Lance Dodes, MD
Training and supervising analyst, Boston Psychoanalytic Society and Institute, Assistant clinical professor of psychiatry, Harvard Medical School
Dr. Dodes has disclosed that he receives royalties for books on addiction. Dr. Balt has reviewed this article and found no evidence of bias in this educational activity.
TCPR: Dr. Dodes, you have written that addictions of all sorts have common psychological roots. Can you describe what you mean by that? Dr. Dodes: The object of any addiction—whether it is alcohol or narcotics or gambling—is not what is important in addiction. What really matters is what drives a person to compulsively seek that drug or that activity. We know this because clinical experience shows that people frequently shift their addictive focus from one drug to another, or from a drug to a non-drug behavior like compulsive gambling or eating. It is clearly not the particular form of addiction that matters, but why people need to repeat an addictive action.
TCPR: What drives this activity? Dr. Dodes: A sense of helplessness. The key moment in addiction is when a person decides to perform an addictive act, not when they take the drug or the drink. Patients say that the moment they decide to engage in an addictive behavior, they no longer feel helpless. They have now made a decision to do something that they expect will make them feel better—something that is entirely in their control. At that moment, far from being helpless, they are empowered. It is this reversal of overwhelming helplessness that drives addiction.
TCPR: So it’s the sense of helplessness that leads addicts to abuse drugs or alcohol? Dr. Dodes: Yes. But it’s not just any helplessness; it’s always about something especially meaningful to the person. For example, if you were exploring a cave and there was a sudden rumbling and 200 tons of rock fell between you and the opening, you might try to stay calm, but it won’t last long. Pretty soon you will be yelling and screaming and pounding at the rocks. This is a normal reaction, a normal kind of rage that occurs when one is completely overwhelmed. But people can feel just as trapped with feelings and circumstances that would not upset others—situations that touch on emotional issues that are important to them. When that happens, the same rage at helplessness occurs, and easily overwhelms the rest of a person’s ability to think and to function. It overwhelms the things that a person normally cares about in life and that he would ordinarily take care to protect. This is what happens in addiction, and explains why people with addictions are mistakenly thought of as selfish or hedonistic when they seem to choose their addictive behavior despite the harm it causes to themselves and those around them.
TCPR: So an addict is displacing the tension from whatever is overwhelming in his life to an addictive act that takes its place? Dr. Dodes: Yes. Here’s an analogy: you are driving and a car swerves in front of you and cuts you off. You become very angry at this, because it touches on old issues about being disrespected. You might be so enraged that you swerve in front of that car, stop, get out, and have a fight. That would not be good, but it would not be an addiction; it would be a direct action. But if, instead, you go home and start to drink, you are dealing with your feelings about being cut off by taking an indirect action. You are displacing a need to reverse the feelings of helplessness you had when cut off, onto the action of drinking. This displacement (or substitution) creates an addiction. In fact, we name addictions precisely by the displacement. In this example, if the person always displaced the reversal of helplessness to drinking, we call him an alcoholic. But if next week he began displacing to placing bets, we would call him a compulsive gambler, and so on.
TCPR: Some might hear those examples and label them “self-medication.” Dr. Dodes: I have no objection to that term. The idea that addiction is a way for people to do something to help themselves function—to self-medicate—is a good idea. I just think it is too vague because the mechanism in addiction, the psychology of addiction, can be described much more specifically.
TCPR: You have written about a distinction between substance abuse and addiction. Can you describe that? Dr. Dodes: “Substance abuse” is simply one form of addiction. Separating it out as if it were a distinct category just confuses matters. It implies that there is something about substances that is special or essential to the nature of addiction. Of course, that is not true, as we know from the fact that people regularly shift from addiction focused on drugs to non-drug addictive or compulsive behaviors. It is related to another confusion: trying to diagnose addiction from behavior, rather than from what causes the behavior.
TCPR: How can we best determine if our patients are using substances to relieve distress, or if they drink or use drugs for other reasons? Dr. Dodes: You can certainly obtain a history of the behavior and the results, but you have to do more. If you listen not for the awful results of addictive behavior, but for the factors that precipitate it—the trapped feelings that precede it—then you are in position to figure out the specific set of issues that always lead to addictive behavior in that person. When the behavior is precipitated by such individual, emotional factors rather than external circumstances, then you can be sure it is a true addiction. And paying attention to addiction as a psychological symptom allows you to better treat the person for everything that is emotionally troublesome to him or her, since the factors that lead to overwhelming helplessness are always the very things that lie at the heart of the person’s emotional life.
TCPR: Once we have determined that a patient engages in a behavior to reverse a feeling of helplessness, what does that say for treatment? Dr. Dodes: Once you discover what is overwhelming for that person, you can begin to help them. For example, in my first book (The Heart of Addiction, William Morrow, New York, NY: 2002), I described a woman who had a domineering husband, to whom she was constantly submitting, and then taking her prescription Percodan. There was something inside of her that led her to need to be submissive. In treating her, it was important to say (compassionately): “I don’t want to hear about your drug use; I want to hear about when you think of taking your drug.” She then said, “When my husband called and told me to make dinner for business guests that evening, at that moment I decided that I had to take a Percodan.” There’s the connection. Taking the drug was a solution to how she felt when he told her to make dinner: trapped and helpless. Once you see addictive behavior this way, it becomes completely integrated with the rest of the psychotherapy, as it should be, because it is just the symptom. The proper way to treat addiction is to understand how and when addictive urges arise, then focus on these precipitating issues that are overwhelming for the person.
TCPR: Do you think 12 step programs work or do they get in the way of this sort of understanding of addiction? Dr. Dodes: Of all people who go to AA, about 5% to 10% become abstinent members. About 40% who stay involved with AA maintain high levels of abstinence (Fiorentine R, Am J Drug Alcohol Abuse 1999;25(1):932–116), and only about 21% of members stay actively involved (Harris et al, J Stud Alcohol 2003;64:257–261). Multiplying these numbers gives an overall success rate of 8.4%. So if you are in that group, you should certainly go and continue to go. But referring every patient who has addiction to a 12-step program is bad practice. Beyond the fact that statistically the great majority of people referred will not be helped, as a clinician, if you say to a patient with addiction, “I will talk to you about everything else, but go to AA for your addiction,” you are giving the patient three bad messages: that you don’t want to hear about their addiction, that their addiction is a thing-in-itself and different from the rest of their psychology, and that you don’t know how to treat it.
TCPR: Are there any aspects of the 12 steps that might actually tap into the person’s ability to understand this sense of helplessness that they feel? Dr. Dodes: AA starts out by telling addicts that they are “powerless over alcohol.” Their solution is to empower people by encouraging them to attach themselves to a “higher power.” But not everyone can accept that idea. And it is not as helpful as actually working out the issues leading to addiction. AA is not an insight-oriented organization.
TCPR: Do you find anti-craving medications to be effective? Dr. Dodes: Cravings are associated with physical addiction, which is a whole different issue. If people are physically addicted, there may be a period after detox when they still have cravings, based on the fact that they were tolerant and have then withdrawn. But that is a completely different matter from the problem of addiction. Anybody can become physically addicted to certain drugs, but that doesn’t turn you into an addict. You have to have the psychology to make use of drugs for emotional reasons to have a true addiction.
TCPR: What are your thoughts about buprenorphine treatment in opiate addicts? Dr. Dodes: I think buprenorphine is a very useful drug and superior to methadone. It is a way of helping people to not use narcotics. But it does nothing to address the psychological origins of why a person was abusing them to being with. So, while it is a very good idea to take buprenorphine instead of shooting up heroin, people on buprenorphine need more to actually get over their addictions.
TCPR: What about the idea that addiction is a chronic brain disease? Dr. Dodes: There is an enormous body of evidence that shows that this is wrong. For example, the Robins study from the early 1970s looked at Vietnam veterans coming back from the war who were physically addicted to heroin. It was expected that they would be unable to quit when they got home, since heroin addicts in the US were proving impossible to treat. But it turns out that about 90% never used heroin again after returning to the States (Robins et al, Arch Gen Psychiatry 1975;32(8)955–961). The veterans had been using the same drug as the stateside addicts, so it was obvious that something about the people were different. Indeed, the difference was that the veterans had used heroin just because of their external environment: wartime Vietnam. They didn’t have an internal, psychological need to take the drug, so when they came home they could stop. That showed the psychological nature of addiction, but also that the “chronic brain disease” idea is not true. According to that idea, people who take high doses of a drug for a long time develop permanent brain changes which make them addicts forever. The veterans should have developed this “disease” and been unable to quit. Since then, there have been many other kinds of evidence that the “brain disease” idea does not apply to humans. Millions of people stopping smoking despite physical addiction to nicotine is one large example. The fact is that the “brain disease” idea came out of rat research and applies to rats, but addiction in humans looks almost nothing like addiction in rats, since we have human psychology and they don’t.
TCPR: Thank you, Dr. Dodes.
Dr. Dodes is the author of Breaking Addiction: a 7-Step Handbook for Ending Any Addiction (Harper Perennial, New York, NY: 2011) and The Heart of Addiction. His books can be purchased at major bookstores and online booksellers.