The Bias against Treating a Presumed Lack of Willpower

Many who understand this biologically based view of ADHD remain reluctant to see medication used as the primary treatment. They tend to think of cognitive problems in ADD syndrome as a special category of impairment, very different from malfunctions of the pancreas, heart, eyes, or other bodily organs. For malfunctions of virtually every other organ sys tem, most educated people today see prescription medication as an appropriate and often necessary treatment. Yet when the problem relates to workings of the brain, these same individuals may object to medication treatments and insist that the individual ought to fix the problems by "willpower" or some other variant of conscious effort.

Indeed, many believe that all cognitive processes can be brought under conscious control, that any individual can make changes in how he thinks, what he feels, and how he acts, if only his determination is strong enough. This is the view that Daniel Wegner (2002) has challenged as "the illusion of free will." Although he acknowledges that this illusion has adaptive functions, Wegner quotes approvingly Bernard Schlink's (1997) words,

I don't mean to say that the thinking and reaching decisions have no influence on behavior. But behavior does not merely enact what has already been thought through and decided. It has its own sources. (p. 342)

Opposite to the view that willpower, or conscious effort, can control all mental processes is the view that most mental processes operate outside the realm of consciousness. As I have explained, executive functions are quick, subtle, and complex, usually operating without much input from conscious thought. Executive-function processes are not usually responsive to "willpower" on any substantial or sustained basis. But this "non-willpower" view of mental functioning is misunderstood by many and strongly opposed by some.

Resistance to the idea that much of the work of the mind is unconscious is not new. In 1917 Sigmund Freud published a short paper as a response to the strong emotional reaction many professionals and lay people had to his emphasis on the role of unconscious processes in mental life.

You believe that you are informed of all that goes on in your mind if it is of any importance at all, because your consciousness gives you news of it. . . . Indeed, you go so far as to regard "the mind" as coextensive with "consciousness," that is, with what is known to you, in spite of the most obvious evidence that a great deal more is perpetually going on in your mind than can be known to your consciousness. (p. 189)

Freud concluded that people generally felt offended by his assertions that "the ego is not master in its own house," that persons are not in conscious and deliberate control of all that they do. He recognized that many individuals are threatened by the idea that their thoughts and actions are shaped by internal forces as well as external events and that these internal forces are, in many ways, not at all under their conscious control or even within their own awareness.

Since Freud's time, much more has been learned about the unconscious workings of the mind. A new view of "the unconscious," quite different from psychoanalytic formulations, is emerging in psychology and neuroscience (see Hassin, Uleman, and Bargh 2005). But still many persons are reluctant to believe that their conscious thought does not reign supreme over their cognition. Even though they do not expect to control by willpower the endocrine malfunctions of diabetes or the growth of a cancer, they want to believe that willpower can sustain control over malfunctioning cognitive processes that, among other important tasks, organize and prioritize, maintain working memory, activate effort, and regulate alertness.

It is ironic that many who strongly resist the notion that prescription medications may be needed to alleviate ADHD have no problem with using everyday stimulants to aid their own cognitive functioning. Richard Rudgley (1993) has described the longstanding and widespread use of stimulants such as coffee, tea, cola, tobacco, and betel nut throughout the world to improve alertness and concentration in daily life. Because one or another of these substances is usually readily available and socially sanctioned, many do not recognize that they are providing—on a more transient, erratic, and somewhat less potent basis—stimulation to cognitive processes very similar to the actions of medications commonly prescribed for ADHD. Use of these nonprescription agents is not seen by most as compromising self-discipline and willpower. But in many cases they are nevertheless prejudiced against the use of such medications to alleviate

ADD syndrome impairments that, they believe, should be corrected by force of conscious will.

This prejudice against use of medications to alleviate cognitive impairments is not merely a philosophical issue. It has very important practical implications for decisions about how persons with impaired executive functioning are to be understood and treated. If one maintains that an individual suffering from ADD syndrome can overcome these impairments simply by trying harder, then intensified instruction and reinforcement with rewards and punishments alone would seem to be sufficient intervention.

But if one understands impairments of ADD syndrome as malfunctions of cognitive processes that operate essentially outside conscious control, then intensified instruction, rewards, and punishment are not enough: medication is required. In this book I have argued that ADD syndrome results from chronic impairments in cognitive processes that, for the most part, operate outside the realm of conscious control, that are not responsive on any sustained basis to "willpower."

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Understanding And Treating ADHD

Understanding And Treating ADHD

Attention Deficit Disorder or ADD is a very complicated, and time and again misinterpreted, disorder. Its beginning is physiological, but it can have a multitude of consequences that come alongside with it. That apart, what is the differentiation between ADHD and ADD ADHD is the abbreviated form of Attention Deficit Hyperactive Disorder, its major indications being noticeable hyperactivity and impulsivity.

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