Peter R. Martin: Historical Vocabulary of Addiction
According to the current electronic version of the Oxford English Dictionary (OED), the noun competence is derived from the French compétence, first defined by the English lexicographer Randle Cotgrave (died c. 1634) as “competencie, conueniencie, sufficiencie, aptnesse, fitnesse, agreeablenesse; also concurrencie, compettitorship” in A Dictionarie of the French and English Tongues (Cotgrave, Hollyband and Sherwood 1632). The French word originated from the post-classic Latin competentia (“meeting together, agreement, symmetry, planetary conjunction”), competent- being the present participle of the verb competĕre. The verb competĕre is a combination of com- (“together”) and the verb petĕre (“to fall upon, assail, aim at, make for, try to reach, strive after, sue for, solicit, ask, seek.”). There are two original meanings of competĕre: 1) “in its earlier neuter sense, ‘to fall together, coincide, come together, be convenient or fitting, be due’”; and 2) “in its post-classical active sense, ‘to strive after (something) in company or together’.” These senses are intermixed in the derivatives that follow, but competence, and its derivatives belong in the main to the earlier sense.
The first use in the English language of competence (“Rivalry in dignity or relative position, vying”) as documented in OED is from the sense of the verb to compete (“To strive with another, for the attainment of a thing, in doing something”). An example appeared in a translation by Richard Carew (1555–1620), a Cornish translator and antiquary, of The examination of mens wits (Huarte and Carew 1616): “Man… seeing that the Angels, with whom he had competence, were immortall [cf. ‘Made a little lower than the angels’].” This is recognized as the volume in which the Spanish physician and psychologist Juan Huarte de San Juan (1529–1588) attempted for the first time to link psychology to physiology. The second use of competence (“An adequate supply, a sufficiency of”), now obsolete, is from the other sense of the verb to compete (“To be suitable, applicable, or ‘competent’”). This is the meaning employed by William Shakespeare (1564–1616), the English playwright, in his Henry the Fourth (Shakespeare 1600): “For competence of life, I wil allow you, That lacke of meanes enforce you not to euills.”
The general meaning of competence (“Sufficiency of qualification; capacity to deal adequately with a subject”) acquired a distinctly legal sense (“The quality or position of being legally competent; legal capacity or admissibility”). Accordingly, the conceptualization of competence gained importance in psychiatry, especially in forensic psychiatry (“Pertaining to, connected with, or used in courts of law; suitable or analogous to pleadings in court”). Additionally, understanding competence as it pertains to addiction presents unique challenges among psychiatric disorders. An example of the legal meaning as first used in the English language is found in Dictionarium Anglo-Britannicum edited by John Kersey the younger (c. 1660-1721), an English philologist, and lexicographer (Kersey 1708): “Competence, or Competency in Law, the Power of a Judge, for the taking Cognisance of a Matter.”
The term competence has been examined specifically with respect to addiction and its ethical treatment (Charland 2020). Understanding that addiction belongs squarely within psychiatry, a medical/scientific discipline, the competence to accept or refuse recommended treatment of an individual suffering from an addictive disorder may be conceptualized as having at least the following three elements:
1) An understanding of the meaning of addiction, which is defined in OED as: “Immoderate or compulsive consumption of a drug or other substance; specifically, a condition characterized by regular or poorly controlled use of a psychoactive substance despite adverse physical, psychological, or social consequences, often with the development of physiological tolerance and withdrawal symptoms...” This definition should rightly be expanded to include behavioral addictions. Accordingly, a more contemporary definition of addiction is self-destructive and out-of-control behavior with or without involvement of psychoactive substances (Martin, Weinberg and Bealer 2007).
2) The presence of informed consent, defined in OED as: “… consent to a medical or surgical procedure given after all relevant information (especially regarding potential risks and benefits) has been disclosed to the patient or the patient's guardian; an instance of such consent.”
3) Possessing decision-making capacity, namely the ability to be informed and then to consent, which is understood to require both mental capacity and mental competence. In OED, mental capacity is defined essentially in psychometric terms that can be operationally measured (“Power or ability…[specifically] mental…”) and mental competence, as noted above, is considered a legal matter adjudicated within a court of law.
Decision-making capacity seems at the heart of the competence to accept or refuse treatment for addiction, however, each of the three factors mentioned above are nonetheless important.
Possibly more for addiction than for many other medical/psychiatric conditions, there are additional issues that should be considered with respect to competence to accept or refuse treatment. Understanding what addiction is and having both mental capacity and mental competence to provide informed consent for treatment are no assurance that an individual can recognize the disorder in themself and either seek or accept treatment when it is offered. It may be difficult to engage a patient in addiction treatment unless the twin characteristics of insight and motivation are also present or can be developed. In OED, insight is defined as: “In studies of behaviour and learning, the sudden perception of the solution to a problem or difficulty... perception of one's mental condition.” The definition of motivation is: “The [conscious or unconscious] stimulus for action towards a desired goal, especially, as resulting from psychological or social factors; the factors giving purpose or direction to human or animal behaviour… the reason a person has for acting in a particular way, a motive.”
Helping an individual recognize that they do, in fact, have a significant problem with addiction that they are willing to tackle are essential for treatment of these disorders. Only with insight and motivation is it possible for the patient to face the challenges required for recovery from addiction - understanding their own role in the development and perpetuation of the disorder and accepting the pharmacopsychosocial treatment that will help them mend a disrupted life. Because of the very real distinction between the treatment of addiction and many other disorders, insight and motivation must factor into a discussion of competence. For example, in common conditions such as appendicitis or pneumonia, the treatment is essentially conducted by the physician with the patient being an interested “bystander.” Even for the most severe psychiatric disorders, the focus of the treatment process (electroconvulsive treatment and antipsychotic, antidepressant or mood stabilizing medications) is administered under the supervision of a psychiatrist.
On the other hand, addiction treatment has long relied primarily upon the individual who has the disorder (Wilson 1855) with variable contributions from a treatment team and/or peers. Accordingly, achieving insight and motivation to change one’s behavior have become the essence of the management of addictive disorders today (Miller 1983; Prochaska and DiClemente 1983). Despite the recent emphasis on pharmacological agents in treatment of addiction, the major role of the physician is to help the patient seize the opportunities offered within the context of a multi-disciplinary treatment program, an integrated blend of pharmacopsychosocial components, in which the patient occupies the central role (Martin, Weinberg and Bealer 2007).
The essential responsibility of the person who is suffering from the disorder in its treatment represents a true paradox for both the patient and for the prevalent viewpoint held within society — if the patient must do much of the work of recovery, is addiction truly a medical disorder? While there is well-accepted scientific evidence that addiction is a disease of the brain and thus a bone fide psychiatric condition (Leshner 1997), accepting that one truly has the disorder can be very difficult as many of the behaviors involved seem to be under the individual’s control. The cavalier attitude (and paradoxically, wisdom) of society about the difficulty associated with discontinuing drugs of abuse is exemplified by a quote attributed to the American writer, humorist and lecturer Samuel Langhorne Clemens (1835–1910), known by his pen name Mark Twain: “Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.”
The notion that the fundamental problem in addiction is loss of control over a pathological behavior is actually very difficult for the patient to understand and acknowledge. Even if the patient can overcome significant denial about having a pathological behavior, it may still be painful to deal with the guilt that typically is a consequences of addiction and the associated stigma (Volkow 2020). Therefore, despite the very real risk of morbidity and mortality associated with addiction, the individual suffering from these disorders may be reluctant to enter treatment.
Physicians who regularly treat patients with addictive disorders have likened addiction to other chronic diseases like type 2 diabetes mellitus (McLellan, Lewis, O’Brien and Kleber 2000). This viewpoint helps patients (and physicians) understand that medical guidance can be an extremely important component of the treatment of addiction. This is because discontinuing such pathological behaviors is not voluntary and can be made even more difficult when the patient is self-medicating a treatable co-occurring other psychiatric disorders. Healing addiction requires learning alternate responses to the environment and strategies to manage the emotions that may be the primary reason for engaging in pathological behaviors (Martin, Weinberg and Bealer 2007).
Additionally, the perspective that one is suffering from a medical disorder can assuage guilt an individual is experiencing by falsely blaming the problem on one’s own “faults” and “weaknesses.” Despite all we have come to know about the pathophysiology and treatment of addiction, consensus is still lacking about attitudes concerning “responsibility” for either the causation or the treatment of addictive disorders, especially whether those who have these problems should be managed within the medical or legal system — should these individuals be considered patients or criminals (Erickson 1992; McLellan, Lewis, O’Brien and Kleber 2000)?
If a patient is unwilling to seek or accept treatment despite serious risk to their health and wellbeing it is far too easy to conclude that this decision is their choice alone to make. On the other hand, if addiction is understood to be a disease of the mind, a psychiatric disorder characterized by loss of control over a pathological behavior, rather than simply a moral failing or depravity, diminished competence to accept or refuse recommended treatment can be recognized as a consequence of the disease process (Kermani and Castaneda 1996; Hall and Appelbaum 2002).
From the legal perspective, the tenet of diminished competence due to addiction can only be accepted if one acknowledges that the pathological behavior associated with addiction ceases to be a voluntary act as it is for the non-addicted (Taylor and Hartshorne 1856). Accordingly, the states of intoxication and withdrawal (these concomitants of neuroadaptation also occur with behavioral addictions although they were first conceived for substance use disorders) which result in psychopathology and possible harm to self and others can be attributed to this impairment of choice. As a result, actions taken by an addicted person while “under the influence,” can only be averted by committal of the individual for appropriate treatment, much as would be customary for individuals at risk for suicide or violence towards others.
This is not a new concept as suggested by the minutes of an annual meeting of the American Association for the Insane wherein physician members agreed that for those “deprived of volition,” involuntary institutional care was a necessary intervention, declaring that inebriates should be restrained on grounds of moral depravity, detained as diseased requiring treatment, or committed as non-compos mentis (Shrady 1860). Although commitment for addiction treatment is still practiced widely (Grahn 2021), mandating treatment that the patient claims they do not want should not occur according to the World Health Organization (2020). In any event, the legal sphere remains uncertain and in many ways resistant to the idea that addiction is a disease — because volition in the act of substance consumption renders the altered mental state resulting from intoxication a predicted precursor and hence renders the user responsible for the consequences (Gendel 2004; Lewy 2012; Israelsson, Nordlöf and Gerdner 2015).
Competence to accept or refuse recommended treatment is a legal construct (Buchanan 2004) contrary to efforts to understand the patient’s perspective (Benaroyo and Widdershoven 2004). The ability to make such decisions is assumed to always be present unless a clinician can gather the requisite data to allow adjudication of incompetence in a court of law (Appelbaum and Grisso 1988). Only if a physician recognizes that addiction is a harmful illness that can benefit from treatment rather than simply a variant of normal behavior under the patient’s control will they seek to restrict the individual’s right to refuse recommended treatment via legal proceedings. Charland (2020) contends that for indicated treatment to proceed, the patient as well must understand the implications of addiction and have an appreciation of the risks and benefits associated with treatment. This necessitates the physician being able to convey such information to their patient in a reliable and compelling manner. Accordingly, determination of the competence to accept or refuse treatment must take into consideration the patient’s perspective of the current understanding of the pathogenesis and complications of addiction, its reliable diagnosis, accepted treatment approaches and the likelihood that intervention can improve their clinical outcome.
As suggested above, the determination of competence in a patient with addictive disorders is greatly influenced by the fact that psychopathology in addiction may wax and wane through the clinical course of the disorder. Significant impairment during intoxication or withdrawal combined with an essentially normal mental state during periods of sobriety (Eckardt and Martin 1986) means that the competence to refuse treatment may be absent when the patient is first seen in the emergency department, only to return by the next morning when the patient wishes to leave the hospital. This can represent an almost insurmountable challenge to the physician as limitations in decision-making that may satisfy the criteria for legal commitment to treatment can be fleeting in these disorders. Physicians may find this especially confusing because this is less of an issue with many other chronic mental illnesses (Christopher, Anderson and Stein 2020), in which the predictability of the course and duration of clinical dysfunction are more consistent with the scope and timeline of legal proceedings. One might certainly argue that if an addicted individual is sober and competent to refuse treatment they are still at high likelihood of re-intoxication. Accordingly, entry into treatment should equally be facilitated rather then allowing them to engage in repeated cycles of being “under the influence” with diminished competence and potential for harm to self and others which characterize recidivism.
The major question in light of the important role played by the patient in treatment of addiction is whether commitment to treatment against the patient’s wishes is effective and actually alters the clinical course of addiction. Physicians who regularly treat patients suffering from addiction believe that commitment to treatment is worthwhile (Jain, Christopher, Fisher et al. 2021) and once the patient is committed it is only a matter of time before both insight about their disorder and the motivation to change their behavior can be developed through the treatment process so that they can begin their journey to recovery (Miller and Flaherty 2000). An alternative perspective is that much more research is required to determine the effectiveness of compulsory/legally mandated treatment for addictive disorders process (Klag, O’Callaghan and Creed 2005; Jain, Christopher and Appelbaum 2018). Nevertheless, if the patient at least has the opportunity to alter their self-distructive and out-of-control behaviors in treatment, it may change the course of their addictive disorder, which has the proclivity to progress over time and can harm not only the patient but also those in their orbit.
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April 21, 2022