Sunday, September 23, 2018

Monterosso and Ainslie (2007) on Recovery from Addiction

John Monterosso and George Ainslie, “The Behavioral Economics of Will in Recovery from Addiction.” Drug and Alcohol Dependence 90(Supplement 1): S100-S111, September 2007.

• Addicts have severe self-control issues with respect to the object of their ardor.

• The goal of this article is to suggest that behavioral economics ideas are fruitful not only in thinking about the process of building an addiction, but also in understanding recoveries from addiction.

• Dynamic inconsistency seems to be tied up in addiction: addicts often express (quite credibly) desires to quit or cut down, but do not follow through on those desires.

• But dynamic inconsistency might also suggest pathways out of addiction – and many treatment programs look to develop these pathways, which involve internal, not external, commitment devices (“private side-betting”).

• Drug use would not be a problem if the pain arose immediately, and the gratification arrived after a delay.

• “Hyperbolic discounting implies that the increase in valuation that occurs when moving a fixed unit of time closer to an expected outcome is proportionately greater the closer one is to that outcome. Think of the experience of waiting for an additional day for an important event that is a year off, versus for one that is imminent [p. 3].”

• Hyperbolic discounting sets one up for dynamic inconsistency of the immediate gratification variety; further, addicts tend to display higher discount rates than non-addicted people (though causality might go both ways). How is it that people with this sort of discounting ever recover, and become dynamically consistent with respect to their intentions to indulge in drugs, say?

• A hyperbolic discounter has a multitude of different (time-based) “interests” – it is Jekyll and Hyde and the rest of the London population, too.

• How does one “interest” protect itself against foreseeable future “interests”? One approach is to make the tempting act unavailable, or raise its cost – perhaps by announcing to your social circle that you are on a diet, for instance, or are having a Dryuary. Or maybe you can deflect your attention (subconsciously) from activities that lead to your problem activity, or develop a repugnance towards them.

• These approaches are not really about willpower; rather, they signal a sophisticated understanding of your own future lack of willpower. And yet many treatment programs harp on building willpower.

• Another method to bolster willpower is a form of mental accounting: you bundle current choices with a string of future choices. In this way, a choice to drink today isn’t just about drinking or not drinking today: a choice to drink means that you will make a similar choice in future days – and that prospect might be sufficiently harrowing to keep you from drinking today.

• Experiments show that humans and non-human animals do choose less impulsively when they know that the current choice will bind similar choices down the road.

• What if you knew that having a drink today would have no effect on your future behavior, that you were pre-determined to drink every future day? What if you were told that you were pre-determined to never drink again, whether or not you drink today? It looks like current abstention is bolstered by the notion that it can influence future choices! But people do abstain, so they must see a link between today’s choice and future choices.

• Bundling can arise when someone sees that “I’ll smoke today and quit tomorrow” will also apply tomorrow, ad infinitum. Then, the actual choices today are “I’ll smoke today and forever” or “I’ll stop today and not relapse.” The personal “rule” becomes “never smoke.”

• The situation is like an intrapersonal repeated prisoners’ dilemma: the only reason you choose to “cooperate” today is if you can thereby make it more likely that your future selves also will choose to cooperate.

• But recall: in iterated prisoners’ dilemmas, it is hard to restore cooperation after a single defection. Likewise, a single lapse from abstinence by a recovering addict can lead to a binge. This sort of behavior looks like it is better described by the “bundling” model or willpower, not a story of binding commitments.

• Why would an addict fall off the wagon?: “[T]o the extent that her abstinence is based on a bundling effect, the primary danger comes from factors that reduce her differential expectation of future abstinence as a function of current abstinence [p. 9].”

• This reduction of perceived danger can derive from overconfidence, underconfidence, or rationalization.

• Twelve-step programs emphasize that willpower is unreliable, yet their adherents seem to do better (than those in other treatment forms) in overcoming cravings.

• Twelve-step treatments seem to respond to the threats created by overconfidence, underconfidence, and rationalization. How? (1) powerlessness and its related credos; (2) the focus on abstinence and the permanence of addiction; and (3) the adoption of doable goals, such as “one day at a time,” while tracking the abstinence streak.

• “When a person structures her choices with personal rules she can be expected to express different preferences than she would if she were making a choice just on the basis of its own merits, and these preferences are apt to differ as well among categories of reward, according to their temporal distribution, emotional relevance, dangerousness, impulse control history, and doubtless many other factors [p. 12].” 

• There is a possibility for a deleterious positive feedback loop, where proximity to the temptation good (or a cue) increases the probability of consumption which increases appetite which leads to increased probability of consumption…