International Journal of Law and Psychiatry, Vol. 13:95-101, 1990
Recently, the New York Times assessed the value of the Helmsley real estate empire at about $50-$60 billion. Why, then, did Leona steal a million dollars or so by casting personal expenditures as business expenses—a figure so piddling in light of their net worth that the Times predicted the family would “not have to liquidate even a small part of its holdings” in order to pay any fines arising from Leona’s conviction? The crime was clearly an act of irrationality on Leona’s part, like a millionaire shoplifting. It should be obvious to any trained clinician that Leona is suffering from addiction to greed, a compulsion to extract financial advantage in the most trivial ways, even when the potential gain has no possible impact on her well-being.
This would probably have been the most successful defense her lawyers could have presented in court. Indeed, Leona’s failure to claim she was addicted could be used as proof that she is addicted, since one of the primary traits of addictive diseases is “denial” that one has the disease of addiction. Denial might also have been the reason Joel Steinberg disregarded his attorney’s advice to claim that cocaine addiction caused him to kill his “adopted” daughter, Lisa. However, although the addiction defense was not formally presented to the jury, some jurors later said they did not vote for the more serious murder charge (Steinberg was convicted of manslaughter) because the killer had been using cocaine for so long they felt his judgment was impaired.
Some killers have subsequently rethought their failure to use addiction defenses, and have appealed their convictions on this basis. Jean Harris was one such person. Shana Alexander, in her book Very Much a Lady, presented the case that Ms. Harris was suffering from amphetamine withdrawal when she shot Dr. Herman Tarnower several times point blank. Alternately, of course, Harris could have claimed that she was driven to kill by the mental abuse Tarnower perpetrated—a variation on the battered-woman syndrome—or that she was distraught from his waning love for her, a case of withdrawal from love addiction. If these diseases caused Harris to kill Tarnower, the argument is, then her “denial” of these diseases would also prevent her from relying on the diseases as a defense strategy. (Jean Harris’s appeal in this case was unsuccessful.)
In these crimes, the evidence for addiction is the puzzling nature of the crime itself—why do well-to-do or educated people kill or steal without any possibility of gaining anything of real value for themselves? Think about petty shoplifting in a store like Bloomingdale’s. Like Leona Helmsley, most of those who shoplift in fashionable department stores do not materially alter their lives by their theft. Rather, they shoplift because they want something badly but may have forgotten their wallets, or their spouses have been checking their credit-card receipts to uncover unwise impulse purchases, or it just makes them feel good to get something for nothing. Really, the motivations to steal are not that different for the well-off financially and the poor. A robber or a drug dealer can often get a job and a decent lifestyle, only this would involve more work for less gain, and the thief prefers the thrills and rewards of the criminal lifestyle.
Why people make these choices may be interesting grist for criminological study. But it is irrelevant to law and punishment. As the proliferation of crime-causing diseases makes obvious, there are a host of motives that feed into people’s stealing, killing, drug-taking, etc. We have laws against these behaviors because they are wrong and because it is hard to manage a society when people (as more and more do) readily satisfy their personal urges at the expense of others. And trying to assess the combination of motives that drives people to commit crimes serves primarily to invite the more resourceful criminals to present the most saleable excuses for their misbehavior.
The starkest example of a crime that shocks and puzzles us so much as to stand as an excuse for itself is infanticide. The typical defense in such a case—one that has now been recognized in several trials—is “postpartum depression.” The essential logic of this defense is “What sane person would kill her own newborn child?” Relying on this defense in 1988, pediatric nurse Ann Green was acquitted in New York of all criminal charges for killing two of her newborn babies and trying to kill a third. Note that Green’s condition extended well after the births of her three children, since she then had to cover up the crimes, become pregnant, and kill (or try to kill) again. Apparently, though, those who accept or even promote the postpartum defense find it hard to comprehend such heinous crimes as crimes—to do so is simply too staggering. After a California court exonerated a 24-year-old woman who had argued that she was suffering from “baby blues” [or postpartum psychosis] when she ran her automobile over her infant son and then left the body in a trash can, her family stood and applauded the verdict in the courtroom.
Of course, allowing postpartum blues to excuse those who kill or maim their children seems to counteract the current campaign against family violence in America. That is, at the same time as we strive to uncover and reduce child abuse, we broaden the legal excuses for parents who abuse their children—in particular those who kill them. This is a considerable number of people—103 children died at the hands of their parents in New York City (two a week) in 1987; 126 (10 a month) were killed by their parents in 1988. While the Steinberg case attracted much attention because of the middle-class status of the parents, it was the exceptional case: how much have you heard about the other 102 children aside from Lisa Steinberg who died in New York at the hands of their parents or guardians in 1987, the large majority of whom were minorities and/or poor?
The History of the Idea of Addiction
America is clearly moving into the 21st century in addictionology—the identification and explication of new addictions, defined as diseases. These addictions include, in addition to the standard drugs and alcohol, shopping and debt, sex and love, gambling, smoking, overeating, and just about anything people can do to excess: there are now AA-type support groups organized around several hundred types of activities. The crucial first step of the 12-step program that AA and its derivatives have made famous is the obligation for the alcoholic or addict to admit he or she is “powerless over alcohol” or any other addictive habit. This is central to the disease and AA focus on loss of control as the definition, the etiology, and the excuse for addiction and addictive misbehavior.
Actually, it is not science that is fueling the movement to label so many activities as comprising addictions. The tendency to see addictions as all being of a single cloth returns us to nineteenth-century (and earlier) usage, where to “addict” meant to be given over to a vice or activity in some unwholesome and morally reprehensible or weak-willed way. The observation that alcoholism (called inebriation and drunkenness in the last century) and drug addiction are items in a much larger class of human behavior is a fundamental realization that has been accepted throughout most of human history, but which American addictionologists have only recently been rediscovering.
What has changed in the twentieth century is the claim that these compulsive activities somehow represent a codifiable disease-state. In the case of alcoholism, the inability to control one’s drinking is today proposed to be an inherited trait. This is wrong and, ironically, biologically-oriented research has proved it is wrong. Research has shown conclusively that loss-of-control is not an inheritable trait, as AA originally claimed. Rather, to the extent that genetic transmission of drinking patterns is indicated (and the scientific underpinnings for even this minimal proposition are far weaker than lay readers suspect), alcoholism is now seen as the cumulative result of a long history of drinking. Some genetic theorists claim people continue drinking heavily for long periods of time to resolve neuropsychological deficiencies or because alcoholics lack the inherited mechanism to determine when they have drunk enough. These theories nonetheless leave room for any number of environmental and personal factors to influence the alcoholism process.
Moreover, research into alcoholism has shown decisively that alcoholics, even while drinking, are crucially influenced by value choices and environmental considerations. That is, alcoholics who seem to be out of control on the street are actually pursuing deliberate drinking strategies designed to achieve specific levels of drunkenness. Street alcoholics allowed to earn credit for booze in a laboratory will work until they accumulate enough chits to attain an exact level of intoxication they seek. Or, allowed to drink freely in an isolation booth, they voluntarily cut down their drinking to spend more time in a comfortable, abstinent environment with other alcoholics watching television. Such alcoholics do get drunk a lot and they prefer drinking over most other options available to them in their natural environments. Nonetheless, alcoholic drinking represents largely purposive behavior, even if alcoholics’ purposes are quite alien to most people and even though alcoholics frequently regret their choices after they become sober—at least until they become drunk again.
Much of the work on alcoholics’ intentions while drinking has been conducted at the Baltimore City Hospital, part of the federally supported Addiction Research Center. Many of these same investigators are now giving their work with cocaine addicts a very different slant from the one they took with alcohol, however. This research group is often shown on television working with addicts attached to electrodes or giving responses recorded on a computer as they take or come down from their cocaine doses. A researcher then explains to the interviewer how cocaine provides a tremendous uplift, followed by an enervating down. Actually, this process is a standard one observed in human beings engaged in activities from eating carbohydrates to sexual intercourse (hence the readiness with which these activities are equated with drug addictions). Often, the researchers observe how the anticipation of the cocaine high or the need to reintroduce cocaine to alleviate the low will drive the addict to do anything. Sometimes reference is made to laboratory studies in which animals continue to inject cocaine through an implanted catheter until they kill themselves.
How addictive are cocaine and crack? Cocaine in any form is less addictive than cigarettes by the two key behavioral measures of addiction. Five times as many regular cigarette as crack smokers become addicted according to Jack Henningfield, a researcher at the National Institute on Drug Abuse (NIDA), and addicts indicate it is easier to give up crack than cigarettes. In fact, if we go by the survey the NIDA conducted of Americans’ drug use to which George Bush alluded in his nationally televised speech, very few cocaine users indeed become addicted. The survey found that 21 million Americans had used cocaine in their lives, 8 million had used it in the last year, 3 million were current users, but that only 300,000 used cocaine daily or nearly every day. Government statistics thus show that 10% of all current users and one percent of lifetime users use the drug close to daily.
What are we to make, then, of the addict who explains how he needed to steal or kill to get more of his drug, or the woman who sold sex—(one notorious addict prostituted her teen-age daughter)—to get money for crack? Aren’t these behaviors drug effects? No, they are not, and it is a mark of naiveté—not science—to mistake the behavior of some drug users with the pharmacological effects of the drug, as though addictive loss of control and crime were somehow chemical properties of a substance.
Notwithstanding all the pseudoscience created around it, addiction engages age-old questions like will-power, self-control, personal responsibility, and values. How are some people able to turn down a fattening dessert or an after-dinner cigar which they might enjoy consuming, but which they have decided is bad for them? Do those who instead indulge themselves have a disease? Or do they have less self-control or think it is less important to be healthy? In fact, science—like law—cannot accurately proceed without taking into account individual responsibility and values. For example, given that cigarettes are harder to quit than crack, what should we learn from William Bennett’s having given up smoking to take his post as drug czar in the Bush administration? The only possible answer is that he was wise enough to recognize that he couldn’t hold an anti-drug post and be a cigarette addict and that he wanted the drug post more than he wanted to continue smoking.
Of course, self control and sound values are not immutable, Platonic ideals either. After all, Bennett inappropriately maintained his cigarette addiction throughout his tenure as Secretary of Education. Smokers and fat people demonstrate similarly weak self-control for years, until they successfully stop smoking or lose weight, after which we all envy them for their superior will power. People do refocus their values as their lives progress and they have different opportunities and options and become better prepared or more willing to change long-term habits. This is the nature of the beast and nothing we learn about the chemistry of one drug versus another can change it. Try to say something sensible about nicotine’s addictive properties as a way of explaining Bennett’s newfound ability to abstain from smoking.
Why do we think crack/cocaine is so much more addictive than heroin, or alcohol, or cigarettes (all of which addicts with multiple addictions say are harder to quit than cocaine, whether smoked, injected, or snorted)? Remember, cocaine was an ingredient in Coca-Cola and other soft drinks into the twentieth century, and research on cocaine effects was conducted for fifty years before cocaine was announced to be addictive in the mid-1980s, coinciding with the explosion of recreational cocaine use in this country. Cocaine came to be addictive among some inner-city users and among a very small percentage of middle-class users who tried the drug.
Why didn’t most of these people become cocaine addicts? The answer is so simple as to defy us to wonder why scientists can’t figure it out—most people have better things to do than to become addicted to cocaine. This is an example where a scientific concept—addiction—develops a symbolic meaning which is contradicted by the data. Nothing about drug use or any other addiction rules out choices and individual values. Without taking these facts of life into account, we cannot understand who becomes addicted and who does not, and why. A study of middle-class users of cocaine by the Addiction Research Foundation of Toronto found not only that most regular users do not become addicted, but also that most of those who develop a steady craving for cocaine eventually cut back or quit the drug on their own. In other words, cocaine resembles just about every other compelling experience people have in being able to upset people’s equilibrium, but this is not a permanent or inexorable condition for most people.
Counterpoised with these data are the reports by the few who give up the ghost to their cocaine habits and enter private treatment centers, or by the addict criminals who testify on television that you would kill and prostitute your children—as they did—if only you took crack. These claims are preposterous, the scientists and clinicians who encourage them are misrepresenting the facts, and we have reached a strange impasse in our civilization when we rely for information and moral guidance about habits on the most debilitated segments of our population—groups who attribute to addiction and drugs what are actually their personal problems. What, really, are we to learn from people who stand up and testify that they couldn’t control their shopping sprees, that they spent all their money and went bankrupt to get material possessions we were smart enough to resist, and that they now want us to forgive them and their debts?
The message in all this is that one of the best antidotes to addiction is to teach children responsibility and respect for others and to insist on ethical standards for everyone—children, adults, addicts. Historical data indicate, for instance, that as soon as we define an experience as being out of control, then more and more people experience such loss of control and use it to justify their transgressions against society. The modern “scientific” view of alcoholism and addiction has actually caused addictive behaviors of all kinds to grow. It excuses uncontrolled behavior and predisposes people to interpret their lack of control as the expression of a disease which they can do nothing about. Treatment advocates attack those who don’t accept the disease viewpoint of addiction as being “unscientific” and “moralistic,” or as practicing “denial.” On the contrary, the refusal to accept the loss-of-control myth seems to inoculate people against addiction.
The Addiction Treatment Myth
One of the worst miscalculations of the idea that addiction and alcoholism are diseases is the notion that substance abuse can be treated away, a view continuously propagated by a large and growing addiction treatment establishment and bought by well-meaning public officials and private citizens. In fact, these treatments are exorbitantly expensive (it costs from $7,500 to $35,000 to put an addict or alcoholic in a private treatment center for a month) while being demonstrably ineffective.
One of the most remarkable works of addictionology of the 1980s was a tome by psychiatrist George Vaillant entitled The Natural History of Alcoholism. Vaillant defended throughout his book the medical model of alcoholism, but then revealed that the alcoholics he treated at Cambridge Hospital in Massachusetts with detoxification, compulsory AA attendance, and counseling fared no better than comparably severe alcoholics who went completely without treatment. Several times in this strange book, Vaillant warns professional readers not to interfere with “the natural healing process”—this, in a work by a psychiatrist who insists that we need to get more alcoholics into treatment.
What works in fact for alcoholism and addiction is giving people the options and values that rule out addictive drug use. Investing more in futile but expensive treatment programs simply subtracts from the resources that are available to influence people’s actual environments in ways that can reduce their vulnerability to addiction. Dr. Herbert Kleber, Bennett’s deputy in charge of “demand reduction,” has indicated that addicts can only be treated by being “given a place in the family and social structures” that they may never have had before. In other words, as Dr. Kleber puts it, they require “habilitation more than rehabilitation.” The head of the government’s National Institute on Drug Abuse (NIDA), Charles Schuster, indicates that in treating drug addicts: “The best predictor of success is whether the addict has a job.” Of course, the best predictor of not becoming an addict in the first place is to have in place social structures, jobs, and values that militate against habitual intoxication. But these are hardly treatment issues, and to approach them as such is to attack the problem in a belated, piecemeal, and ultimately self-defeating, way.
Thus, to the extent that Bennett’s and Bush’s “war on drugs” focuses on external agents and supplies, it not only misses the point of addiction, it actually deprives domestic programs of the resources they need to have any impact on the conditions in inner cities that fertilize drug abuse. As for Bennett’s resolve to stamp out casual drug use as a part of his attack on addiction, there really is no relation between the two. As Bush himself indicated in his nationally televised speech in September, the NIDA found that 23 million Americans had used an illicit drug during the previous month when questioned in 1985, a number that declined to 14.5 million in 1988. Yet during this same period, daily drug use—and especially cocaine addiction—climbed.
Clearly, although we convinced those with the most personal resources and responsibility to stop experimenting with drugs, those who are unable or unwilling to control their drug involvements grew more numerous and found themselves in a deeper hole. At the same time, as we have seen, the NIDA survey to which Bush alluded found that miniscule numbers of those who have experimented with cocaine become addicts. Here we see how the administration’s own statistics disprove the link between recreational drug use and addiction Bennett seeks to claim. In the area of addiction, what is purveyed as fact is usually wrong and simply repackages popular myths as if they were the latest scientific deductions. To be ignorant of the received opinion about addiction is to have the best chance to say something sensible and to have an impact on the problem.