How Do Addicts Make Decisions?

Learning about the economics of decision-making could mean the difference between relapse and long-term sobriety.

How do people with addiction make decisions? Research shows that addiction changes how the brain weighs rewards. A small, quick reward (using now) starts to outweigh a much bigger, later one (health, family, a sober future), and the brain’s “brake” system has a harder time holding back the “accelerator”^1,7.

Most, if not all, people with alcohol or drug addiction struggle with quitting and staying sober, and many have an equally hard time understanding why. This article explains the science of decision-making in addiction: temporal discounting, the “two minds” of the brain, and the treatments that help people rebuild judgment. Knowing how setting goals and valuing rewards goes wrong can make life in recovery easier.

What is temporal discounting?

The idea behind temporal discounting is not new. It can be traced back to the earliest philosophers. In temporal discounting (also called delay discounting), people put less value on rewards that are further away in time.

“A bird in the hand is worth two in the bush,” as the saying goes. The distant, seemingly uncertain reward, even when it’s bigger, feels less valuable than the immediate, certain one.

Why temporal discounting matters in addiction

Many studies have shown that people with addiction discount future rewards more steeply than people without it¹. One meta-analysis found the effect was large in people dependent on stimulants and moderate in people dependent on opioids or alcohol¹.

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. He wrote an article with Dr. George Ainslie on the behavioral economics of will in recovery².

Hyperbolic discounting: why choices flip in the moment

Temporal discounting means giving greater value to rewards that are closer in time, even when they are smaller. But something else happens too. Animals, including humans, are not always rational when making decisions.

Dr. Ainslie was the first to show that preferences don’t follow a curve that would produce consistent choices over time³. Both humans and animals follow a hyperbolic curve. In hyperbolic discounting, a reward loses value fastest as it gets close². In other words, people are not consistent in the value they place on near and distant rewards.

For example:

• Offered $50 now or $100 a year from now, many people choose the $50.
• Offered $50 in five years or $100 in six years, many choose the $100.

It’s the same one-year difference, but the choice flips when the smaller reward is close.

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 feels weaker the further away a choice is.

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Why some people struggle more to wait

Why are people with addiction more likely to be unable to wait for a delayed reward? Some may be predisposed: genetics may make them more impulsive or more anxious. Studies also show that addiction itself can cause changes in these areas¹.

“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,” says Dr. Ibrahim Senay, an assistant professor of psychology at Istanbul Sehir University.

Dr. Senay co-authored a paper showing that people were more likely to work toward their goals if they asked themselves, “Will I?” instead of telling themselves, “I will”⁴.

Impulsivity, conscientiousness and neuroticism

Dr. Senay believes impulsivity is a personality trait that comes into play in decision-making. Impulsivity increases with addiction, and this affects 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 trait that may work against delayed gratification is neuroticism, which he describes as 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.”

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Of two minds: emotion vs. the reflective brain

Temporal discounting can be viewed as a battle between the present self and the future self, or, in plain terms, the good angel and the bad angel. Decades of research by USC’s Dr. Antoine Bechara suggest there may be more to the “two brains” theory than meets the eye.

Dr. Bechara created the Iowa gambling task while a professor at the University of Iowa. His work showed that emotions are deeply involved in decision-making, working alongside, and sometimes against, the frontal cortex, our more reflective brain.

What brain damage studies showed

In work dating back to the 1990s, Dr. Bechara and Dr. Antonio Damasio, another leading neuroscientist now also at USC, showed that damage to either the frontal cortex or the amygdala impairs decision-making^5,6. People with frontal damage became insensitive to future consequences.

The prefrontal cortex is the part of the brain that powers planning, problem-solving, decision-making and self-control over impulses. Drug use can shift the balance away from it, so a person seeks drugs compulsively with less impulse control⁹.

The accelerator and the brake

In a 2005 paper in Nature Neuroscience, Dr. Bechara proposed that the amygdala, an emotional center of the brain, can override the frontal cortex in decision-making⁷. The result is a loss of willpower, 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.”

Stress, fatigue and self-control

When it comes to balancing emotional and reflective behavior, self-control might boil down to simple fatigue. In the 1990s, Roy Baumeister at Florida State University studied self-control and argued that mental challenges drain the energy needed to rein in habitual but unhealthy behaviors. So any task requiring focus or concentration may weaken self-control for a while.

“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.

The stress side of the brain matters too. NIDA explains that the extended amygdala, which drives anxiety and irritability during withdrawal, becomes more sensitive with repeated drug use. Over time, people may use to get relief from that discomfort rather than to get high⁹.

How treatment helps rebuild decision-making

Ironically, the areas most damaged in addiction, the frontal cortex or executive decision-making area, are the ones most needed to quit using or drinking. How, then, do people begin to recover?

Choice bundling: seeing each decision as part of a pattern

Dr. Monterosso believes that intertemporal bargaining, which involves bundling rewards, offers the “best framework for scientific progress in the understanding of recovery from addiction”².

Intertemporal bargaining is something we all do. If a person believes the choice at hand (whether to smoke one cigarette) affects every future choice about smoking, they 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 not smoking one cigarette means you won’t smoke a hundred or a thousand more, then your bundled reward is not smoking a hundred or a thousand cigarettes, not just one. Monterosso and Ainslie note that 12-step ideas such as “one day at a time” and total abstinence strengthen this link between today’s choice and tomorrow’s².

Reconnecting with something bigger

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.”

Motivation and the “Will I?” mindset

Motivation matters too, and Dr. Senay’s study touched on this. “In our paper, we found that the interrogative mindset makes intrinsically motivating reasons more available for engaging in a target behavior,” he says.

The “Will I?” works better than the “I will” because there are no self-imposed constraints⁴. But 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 possible to motivate addicted individuals. For example, a therapy technique called motivational interviewing, which encourages question-asking, is successfully used in treating alcohol addictions.”

Motivational enhancement therapy (MET)

Motivational enhancement therapy, or MET, is a counseling approach that helps people resolve their mixed feelings about treatment and about stopping drug use. NIDA reports it has been used successfully with alcohol use, and with marijuana use when combined with cognitive behavioral therapy. Results are mixed for other drugs, and it seems most helpful for getting people engaged in treatment⁸.

In MET, the therapist⁸:

1. Starts with an assessment, then gives feedback on the results
2. Draws out the person’s own reasons for change, using motivational interviewing
3. Helps build a plan for change, including coping strategies for high-risk situations
4. Checks progress in later sessions and keeps encouraging commitment

Unlike approaches that guide a person step by step, MET aims for change that comes from inside. A plan will usually include cutting back or stopping if using gets in the way of new life goals.

Recovery is a skill you can build

Decision-making in addiction isn’t a character flaw. It reflects changes in how the brain weighs now versus later. The good news is that people can strengthen the reflective side through practice: making rules ahead of time, treating each choice as part of a pattern, lowering stress, and working with a therapist on motivation and relapse prevention.

Original Article from TheFix.com

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