What price sobriety (in vouchers)?

BBC Radio 4 recently ran a fascinating one-off programme called Sugaring the Pill on schemes that pay people to lose weight, get vaccinated or stay off drugs. Payment turns out to be particularly effective at keeping addicts clean and this caught my eye because it seems to go against some of the core scientific beliefs about persistent drug users.

The programme explores the ethics of payment programmes and the public’s discomfort, particularly when applied to drugs, with handing out rewards for something we should perhaps be doing anyway.

Payment as treatment is known in the medical literature as ‘contingency management’ and has been found to be most effective in keeping heroin and cocaine addicts clean.

As the programme, and the research summary linked above, describe, a typical payment scheme will give a ticket for every clean urine test – usually starting with a small value like £1, and increasing by 50p each time.

Only when the patient has completed a whole series of clean drug tests, maybe after a month or two, can they exchange their tickets for shopping vouchers which they can spend in the high street.

The fact that these schemes are so effective is surprising, because they rely on abilities thought to be lacking or impaired in addicts – mainly the capacity to delay rewards and gratification.

There is now a host of research showing that addicts have problems with temporal discounting. We all have the tendency to judge future benefits as significantly less important than immediate ones but this seems to be enhanced in drug users who greatly overly prioritise rewards that arrive sooner.

Also, persistent drug use is widely believed to alter the brain’s reward system so positive reinforcement (wanting benefits) becomes less persuasive than negative reinforcement (the desire to escape an unpleasant sensation).

Similarly, research suggests that in addiction, the desire to take drugs become less modifiable by our executive system and so less amenable to voluntary control.

So, for people who should be primarily motivated by immediate chemical rewards over long-term abstract benefits, a slowly accumulating shopping voucher scheme would be the last thing you would predict to have such a reliable effect on keeping people off the smack or blow.

I note this purely as a curious inconsistency and if you have any suggestions that might explain it, do add them in the comments.

The BBC programme is excellent, by the way, and is also available as a podcast.

Link to Sugaring the Pill info and streamed version.
Link to page with podcast (for four weeks).

Khat among the pigeons

All in the Mind kicks off a new three-part series on ‘Cultural Chemistry’ with a programme about the effects and politics of the stimulant khat which has an important place in several East African cultures.

The plant is used widely in Somalia, Ethiopia and Yemen and when chewed it causes a mild buzz owing to low levels of a naturally occurring amphetamine-like compound called cathinone.

Although originally rooted in Africa, the plant is available across the world although its legal status varies – from banned in the USA to completely legal in Britain.

It is used traditionally like coffee to perk people up and make them more chatty although it is often the subject of controversy because it has been linked with triggering psychosis and aggression in some people – although the scientific evidence is far from clear.

I managed to try khat once after I discovered it on sale at a grocery in Leicester. Although it did cause a slight buzz I was most struck by the taste as it is incredibly tannin-like, making the experience a little like chewing on a tea bag.

But as All in the Mind notes, as the plant is strongly linked to specific social settings, it’s difficult to understand its effects without considering the environment in which it’s taken and the programme does a fantastic job of exploring the complex mix.

Coffee is next up in the ‘Cultural Chemistry’ series which should be worth keeping an eye on as there might be something a little special later on. Also, there’s more on the All in the Mind blog and a call for you to contribute your own recordings.

Link to All in the Mind Cultural Chemistry series on khat.
Link to more details and additional audio on the AITM blog.

It only exists if I can see colours on a brain scan

Bad Science has an excellent piece on the recent hot air from a researcher who claimed that brain activity differences between people with high and low sex drive proved that ‘hypoactive sexual desire disorder’ was ‘a genuine physiological disorder and not made up.’

This strikes me as an unusual world view. All mental states have physical correlates, if you believe that the physical activity of the brain is what underlies our sensations, beliefs and experiences: so while different mental states will be associated with different physical states, that doesn’t tell you which caused which. If I do not have the horn, you may well fail to see any increased activity in the part of my brain that lights up when I do have the horn. That doesn’t tell you why I don’t have the horn: maybe I’ve got a lot on my plate, maybe I have a physical problem in my brain, maybe I was raped last year. There could be any number of reasons.

But far stranger is the idea that a subjective experience must be shown to have a measurable physical correlate in the brain before we can agree that the subjective experience is real, even for matters that are plainly experiential. If someone is complaining of persistent low sex drive, then they have persistent low sex drive, and even if you could find no physical correlate in the brain whatsoever, that wouldn’t matter, they do still have low sex drive.

One of the reasons why attempts to make problems of behaviour or experience seem ‘biological’ is that the concept is strongly linked to the idea that if something is a ‘biological disorder’ we are less to blame because we have less control over the symptoms.

This is daft, of course, because although biology uses less talk of free will and agency, it is really just another level of explanation.

The beauty of a captivating picture doesn’t somehow disappear if we discuss the molecules of the paint and, in a similar way, discussing the interactions of neurons won’t mean that the problem of free will no longer applies.

But the drive to try and eliminate free will is, in part, because of the stigma still attached to many types of problems. Instead of trying to tackle stigma we often try to misguidedly reclassify the object of the stigma.

It’s like trying to fight racism by classifying a wider range of skin colours as white – it really misses the point and actually maintains the prejudice. In the same way, we should be working towards accepting all human difficulties, however they are most appropriately described by scientific theories, as valid and worthy of concern.

This does not mean all necessarily need to be classified and treated as medical disorders, but it does mean that we should respect the difficulties people face and think about constructive ways of helping ourselves and other people to tackle them.

Link to Bad Science on ‘Neuro-realism’.