One Foundations: Before "Addiction" I get an immediate sense of how Susan''s doing from the moment she walks through my office door. When she''s not drinking, she''s meticulously groomed, hair just so, sharp business-formal blazers and crisp shirts over her tense, thin frame. But today, I can tell, she''s slightly off. Over the years I''ve learned the tells. A little too much perfume to mask the smell of morning drinks. Hair askew. Rumpled shirt. Slightly sloppy makeup.

I''ve also seen her in total crisis, with dirt caked under her fingernails and alcohol fumes lingering in the room long after she leaves. But to her, just to be drinking at all feels like a crisis. She identifies as an alcoholic, she is certain that she wants to stop drinking, and yet she does not, and this is what she hates the most-the disorder, the lack of control. I can see she is struggling with this feeling now. She tells me about the most recent relapse. Alone in her room, she felt restless, and she couldn''t get the thought of drinking out of her mind. She had firmly decided that she wouldn''t have wine that night. She absolutely would not go to the liquor store.

Then, in a twisted compromise, she watched herself walk to the corner store and buy a few bottles of vanilla extract. The vile liquid made her drunk, then sick to her stomach, she tells me. Eyes wide, she says, "It was ridiculous." These days in my psychiatry practice, I mostly see people with complicated substance use problems: people who still struggle after spending thousands of dollars on rehabs and outpatient programs, people for whom the traditional treatments don''t work nearly often enough. Susan has gone to those programs-both the old-school abstinence-based rehabs and the more modern and flexible treatment programs-but she''s never stopped drinking. For months, she''s lingered in that in-between place, still doing some minimal work in her private legal practice, making enough to get by, but well below what she could. She is in a notable minority: the fewer than 5 percent of people in the United States with substance use problems who actually believe they have a problem and want treatment. Even so, despite the alcohol withdrawal seizure she had a few months ago, despite the blackouts, despite losing her corporate job, she has not been able to stop.

She is not in any physical danger now. She hasn''t had enough to be in alcohol withdrawal. Still, she says, this is awful for her. She dwells on the last month of failed resolutions and unsuccessful attempts to cut down, and as she goes around and around, butting up against the limits of language and reason and trying to make sense of it all, a note of frustration, even desperation, enters her voice. "I know what I need to do. I want to do it. But I don''t do what I want to do. And then I''m drinking again, and I just don''t know why or how.

" Addiction is a terrifying breakdown of reason. People struggling with addiction say they want to stop, but, even with the obliterated nasal passages, scarred livers, overdoses, court cases, lost jobs, and lost families, they are confused, incredulous, and, above all, afraid. They are afraid because they cannot seem to change, despite the fact that they so often watch themselves, clear-eyed, do the very things they donÕt want to do. For thousands of years, people have struggled with the frightening phenomenon that Susan faced. It''s not always easy to find, as few ancient cultures had a term for what we would recognize as addiction. For example, the ancient Greeks had the word philopots, a "lover of drinking sessions," but the word itself didn''t necessarily indicate that someone had a problem. And yet, in other times and cultures, addiction is clearly present. Teng Cen (AD 1137-1224), a Chinese poet of the Song dynasty, described how he made a pact with the gods to stop drinking, only to succumb to cravings during a banquet-he ultimately rationalized it by convincing himself that it was in his "true nature" to drink.

The Chinese literature scholar Edwin Van Bibber-Orr has documented several other Song dynasty works describing shi jiu, a love of drinking marked by craving, desire, and thirst that bears striking similarities to what we call addiction today. But one of the oldest examples of addiction in history concerns not substances but gambling, a behavior nearly as old as human civilization itself. In the Rig Veda, an ancient compilation of Vedic Sanskrit hymns from India, among the oldest surviving compositions in any language, an evocative poem known as the "Gambler''s Lament" presents an unambiguous description of gambling addiction. In a text that likely dates to before 1000 BC, a fourteen-line poem captures in vivid detail the despair of a man who struggles unsuccessfully against his desire to play at dice. At the start of the poem, we learn that the dice have already inflicted a heavy toll. The gambler has driven away his true community, his devoted wife and mother. Yet despite that wreckage, for much of the poem, he struggles to stop. He resolves not to play with his fellow gamblers-but then, at the sound of the dice''s voice, he rushes to them "like a girl with her lover.

" His body is aflame. He feels as if the dice themselves have power over him: The gambler goes to the hall of play asking himself, "will I win?" puffing himself up with "I will win!" The dice run counter to his desire, conferring the winning throws on his opponent. They are just "dice"-but hooking, goading, debasing, scorching, seeking to scorch, giving (temporarily) like a child, then in turn slapping down the victor, infused with honey, with power over the gambler. The power of the dice is mystifying. (Note: the dice acquire their own agency, going from "scorching" to "seeking to scorch.") The gambler swings between guilty excitement, anger at the dice, scorn at his weakness, and shame. The very roll of the dice evokes the gambler''s own descent into the pit of addiction: "Downward they roll, and then spring quickly upward, and, handless, force the man with hands to serve them." Still, the gambler is not completely compelled, as there is a paradoxical play between the gambler''s agency and helplessness; at times he is able to exert some choice; at others he is completely overpowered.

The final stanza of the poem is intriguingly ambiguous; contemporary scholars have arrived at drastically different translations. In one possibility, the man is freed from the shackles of gambling and he beseeches his friends not to resent him for it and to seek their own release. In another version, he begs the dice to have pity on him, to calm their inner fury, and to move on to another victim. In yet another interpretation, somewhat chillingly, the dice themselves speak of how it is futile to be angry at the awful, sublime, and timeless power of addiction over humanity: "Old gambling friends, be kind to us! Don''t be disgusted with our power. / Calm your resentment from within, and pass us to another foe to conquer." IÕve been using the word Òaddiction,Ó but before going further, itÕs important to reemphasize that addiction is not a tumor or a bacterium but an idea-or, more correctly, a set of ideas. Addiction is not outside of the historical process, sitting there as an independent fact waiting to be discovered. The term ÒaddictionÓ was not adopted until recent centuries, but the concept of addiction, loosely conceived, could include everything from the notion of addiction as a disease to sweeping philosophical formulations of will and self-control.

Well before our modern notions of addiction took shape, thinkers puzzled over those concepts-in fact, they form the foundation of our ideas about addiction. Addiction is often explained in terms of a dichotomy of free choice versus total compulsion. By claiming that addictive behaviors are simply a kind of choice, people have justified punitive measures for centuries, from putting drunkards in the stocks to imprisoning people for drug possession. If their drug use is a free choice like any other, the argument goes, people should accept responsibility for their behavior, including punishment. The opposite view, which these days is commonly presented as a compassionate counterargument by neuroscientists and advocates, is that addictive behaviors are involuntary and uncontrollable compulsions, and thus people with addiction deserve compassion and treatment, rather than punishment. But in cases from the gambler of the Rig Veda to my patient Susan, this dichotomy between choice and compulsion is unsatisfying. Lived experience flies in the face of such a stark binary, and many people with addiction feel themselves occupying a confusing middle ground between free choice and total loss of control. The thing that is terrifying to Susan, and to many others like her, is that they watch themselves making a choice even while feeling there is something wrong with the choosing.

It is, in other words, an issue of disordered choice: a problem with choice, choice gone awry. The ancient Greeks had a word for this experience of acting against your present judgment: akrasia, often translated as "weakness of the will." Akrasia isn''t just doing something that is arguably harmful, like eating too much pie or spending too much money on clothes. Everyone indulges, even though indulgence is rarely the best option according to a cold, utilitarian calcul.