Social odor choice buffers drug craving.

Social interactions are rewarding and protective against substance use disorders, but it is unclear which specific aspect of the complex sensory social experience drives these effects. Here, we investigated the role of olfactory sensory experience on social interaction, social preference over cocaine, and cocaine craving in rats. First, we conducted bulbectomy on both male and female rats to evaluate the necessity of olfactory system experience on the acquisition and maintenance of volitional social interaction. Next, we assessed the effect of bulbectomy on rats given a choice between social interaction and cocaine. Finally, we evaluated the influence of olfactory sensory experience by training rats on volitional partner-associated odors, assessing their preference for partner odors over cocaine to achieve voluntary abstinence and assessing its effect on the incubation of cocaine craving. Bulbectomy impaired operant social interaction without affecting food and cocaine self-administration. Rats with intact olfactory systems preferred social interaction over cocaine, while rats with impaired olfactory sense showed a preference for cocaine. Providing access to a partner odor in a choice procedure led to cocaine abstinence, preventing incubation of cocaine craving, in contrast to forced abstinence or non-contingent exposure to cocaine and partner odors. Our data suggests the olfactory sensory experience is necessary and sufficient for volitional social reward. Furthermore, the active preference for partner odors over cocaine buffers drug craving. Based on these findings, translational research should explore the use of social sensory-based treatments utilizing odor-focused foundations for individuals with substance use disorders.

Is addiction a brain disease? A plea for agnosticism and heterogeneity.

RATIONALE: Although increasingly subject to criticism, the brain disease model of addiction (BDMA) remains dominant within addiction science. Yet few advocates or critics of the BDMA have provided an account of what a brain disease is. The aim of this review is to conceptually clarify what it would mean for the BDMA to be true, rather than to argue decisively for or against it. OBJECTIVES: Conceptual clarification of the BDMA requires consideration of possible models of disease and their relationship to the BDMA. A barrier to such consideration is belief that the BDMA is necessary to combatting addiction stigma. To address this barrier, I begin with discussion of what we know about the effects of the brain disease label on addiction stigma, and why labelling effects should have no bearing on the validity of the BDMA. I then distinguish strong, minimal, network, and mismatch models of disease, and I argue that the BDMA aligns with a strong disease model. This means that underlying brain pathology is hypothesized to be the cause of the personal-level observable signs and experienced symptoms characteristic of addiction. Evaluation of the BDMA therefore requires analysis of the concepts of brain dysfunction and causation, and their application to addiction science. RESULTS: Brain dysfunction cannot be analyzed merely as brain changes or brain differences; nor can it be inferred merely from the presence of personal-level signs and symptoms. It is necessary to have an account of normal brain function by which to measure it. The theoretical and empirical challenges to developing such an account are not insurmountable, but they are substantial. Although there exist competing analyses of causation, there is a relatively standard method used to establish it within experimental science: intervention. Using this method, the causal significance of brain states, such as, e.g., extensive gray matter loss and/or neuroadapations in the mesocorticolimbic dopamine system, is not yet fully demonstrated. Further studies are necessary to determine their effect compared with other possible variables, such as, e.g., alternative reinforcers. CONCLUSIONS: Conceptual clarification and preliminary empirical assessment of the BDMA recommends agnosticism about its validity and an openness to heterogeneity; in some cases addiction may be a brain disease, in others not. Either way, addiction stigma can be combatted by fighting moralism about drugs and moralistic drug policies directly, as opposed to resting hopes on the brain disease label.

"Chasing the first high": memory sampling in drug choice.

Although vivid memories of drug experiences are prevalent within clinical contexts and addiction folklore ("chasing the first high"), little is known about the relevance of cognitive processes governing memory retrieval to substance use disorder. Drawing on recent work that identifies episodic memory's influence on decisions for reward, we propose a framework in which drug choices are biased by selective sampling of individual memories during two phases of addiction: (i) downward spiral into persistent use and (ii) relapse. Consideration of how memory retrieval influences the addiction process suggests novel treatment strategies. Rather than try to break learned associations between drug cues and drug rewards, treatment should aim to strengthen existing and/or create new associations between drug cues and drug-inconsistent rewards.

What We're Not Talking about When We Talk about Addiction.

The landscape of addiction is dominated by two rival models: a moral model and a model that characterizes addiction as a neurobiological disease of compulsion. Against both, I offer a scientifically and clinically informed alternative. Addiction is a highly heterogenous condition that is ill-characterized as involving compulsive use. On the whole, drug consumption in addiction remains goal directed: people take drugs because drugs have tremendous value. This view has potential implications for the claim that addiction is, in all cases, a brain disease. But more importantly, it has implications for clinical and policy interventions. To help someone overcome addiction, you need to understand and address why they persist in using drugs despite negative consequences. If they are not compelled, then the explanation must advert to the value of drugs for them as an individual. What blocks us from acknowledging this reality is not science but fear: that it will ignite moralism about drugs and condemnation of drug users. The solution is not to cleave to the concept of compulsion but to fight moralism directly.

Responsibility without Blame for Addiction.

Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good.

Choice, deliberation, violence: Mental capacity and criminal responsibility in personality disorder.

Personality disorder is associated with self-harm and suicide, as well as criminal offending and violence towards others. These behaviours overlap when the means chosen to self-harm or attempt suicide put others at risk. In such circumstances, an individual's mental state at one and the same time may be deemed to meet the conditions for criminal responsibility, and to warrant involuntary hospital admission. I explore this tension in how people with personality disorder are treated at the hands of the criminal and civil law respectively in England and Wales: they may be deemed sufficiently mentally well to be punished for their crimes, but not deemed sufficiently mentally well to retain the right to make their own decisions about matters of serious importance to their own lives, including whether or not to continue them. The article divides into four sections. After introducing this tension, Section 2 sketches the nature of personality disorder and the psychology underlying self-directed and other-directed violence. Section 3 addresses the questions of whether people with personality disorder who are violent, whether towards self or others, typically meet the conditions for criminal responsibility and mental capacity respectively, considering in particular whether their underlying desires and values, or their emotional distress, affect their mental capacity to make treatment decisions. Section 4 then considers what we might do to address the tension, within the confines of current legislation. Drawing on The Review of the Mental Health Act 1983, I argue that we are ethically justified in involuntarily admitting to hospital people with personality disorder who pose a serious risk to themselves only if we simultaneously undertake to offer genuine help for their future, in the form of appropriate treatment, social support, and better life opportunities - a provision which, as things stand in England and Wales, is sorely lacking.

Psychopathology and the Ability to Do Otherwise.

When philosophers want an example of a person who lacks the ability to do otherwise, they turn to psychopathology. Addicts, agoraphobics, kleptomaniacs, neurotics, obsessives, and even psychopathic serial murderers, are all purportedly subject to irresistible desires that compel the person to act: no alternative possibility is supposed to exist. I argue that this conception of psychopathology is false and offer an empirically and clinically informed understanding of disorders of agency which preserves the ability to do otherwise. First, I appeal to standard clinical treatment for disorders of agency and argue that it undermines this conception of psychopathology. Second, I offer a detailed discussion of addiction, where our knowledge of the neurobiological mechanisms underpinning the disorder is relatively advanced. I argue that neurobiology notwithstanding, addiction is not a form of compulsion and I explain how addiction can impair behavioural control without extinguishing it. Third, I step back from addiction, and briefly sketch what the philosophical landscape more generally looks like without psychopathological compulsion: we lose our standard purported real-world example of psychologically determined action. I conclude by reflecting on the centrality of choice and free will to our concept of action, and their potency within clinical treatment for disorders of agency.

The Chimera of Proportionality: Institutionalising Limits on Punishment in Contemporary Social and Political Systems.

The concept of proportionality has been central to the retributive revival in penal theory, and underlies desert theory's normative and practical commitment to limiting punishment. Theories of punishment combining desert-based and consequentialist considerations also appeal to proportionality as a limiting condition. In this paper we argue that these claims are founded on an exaggerated idea of what proportionality can offer, and in particular fail properly to consider the institutional conditions needed to foster robust limits on the state's power to punish. The idea that appeals to proportionality as an abstract ideal can help to limit punishment is, we argue, a chimera: what has been thought of as proportionality is not a naturally existing relationship, but a product of political and social construction, cultural meaning-making, and institution-building. Drawing on evolutionary psychology and comparative political economy, we argue that philosophers and social scientists need to work together to understand how the appeal of the idea of proportionality can best be realised through substantive institutional frameworks under particular conditions.

To Blame or to Forgive? Reconciling Punishment and Forgiveness in Criminal Justice.

What do you do when faced with wrongdoing-do you blame or do you forgive? Especially when confronted with offences that lie on the more severe end of the spectrum and cause terrible psychological or physical trauma or death, nothing can feel more natural than blame. Indeed, in the UK and the USA, increasingly vehement and righteous public expressions of blame and calls for vengeance have become commonplace; correspondingly, contemporary penal philosophy has witnessed a resurgence of the retributive tradition, in the modern form usually known as the 'justice' model. On the other hand, people can and routinely do forgive others, even in cases of severe crime. Evolutionary psychologists argue that both vengeance and forgiveness are universal human adaptations that have evolved as alternative responses to exploitation, and, crucially, strategies for reducing risk of re-offending. We are naturally endowed with both capacities: to blame and retaliate, or to forgive and seek to repair relations. Which should we choose? Drawing on evolutionary psychology, we offer an account of forgiveness and argue that the choice to blame, and not to forgive, is inconsistent with the political values of a broadly liberal society and can be instrumentally counter-productive to reducing the risk of future re-offending. We then sketch the shape of penal philosophy and criminal justice policy and practice with forgiveness in place as a guiding ideal.

Responsibility without Blame: Therapy, Philosophy, Law.

I offer a philosophical account of the meaning of responsibility and the meaning of blame which shows how it is possible to distinguish them, in theory and in practice. Drawing on clinical interventions targeting problematic behaviour in service users with personality disorder, I explain why it is essential to maintain responsibility and accountability in order to enable learning and change, while it is essential to avoid blame. I suggest that the clinical stance of Responsibility without Blame be adopted within the criminal justice system, as a framework for addressing offending behaviour in a way which serves not only justice, but also reform and rehabilitation, by attending to the mental health of offenders while yet holding them responsible and to account.

Irrational Blame.

I clarify some ambiguities in blame-talk and argue that blame's potential for irrationality and propensity to sting vitiates accounts of blame that identify it with consciously accessible, personal-level judgements or beliefs. Drawing on the cognitive psychology of emotion and appraisal theory, I develop an account of blame that accommodates these features. I suggest that blame consists in a range of hostile, negative first-order emotions, towards which the blamer has a specific, accompanying second-order attitude, namely, a feeling of entitlement - a feeling that these hostile, negative first-order emotions are what the blamed object deserves.

Substance abuse as a risk factor for violence in mental illness: some implications for forensic psychiatric practice and clinical ethics.

PURPOSE OF REVIEW: To review recent research on the relationship between substance abuse, crime, violence and mental illness, and suggest how this research could aid forensic psychiatrists, psychologists and other mental health professionals in assessing and managing risk, and balancing patient care and public protection. RECENT FINDINGS: Substance abuse in mentally ill forensic psychiatric patients should be considered an important risk factor for violence and re-offending. SUMMARY: Improved treatment for substance abuse in forensic psychiatric patients and other mentally disordered offenders together with the offer of monitored abstinence as a condition of leave or discharge could be usefully considered as a means of reducing and managing risk. This may improve patient care by addressing mental health needs and increasing opportunity and likelihood of successful re-integration into the community and better life prospects; protect the public by reducing risk of re-offending and offering real time monitoring and potential intervention when risk is heightened; and help forensic psychiatrists strike a balance between patient care and public protection, potentially alleviating some of the difficulty and anxiety that decisions to grant leave or discharge can create.

From the Consulting Room to the Court Room? Taking the Clinical Model of Responsibility Without Blame into the Legal Realm.

Within contemporary penal philosophy, the view that punishment can only be justified if the offender is a moral agent who is responsible and hence blameworthy for their offence is one of the few areas on which a consensus prevails. In recent literature, this precept is associated with the retributive tradition, in the modern form of 'just deserts'. Turning its back on the rehabilitative ideal, this tradition forges a strong association between the justification of punishment, the attribution of responsible agency in relation to the offence, and the appropriateness of blame. By contrast, effective clinical treatment of disorders of agency employs a conceptual framework in which ideas of responsibility and blameworthiness are clearly separated from what we call 'affective blame': the range of hostile, negative attitudes and emotions that are typical human responses to criminal or immoral conduct. We argue that taking this clinical model of 'responsibility without blame' into the legal realm offers new possibilities. Theoretically, it allows for the reconciliation of the idea of 'just deserts' with a rehabilitative ideal in penal philosophy. Punishment can be reconceived as consequences-typically negative but occasionally not, so long as they are serious and appropriate to the crime and the context-imposed in response to, by reason of, and in proportion to responsibility and blameworthiness, but without the hard treatment and stigma typical of affective blame. Practically, it suggests how sentencing and punishment can better avoid affective blame and instead further rehabilitative and related ends, while yet serving the demands of justice.

How therapeutic communities work: specific factors related to positive outcome.

BACKGROUND: Therapeutic communities (TCs) are becoming increasingly widespread as a form of treatment for entrenched mental health problems, particularly addictions and personality disorders, and are equally used in educational, prison and learning disability settings. Despite growing evidence for their effectiveness, little research has been conducted to establish how TCs work to produce positive outcomes. We hypothesize that there are two specific factors that in combination contribute to TC effectiveness: the promotion of a sense of belongingness and the capacity for responsible agency. Although both factors are found in other therapeutic approaches and are important to the psychosocial aspects of psychiatric care more generally, we argue that their combination, extent and emphasis are unique to TCs. MATERIAL: Drawing on social and experimental psychology, we: (1) review research on a sense of belongingness and the capacity for responsible agency; (2) establish the mechanisms by which TCs appear to promote them; (3) draw lessons for TC practice; and (4) suggest why they may contribute to positive outcome. DISCUSSION: A sense of belongingness is correlated with improved self-esteem and overall well-being. The capacity for responsible agency is central to behavioural change. TCs are typically used in fields where positive outcome requires both personal growth and behavioural change. We suggest that TCs are uniquely placed to demand such growth and change of their members because the sense of belongingness engendered by TC methods protects against the risks engendered by this demand. CONCLUSION: Empirically informed, evidence-driven research is necessary to understand how TCs work and how TC practice can be improved. This understanding may offer lessons for the improvement of psychosocial aspects of psychiatric care more generally.

The Purpose in Chronic Addiction.

I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to "mature out" in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders. I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems. On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided. I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve. I conclude by drawing lessons for research and effective treatment.

The instrumental rationality of addiction.

The claim that non-addictive drug use is instrumental must be distinguished from the claim that its desired ends are evolutionarily adaptive or easy to comprehend. Use can be instrumental without being adaptive or comprehensible. This clarification, together with additional data, suggests that Müller & Schumann's (M&S's) instrumental framework may explain addictive, as well as non-addictive consumption.

Responsibility Without Blame: Empathy and the Effective Treatment of Personality Disorder.

Effective treatment of personality disorder (PD) presents a clinical conundrum. Many of the behaviors constitutive of PD cause harm to self and others. Encouraging service users to take responsibility for this behavior is central to treatment. Blame, in contrast, is detrimental. How is it possible to hold service users responsible for harm to self and others without blaming them? A solution to this problem is part conceptual, part practical. I offer a conceptual framework that clearly distinguishes between ideas of responsibility, blameworthiness, and blame. Within this framework, I distinguish two sorts of blame, which I call 'detached' and 'affective.' Affective, not detached, blame is detrimental to effective treatment. I suggest that the practical demand to avoid affective blame is largely achieved through attention to PD service users' past history. Past history does not eliminate responsibility and blameworthiness. Instead, it directly evokes compassion and empathy, which compete with affective blame.