Out of mind

To what extent do we control our own behaviour? The question of free will is, on a psychiatric ward, a brute, practical problem. Treatment is determined by the extent to which patients are unable to master their own minds. The dilemma is most pronounced when the damage is self-inflicted. Take the alcoholics. Are they the agents or the victims of the habit that destroys them?

The young psychiatrist finds himself baffled by the drunks who wind up on the ward. His views on the nature of addiction—whether it is a biological predisposition or an acquired problem—are unresolved, and he tends to bow to the instincts of his consultant, an austerely bespectacled woman who works by experience rather than theory.

One particular Wednesday, the first patient into the shabby consulting room is Mick, a well-known alcoholic who has been making death threats to his wife and neighbours. Admitted to the ward in a drunken, paranoid rage, he started making similar threats to the nurses. Now sober, he is still paranoid, but the consultant is convinced that no other mental illness is present. She tells Mick that he will be discharged—alcoholism alone is not sufficient for detention under the 1983 Mental Health Act. Mick is all talk. He has no history of actual violence. But the consultant nevertheless informs him sternly that each threat he makes will be reported to the police. The young psychiatrist takes note: she is talking to Mick about consequences, treating him as the agent of his own fate. It is hardly psychiatry, but it is effective. Mick is outraged by the suggestion that he should bear his own burden. "I am a dangerous alcoholic and it's your job to deal with me," he shouts as he leaves. "This is who I am!"



The next patient to walk in, however, puts Mick's alcoholism in the shade. John is a man so hollowed out by addiction he barely seems present. A week earlier, he had been found writhing naked on the floor of his bedsit, lathered in his own excrement, contorted by seizures and hallucinating Lilliputian figures. The consultant had sectioned John for treatment, bestowing on him the status of a mental illness superseding the alcoholism. Thus the law can grant that he is not responsible for who he is.

Now John has been detoxed on vitamins and valium, washed and fed. His yellow skin is stretched around small, distracted eyes. The delusions of persecution have abated and a social worker has been invited in to plan his discharge. "We want to avoid a relapse of your illness," the consultant tells John. "We need to organise other things to fill your time." John couldn't care less. He is not interested in what his "illness" may be or how he could improve his life. He wants a drink. He wants to be set free in order to succumb to his fate. "Let me go," he says distantly. "I don't want your help. I have my rights."

That evening, the young psychiatrist goes out for a drink with his friend Leonard, a talented writer, a dedicated family man and, for 20 years of his life, an alcoholic and drug addict. Bird-shaped and angular with opinion, Leonard sticks to roll-ups and coffee, indifferent to the psychiatrist's pint of bitter. Leonard is intrigued by clinical accounts of alcoholism, because he spent years in psychoanalysis trying and failing to conquer his habits. He and his shrinks had decided that abuse and abandonment at the hands of his mother lay at the root of his addictions. Leonard would come in drunk or strung out on drugs, and they would talk about his terrible mum. The mind-bending intoxication in the room was simply ignored. Then, one day, Leonard decided this was absurd. He sacked his last analyst and joined Alcoholics Anonymous. He didn't buy into the AA idea of seeking help from a higher power, but, just like Mick, he came to believe that he was an addictive personality. Having accepted this, Leonard, unlike Mick, never drank again.

On the night bus home, snaking its way through the winter rain, the young psychiatrist ponders the three alcoholics. What makes them different? Mick wanted to palm off responsibility, viewing himself as a predetermined medical fact. Some science would support him in this. Motivational pathways in the frontal lobe of the brain are associated with addictive behaviour—and drugs such as cannabinoid receptor antagonists are being developed to block the relevant synapses. The consultant, however, refused to reduce Mick to his brain, viewing him instead as a moral agent.

Which is not what she did for John, who seemed so fully to embody his addiction that it was hard to discern any human agent separable from the motivational distortions of his habit. So she defined his addiction as a "disease." Yet at the very point she divested him of responsibility for his behaviour, John claimed his right to do what he chose. And the law says he can, even if his will is in thrall to a pathological condition.

The last paradox of the enslaved will is Leonard. He is lucky, redeemed partly by circumstances: his intelligence, a career, the hope inspired by his family. Yet circumstances are insufficient explanations. Having spent years trying to unearth the psychological roots of his addiction, Leonard found none. Instead he accepted his lot as a predetermined biological and genetic fact—a matter over which he has no control. And it was at that moment he found the strength to make a free choice, and walk away.