Addiction, self-control and the self: an empirical, ethical study

Addiction is often equated with loss of self-control. Determining what constitutes loss of self-control, however, is complicated. On one hand, substance dependent people often describe their use as involuntary and life-ruining. On the other, substance use requires planning and intentional actions. I will argue that loss of self-control in addiction is poorly understood because current theories do not make explicit which level of self-control they are describing. In this thesis I argue that developing a hierarchical account of self-control is critical when analysing loss of self-control in addiction. I distinguish three hierarchical levels of self-control: 1) intentional self-control, or doing what one intended 2) instrumental self-control, or reaching ones goals, and 3) normative self-control, or living the life one values living. Loss of self-control in addiction is not underpinned by failure on just one level, but rather by a set of interacting factors. Still, to judge whether someone has lost self-control or not, knowledge of the normative level is essential – are people able to live the life they value living and be the person they value being? This normative perspective is poorly examined in the current literature. To gain insight into the circumstances in which normative agency is developed or impaired, I designed a longitudinal, qualitative study involving opioid and alcohol dependent people. I followed 69 participants over a period of 3.5 years, asking them what hampered their self-control and the goals they set for themselves. I conclude that loss of self-control in addiction is often a loss of self. People must see their actions as making sense within their concept of self and their life stories. My first finding is that addiction impacts heavily on people’s bodies – their appearances and how others reacted to them, their energy levels, potential life threatening illnesses, and the risk of overdosing when relapsing. Many participants lost trust that their bodies would carry them into the future. They stopped setting goals for themselves. They lost belief in self-efficacy. I also find that people’s agency is threatened when they lose hope, resulting in a resignation from their normative goals. People struggling with substance dependency are disproportionally vulnerable to adverse circumstances which often cause them to abandon plans. The link between resignation and loss of self-control is frequently misunderstood in the current literature. It is often viewed as a choice-based, justified change of normative outlook, rather than a forced abandonment of the outlook. Resigned, addicted people are perceived as ‘willing addicts’. Finally, regaining belief in self-efficacy is a key aspect of recovery. One respondent said, for instance, that he had many capacities for self-control, but only started using them when he began to believe he could attain the future he valued. My findings highlight the importance of evaluating loss of control within someone’s existential situation and normative framework. The findings have implications for treatment. The model of hierarchical levels of self-control I described can be used by practitioners to assess on which levels the self-control of their clients is impaired. I argue practitioners should evaluate whether current dominant treatments are sufficient for boosting their client’s normative agency. They should help clients reconnect with their image of their ideal future self. They can do so by showing trust in clients’ agency and self-efficacy by assuring them that it is possible to live the life they value living, and to be the person they value being.