“It all comes down to your choices.”

Written by Geoff Kane, MD, MPH. Posted on
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“It all comes down to your choices.”

“It all comes down to your choices,” said a man in his fifties as he completed treatment following a brief return to drinking lots of alcohol.

In the company of supportive peers and an empathic treatment team, this man had immersed himself for three weeks in mindfulness practices structured by Acceptance and Commitment Therapy (ACT). He also maintained connections with his sponsor and Alcoholics Anonymous.

The man recounted how an offer of alcohol—made amid physical, interpersonal, and financial stressors—precipitated his most recent drinking episode. Similar situations had instigated previous binges.

In the future, he plans to minimize exposure to stressors and drinking opportunities. When stressors or alcohol are unavoidable, he anticipates choosing to notice them without reacting in ways that conflict with his values. “Personal responsibility” for “choices” protects his paramount value, sobriety.

Such clarity is too rare. Many others with addiction—and people around them—would do well to adopt this perspective. Choices represent the way out of active addiction, much as they represent the way in.

It’s confusing because conscious choices made by individuals in active addiction often don’t matter. Addiction is compulsive—people in addiction behave opposite to their own wishes. Science explains that addictive behavior is driven by the primitive region of the brain that does not reliably respond to intentions or to conscious decisions. Even though people in addiction may repeatedly declare they value self-preservation, family, and community, their behavior suggests they do not.

Addictive substance use—and the self-destructive and relationship-damaging consequences that typically accompany it—generates anger and frustration largely because people often assume that the substance use is a chosen behavior. For example, individuals with addiction berate themselves when they choose to stop using but don’t. And people around them berate them not only for not stopping but also because they frequently do not seem to take responsibility for the harm brought about by their apparent choices.

It’s helpful to understand that human behavior may be either chosen or determined (unaffected by choice). It can also be a blend of the two. Chosen behaviors are often guided by values and preferences (like selecting music). Determined behaviors are often driven by instinct (like gasping for air when you can no longer hold your breath) or unrecognized feelings (like intending to be funny, not recognizing anger, and coming out with sarcasm). As for a blend, how many of our good deeds are motivated by a conscious desire to serve and an unconscious desire for approval?

In addiction, the urge to obtain and consume more substance is strong and irrational, like the urge to survive or reproduce. A man in his twenties, addicted to opioids, said, “I use like my life depends on it!”

Timing, values, and accountability.

Choices to exit active addiction or not to enter addiction at all, are much more likely to matter if they are made before or after the person is consumed with seeking and using more substance. The man described above, who recognizes and accepts his personal responsibility to avoid drinking, reached his conclusions only after friends brought him to a hospital for alcohol detoxification and further treatment.

It can be difficult for young people who prefer not to overdose or become addicted to make choices that protect those values. They may, for example, be vulnerable to addiction due to genetics and adverse childhood experiences, obtain addictive substances easily, and hang out with peers who glorify substance use. An article in this series on the dangers of synthetic marijuana and salvia attracted young readers because the title— “How to Blow Your Mind” —appeared to offer new ways to get high.

Many individuals now in addiction recovery learned to take more responsibility for their choices when they “hit bottom” and realized it would be more painful to stay the same than to change. We make it less comfortable to stay the same when we respectfully hold those in addiction accountable for their behavior. They don’t have to enjoy the process—drug courts work even when people in them don’t want to be there.

A counselor reminds others of responsibility and consequences/accountability with this plaque: “Have a nice day, unless you’ve made other plans.”