to work toward long-term goals—losing weight, quitting smoking, finding a new job—so long as they are not mentally or emotionally taxed, in which case cravings, and the old habits that go with them, grab the wheel,” write psychologists Dr. Wilhelm Hofmann and Dr. Malte Friese in the May/June 2011 issue of Scientific American Mind.
Ironically, the areas that are most damaged in addiction—the frontal cortex, or the executive decision-making area—are the most needed to quit using or drinking. How, then, do addicts begin to recover?
Dr. Monterosso believes that intertemporal bargaining—which involves bundling rewards—offers the “best framework for scientific progress in the understanding of recovery from addiction,” he writes. Intertemporal bargaining is something we all do, and it’s something that addicts and alcoholics will naturally hit on, if they’re thinking at all about how to quit. If they believe the choice at hand—whether to smoke one cigarette—has already affected every other single future choice of whether to smoke, smokers are more likely to say no. “Once you’ve [vowed to quit smoking], that means that you’re in a position where individual decisions from that point forth have some connection to this big plan you have…so it’s a natural byproduct of caring about the future and seeing behavior in categories,” Dr. Monterosso says. If your choice to not smoke that one cigarette means that you won’t smoke a hundred or a thousand more; then your bundled reward—coming to your future self—will be not smoking a hundred or a thousand cigarettes, instead of not smoking just one.
Dr. Monterosso sees putting value back onto bigger rewards as key to recovery. “For somebody who’s spiraled into an addiction, there is a loss of all these connections to larger, bigger things,” he says. “A big piece of that [is] reconnecting with things larger than the drug, than yourself—bigger, more enduring things—and you can think about that as related to the issue of bundling, of temporal discounting.”
It involves motivation, too, and Dr. Senay hit on this in his study. “In our paper, we found that the interrogative mindset makes intrinsically motivating reasons more available for engaging in a target behavior,” he says. Therefore, the “Will I?” works better than the “I will,” because there are no self-imposed constraints. However, in addiction, brain systems are damaged, especially the reward centers. “Even when the interrogative mindset makes autonomous reasons more available, the patient might not find the feeling of autonomy as pleasurable as the addicted substance,” he says. “With more practice with using the interrogative form, however, it is be possible to motivate addicted individuals. For example, a therapy technique called motivational interviewing, which encourages question-asking, is successfully used in treating alcohol addictions.”
Indeed, motivational enhancement therapy, or MET, has taken off for treating addiction—especially to alcohol, marijuana, and nicotine. In MET, the therapist works with the addicted patient to cultivate an inner willingness, or motivation, to stop using. It is unlike other therapies, which address external factors in getting the patient to change. MET focuses on discussion, motivational interviewing, and creating a plan for change—which will necessarily include cutting back or abstinence if using is getting in the way of these new life goals.