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Why There Is Lunacy – Literally – in 28-day Rehabs

Another one-size-fits-all myth.
Published on April 22, 2012 by Lance Dodes, M.D. in The Heart of Addiction

A recent television show Nurse Jackie portrayed the main character as foolish for leaving an addiction rehabilitation program before the 28 days were up. That idea is lunacy – literally. The only magic in staying 28 days is that it is approximately one full cycle of the moon around the earth.

We do many things according to numbers that have become important to us for reasons having nothing to do with their current use. Because we have 10 fingers and toes, our entire number system is based on 10. With our anatomy we count down from 10 before blasting off, and have grocery aisles with 10 items or less. If 3-toed sloths were smart enough, they would have developed a 6-based system. Intelligent octopi would count to 16 before having to come up with a two-digit number. Ten is important because of the way our bodies are made, nothing more or less.

Similarly, our week has 7 days most likely because it takes about 28 days from “new moon” to “new moon”. People have developed calendars based on the lunar cycle since Late Paleolithic times, around 30,000 years ago. The actual lunar cycle is 29.5 days, but early civilizations in Babylon and Sumeria managed this by adding days to the last week of the month to make the first 7-day period start on each new moon.

So, now we come to 28-day rehabilitation programs. There is simply no evidence that 28 days has any bearing on how long a person should be in a rehabilitation treatment program. (Of course, the same applies to 30-day programs, which are also based on the lunar cycle.) The real question is: why would people design – and defend – a treatment based on the time it takes for the moon to revolve around the earth?

Here’s the sad part. They do it because they don't understand addiction. Anyone who has read this blog, my academic papers, or my books, “The Heart of Addiction” and “Breaking Addiction,” knows that addiction is a psychological symptom, a mechanism of the mind identical to other psychologically-based compulsions. Symptoms such as this are highly treatable by understanding their basis and using that awareness to anticipate and master the addiction urge, usually well before it even emerges. There can be no set time period to master this, nor is it necessary to be hospitalized.

Hospitalization does make sense sometimes. Medical detoxification may require an inpatient stay, usually for just a few days. And when folks cannot stop their addictive behavior and it poses a danger to their lives, a break may be the best idea. But if you or a loved one does need that break, try to find someplace that sees you as an individual whose individual reason for performing your addictive behavior needs to be understood, not a place that fits you into their preset “program.” And by all means, if you are told that the program lasts for a lunar cycle then turn around and fly back to earth.

Posted on Monday, April 23, 2012 at 10:13AM by Registered CommenterLance Dodes, M.D. | Comments1 Comment | References6 References

Don’t Judge People for Not Trying

It’s more complicated than that

"You could stop if you really tried!" We have all heard this idea. It contains two assumptions: that making an effort - trying - can stop addiction, and that trying is a matter of conscious choice, a decision to exert willpower. Both these assumptions are dead wrong.

Addiction is a psychological compulsion to perform certain acts. Like other compulsive behaviors, addiction is driven by deeper emotional factors. These involve feelings of overwhelming helplessness, for which the addictive behavior is an attempted solution. With such a powerful internal mechanism, it should be obvious that you can have all the willpower in the world and be putting out all the effort in the world and still find yourself unable to stop addictive behavior.

But what are we to make of people with addictions who don't seem to be even trying to stop?

Some of these folks don't try because they see no reason to do so ("My drinking isn't a problem, so get off my back."). Here the issue is not a failure of effort, but minimization or denial. Such denial has its own origins and meanings, however, which can be addressed in treatment. For example, I've found that what is commonly called denial is often little more than an understandable defensiveness about being labeled an "addict" with all the denigrating connotations that have been associated with that word. This denial tends to dissolve when people understand that addiction, while often disastrous, is at heart driven by a healthy need - to reassert power against helplessness. It is far easier for folks to acknowledge this problem than have to accept that they are weak or powerless, or that they suffer with some character deficiency.

Other individuals have an apparent lack of effort because they have given up on ever managing their addictive behavior. Since addiction is so badly misunderstood in this country, addiction treatment is often unsuccessful. After repeated failures in traditional treatment approaches many people just throw up their hands. Who could blame them? The solution here is not to attack them for lack of effort, but to find a therapist who understands the psychological basis for addictive behavior and isn't wedded to old ways of seeing addiction that have failed them before.

Still others recognize their problem, haven't given up, and say they want to stop - yet don't seem to work at it. Surely the issue must be laziness or lack of willpower here, right? No, because for many people, their apparent lack of willpower is simply the result of the greater power that drives their behavior. Their deeper need to reverse intolerably helpless feelings simply crushes more conscious wishes, such as the desire to quit. Outwardly, these folks may appear to be indifferent. But as I describe in many cases in my books, "The Heart of Addiction" and "Breaking Addiction," these same people often prove to be quite able and willing to end their addictive behavior once they work out the powerful factors behind it. Awareness of the deeper emotional precipitants for their addictive urges enables them to separate these powerful issues from their addictive behavior. When that happens, any issues of willpower vanish: it's like unplugging the power cord to the addiction.

There is one more group who appear to lack effort: those who have, over time, just adapted to a lesser life. They live in a stable compromise where they tolerate the costs of their addiction in exchange for its immediate feelings of relief. One man I saw, for example, lived for decades with chronic alcoholism and the resulting endless tension in his marriage. Growing up, he had never expected more from life, so he viewed his unhappy existence as inevitable. After a significant time in therapy, and as a consequence of resolving these lifelong issues, his "willpower" to stop drinking miraculously returned.

The appearance of putting forth effort is a misleading and harmful way to gauge the desire of someone to get better. We would all be better off if we tried to understand the factors that lead people to be passive or opposed to controlling their addictive actions - and support them in seeking good psychological help to work out these factors.

Posted on Friday, March 23, 2012 at 02:01AM by Registered CommenterLance Dodes, M.D. | Comments2 Comments | References2 References

The Worst Addiction Advice You Can Get

On the insanity of stopping addiction before you treat it

Published on February 28, 2012

Not long ago, a woman suffering with alcoholism told me she'd been advised by a self-styled "addiction expert" that she should stop drinking before seeking psychotherapy to work out the problems bothering her. In essence, she was being told, "First get better, then get treatment." This ridiculous idea is even stranger if you imagine it being said by a therapist: "Go away and stop drinking, then I'll treat you." Incredibly enough, there are therapists who say just that.

Since addictive (or compulsive) behavior is a psychological symptom—a disastrous effort to manage feelings of overwhelming helplessness—it makes sense that psychotherapy is an optimal way to understand its causes and precipitants, and ultimately the best way to manage it. Of course, there are some people who are unable to do psychotherapy. They are incapable of being introspective or thoughtful about themselves. For these folks a modified approach is needed that does not call upon them to be self-observing. But people with addictions are like anybody else. Most people with addictive symptoms are quite capable of thinking through their problems with competent help.

Naturally, you might note that besides psychotherapy there are other treatment approaches. The most common and famous of these are 12-step programs. They work great for some. But widely publicized academic studies have repeatedly shown that only 5 to 10 percent of all people who attend AA become sober members. That's a lot better than zero percent, of course. But that means that advising people with addictions to delay other treatment in favor of going to a 12-step program will be the wrong recommendation at least 90% of the time. This is unfortunate, since AA is free and widely-available, but there is no getting around the facts. That's not to say AA can't have a supportive role. Sometimes people do well with both psychotherapy and AA. I wrote a paper about that many years ago. But that's different from advising folks to go to AA first and therapy later.

There is one more thing to consider. How do you ever "get" someone to stop doing a compulsively driven behavior? We all know that this is fundamentally impossible. When people change behavior it is because something has changed inside of them. That's what happens in a successful psychotherapy. It can also happen through transformative life experiences, and sometimes through internalization of loving support of others. But neither of these things can be prescribed or counted upon to cause folks to stop drinking, taking other drugs, gambling, or compulsively seeking sexual activities. So it makes no sense to advise people to delay psychological help for their psychological problem in the hope that something else will fix it first.

Here is some advice, though, that I believe you truly can count on. If someone tells you to first stop your addiction before seeking psychotherapy, turn around and walk away as fast as you can.

Posted on Tuesday, February 28, 2012 at 08:54PM by Registered CommenterLance Dodes, M.D. | Comments1 Comment | References16 References

Do not suppress addictive thoughts!

Knowledge is better than ignorance.

Published on January 23, 2012

Recently, a man suffering with alcoholism told me how he approached his problem: when he had thoughts of drinking, he tried to push them out of his mind. This didn't always work of course, and even when it did he regularly drank later. But he was still pleased that he was "putting up a good fight" against his enemy - his terrible drive to drink. He asked me if I agreed with his plan, and whether I thought that his intermittent success was a sign that he was making progress. I was sorry to say I did not. Pushing away thoughts of performing addictive actions is, in fact, a terrible idea. His technique was not just doomed to failure but actually interfered with ever mastering his addiction.

Addictive thoughts are never random, so the moments when they occur provide critical opportunities to learn what drives an addiction. Whatever event, circumstance, interaction, thoughts or feelings that occurred just before the appearance of addictive thoughts will be a clue to the issues for which addiction is a solution. To distract oneself at just that moment is the last thing to do if you hope to gain control of addictive behavior.

Naturally, paying attention to any single episode of thinking about drinking or another addictive act may not be sufficient to see the underlying theme behind all one's addictive acts. But the more occasions spent focusing on the precipitating circumstances behind that first instant of addictive thought, the easier it becomes to solve the mystery.

Focusing on these key moments when addictive thoughts first arise also has an immediate value. Even if the precipitating factors are unclear, just thinking about them at these times creates a helpful separation from the helpless feelings that always precede and precipitate addictive thoughts. After all, to think about oneself is to stand beyond one's inner world and observe it, not be immersed in it. Self-observation is an antidote to feeling helplessly trapped.

Suppressing addictive thoughts is also part of another problem. The man I'm describing tried to squelch his addictive thoughts because he viewed his addiction as an enemy to be stamped out. But seeing addiction as his enemy kept him from seeing it as a part of himself: an attempt to resolve intolerably helplessness feelings by taking an action that would restore an immediate sense of power. Instead of thinking of his drinking, or even his thoughts of drinking, as the enemy, he would have been much better off seeing his addiction as a symptom with an understandable emotional purpose and drive. Instead of looking away from his problem, he could have looked toward it and learned about it.

Working to suppress thoughts involves yet another mistaken notion: the false and destructive idea that addiction can be mastered through willpower. The idea that people can control addictions just by trying hard is a longstanding myth that has led to denigration of people with addictions as "weak" or lacking in "character." Of course, people with addictions have as much willpower as anyone else. Like every other psychological symptom, addiction arises from internal, at least partially unconscious, emotional issues and is an attempt to deal with them. Emotional symptoms (which we all have to one degree or another) are not treatable simply through conscious effort. People with addictions can no more stop their symptomatic behavior through willpower than can people with depression, anxiety or phobias. And beyond the unwarranted criticism directed at people with addictions, those who themselves believe that their addiction can be "defeated" by force of will (for example, suppressing addictive thoughts) are setting themselves up to feel worse about themselves when willpower inevitably fails.

It does take work to deal with addiction, but not the work of pushing away thoughts. It is the work of observing one's complex feelings, motivations and conflicts, especially at the time of first thinking of performing an addictive act. Self-observation is not easy for anyone, and is especially hard if thoughts are quickly followed by strong urges to act. But this is where learning about the underlying issues precipitating addiction pays dividends down the road. Once you have identified the specific emotional factors leading to feeling overwhelmingly helpless - and then to addictive thoughts - it becomes possible to predict in advance when these thoughts will arise. That allows time to find ways to deal with these emotional precipitants before feeling flooded by them, not by crushing your own thoughts, but by understanding them.


Is addiction really a disease? And if not, what is it?

A new look at an old idea.

Published on December 17, 2011

For many decades it's been widely accepted that alcoholism (or addiction) is a disease.  The "disease concept" is taught in addiction training programs and told to patients in treatment programs.  It is unquestioned by public figures and the media.  But is it true?  And if it is not true, is there a better and more helpful way to define addiction?

Let's start with a short history.  In the bad old days, before the disease concept became widely popular (about 40 years ago), our society was even more prejudiced against people with addictions than it is now.  "Addicts" were seen as different and worse than "normal" folks.  They were thought to be lacking in ordinary discipline and morality, as self-centered and uncaring.  They were seen as people who were out for their own pleasure without regard for anyone else.  They were viewed as having deficiencies in character.

Then came the idea that addiction is a disease: a medical illness like tuberculosis, diabetes or Alzheimer's disease.  That meant that people with addictions weren't bad, they were sick.  In an instant this changed everything.  Public perceptions were less judgmental.  People were less critical of themselves.  Of course, it wasn't welcome to hear that you had a disease, but it was better than being seen as immoral and self-centered.  So, the disease concept was embraced by virtually everyone.  With all its benefits, it's no wonder this idea continues to attract powerful, emotional support.

Widespread enthusiasm for the disease model, however, has led to willingness to overlook the facts.  Addiction has very little in common with diseases.  It is a group of behaviors, not an illness on its own.  It cannot be explained by any disease process.  Perhaps worst of all, calling addiction a "disease" interferes with exploring or accepting new understandings of the nature of addiction.

This becomes clear if you compare addiction with true diseases.  In addiction there is no infectious agent (as in tuberculosis), no pathological biological process (as in diabetes), and no biologically degenerative condition (as in Alzheimer's disease).  The only "disease-like" aspect of addiction is that if people do not deal with it, their lives tend to get worse.  That's true of lots of things in life that are not diseases; it doesn't tell us anything about the nature of the problem.  (It's worthwhile to remember here that the current version of the disease concept, the "chronic brain disease" neurobiological idea, applies to rats but has been repeatedly shown to be inapplicable to humans.  Please see earlier posts in this blog or my book, Breaking Addiction, for a full discussion of the fallacy of this neurobiological disease model for addiction.)

As readers of this blog or my books knows, addictive acts occur when precipitated by emotionally significant events, they can be prevented by understanding what makes these events so emotionally important, and they can be replaced by other emotionally meaningful actions or even other psychological symptoms that are not addictions.  Addictive behavior is a readily understandable symptom, not a disease.

But if we are to scrap the disease concept and replace it with something valid, our new explanation must retain all the beneficial aspects of the old disease idea.  It must not allow moralizing or any other negative attributions to people suffering with addictions.  In fact, we'd hope an alternative explanation would have more value than the disease label, by giving people with addictions something the disease concept lacks: an understanding that is useful for treating the problem.

Knowing how addiction works psychologically meets these requirements.  Recognizing addiction to be just a common psychological symptom means it is very much in the mainstream of the human condition.   In fact, as I've described elsewhere, addiction is essentially the same as other compulsive behaviors like shopping, exercising, or even cleaning your house.  Of course, addiction usually causes much more serious problems.  But inside it is basically the same as these other common behaviors.  When addiction is properly understood to be a compulsive behavior like many others, it becomes impossible to justify moralizing about people who feel driven to perform addictive acts.  And because compulsive behaviors are so common, any idea that "addicts" are in some way sicker, lazier, more self-centered, or in any other way different from the rest of humanity becomes indefensible.

Seeing that addiction is just a compulsive symptom also meets our wish for a new explanation: unlike the "disease" idea, it actually helps people to get well.  As I've described in this blog and my books, when people can see exactly what is happening in their minds that leads to that urge to perform an addictive act, they can regularly learn to become its master, instead of the urge mastering them.

Despite all its past helpfulness, then, we are better off today without the disease idea of addiction.  For too long it has served as a kind of "black box" description that explains nothing, offers no help in treatment, and interferes with recognizing newer ways to understand and treat the problem.

And there is one more advantage.  If we can eliminate the empty "disease" label, then people who suffer with an addiction can finally stop thinking of themselves as "diseased."


How To Tell Who is Right about Addiction

Examining the arguments.

We all know that there are vastly different, widely-disseminated views about the very nature of addiction. When I give lectures about addiction, I am sometimes asked, "With all these opinions, how can I tell who is right?" It turns out that there is a surprisingly straightforward way to figure this out.

To set the stage: as I've discussed and illustrated in this blog and my books on addiction, addiction is a psychological symptom like other common symptoms that we call compulsions. While physical dependence is quite real, it cannot explain the clinical picture of addiction: the recurrence of addictive behavior years after physical dependence has faded, the frequent substitution of non-drug addictions for drug addictions, and so forth.

Now, when two sides debate, we judge which side to believe based on their expertise - their knowledge and experience of the issue at hand. If a chef debates a nuclear engineer about nuclear physics, we believe the engineer. If the topic shifts to the best way to cook a duck, we believe the chef.

We also want to know whether each side has studied the other's position. Generally speaking, if Side A doesn't know the basis for Side B's viewpoint, we should dismiss Side A for basing its conclusions only on its own perspective. How believable are they if they aren't aware of the errors or limitations others have identified?

On the subject of addiction, let us first consider the question of expertise. Neurobiologists who study drug effects on the brain have devoted their professional lives to studying just that. They have both training and experience in the anatomy and physiology of brains, and their work largely consists of conducting laboratory experimentation on animal brains (mostly rats). It is therefore reasonable to believe what they say about how these animal brains work and how they are affected by drugs. But these scientists typically have little or no experience treating people, and their training is not mainly devoted to human psychology. (Even those neurobiologists who are psychiatrists have chosen this career path largely in place of clinical work with patients.) This has resulted in a fundamental problem with the neurobiological theory: it takes findings with rats and generalizes them to humans. It is a leap that would never be made by people who have training and experience with addictions in people.

To those familiar with addiction in human beings, it is obvious that the "addictive" behavior observed in rats is nothing like the behavior of people with addictions. When rats have long-term exposure to opiates, they increase seeking behavior in response to cues associated with the drugs, just as in Pavlov's famous dogs. But the changes in rats' brains that lead them to automatically seek drugs when exposed to cues either do not occur in humans, or if they do occur, do not produce addictive behavior. As I have described elsewhere in this blog, a massive body of evidence has proven that exposing people to drugs for long periods does not turn them into addicts as the "chronic brain disease" theory would predict. And addiction in humans looks very little like rat behavior in a number of other important ways:

  • Addiction in humans is not thoughtless or instantaneous or automatic. People often wait hours to get a drug supply, or to drive to a casino, or to pick up a bottle of liquor.
  • Acts of addiction in humans are virtually always precipitated by emotionally important factors, not simple external cues.
  • Humans can substitute non-addiction compulsive behaviors like cleaning the house for drug addictions. That cannot be explained by the "chronic brain disease" model.
  • Once people with addictions understand how their addictions work psychologically, they are regularly able to control or stop their addictive behavior.

Let's now consider the question of expertise on the psychological side of the debate: people who treat human beings with addiction. For myself, I have trained extensively in human psychology, first as a psychiatrist and then as a psychoanalyst. I have devoted my career to treating people, as director of major addiction treatment programs involving thousands of people where I treated and supervised the treatment of many of them myself, and in my individual psychotherapy practice for over 35 years. I have written many academic papers and books about the psychology of addiction. This is the training and experience behind my views about human addiction.

But what about the other big criterion we use to evaluate an argument: understanding the other side's facts and logic? Although my interest is in human psychology, I read the neurobiological literature. In 2009 I published an academic paper on the respective roles of neurobiology and psychology, referencing and describing the neurobiological view and explaining where it is applicable and where it falls short.

It is possible that some of the leading neurobiologists have read the psychological literature, but I can tell you that I have not found any sophisticated consideration of the psychology of addiction in any of the neurobiological addiction literature (and I am a reviewer for more than one addiction journal). What passes for psychological insight (if it appears at all) is questionnaires about general traits like "interest in risky activities." This absence of sophistication quite simply makes it impossible for the authors to recognize or meaningfully engage the psychology behind addictive behavior.

So, who is right? I offer this rule of thumb: for questions about how drugs affect brains and where in the brains drugs act, believe the scientists who study those issues. For understanding addiction in humans, believe those who have experience and training with humans. If still in doubt, remember that human addictive behavior is vastly different from the behavior called "addiction" in rats which is the basis for the neurobiological view.

One final point. Some authors like to split the difference and say addiction (in humans) is both psychological and neurobiological in origin. This approach tends to make everyone feel good. However, since the "chronic brain disease" idea doesn't apply to people, it isn't good science to include it in the explanation.


Posted on Friday, September 2, 2011 at 02:33PM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References14 References

Failures to understand addiction are everywhere

Even so-called experts often misunderstand the nature of addiction

Published on July 19, 2011

Jonathan Rhys Meyers, star of Bend It Like Beckham and The Tudors, was hospitalized recently due to an alleged incident involving alcohol, possibly mixed with prescription drugs. It didn't take long before speculation began to focus on the question of whether this was a "relapse" or even a suicide attempt. As an addiction psychiatrist, I fielded a number of questions about this news from patients and colleagues alike.

One quote came from the CEO of Promises Treatment Centers, Dr. David Sack, who went on the record with People magazine to discuss his take on the intimate details of this alleged incident:

"[T]o recover, an individual has to believe they have a problem. The fact that Rhys Meyers was trying to send away the ambulance suggests he didn't recognize the seriousness of the problem and that he was still hoping to conceal it. If on reflection he decides to re-engage in treatment, his prognosis could be very good."

This statement reveals something about the mistaken way our society thinks of addiction. First, I think it's safe to say that Mr. Rhys Meyers is aware that he has a problem: he has been in and out of trouble with the law for years surrounding alcohol-related incidents. Of course without knowing him, I cannot say whether or not he has an addiction. But I can say that nearly everyone with compulsive or addictive behavior is aware that something is wrong.

But acknowledging this problem by name ("I have an addiction") is another matter altogether. Why is this so hard? Probably because of our culture's mistaken view of addiction. After all, if you believe addiction to be a pleasure-seeking behavior due to some defect in character, or the modern version of this error, that addiction is a pleasure-seeking behavior due to a "brain disease" that biologically enslaves you into seeking the pleasure of drugs, then of course you will deny that you have an addiction. Who wouldn't?

But addiction is about something entirely different, and people with addictions are no different from anyone else. Addiction is about taking active steps to reverse an intolerable sense of helplessness. When this response is directed toward a displaced or substitute behavior, we call that behavior an addiction. This essential fact - that addiction is just a healthy emotional response gone awry - makes it far easier for people to "admit" this problem and name it accordingly.

That said, acknowledging the problem by name is hardly a prerequisite to getting well. If that were true then therapists would turn away anyone who didn't begin treatment by agreeing to the label. On the contrary, it is often necessary to start someplace that makes sense to the person seeking help. That doesn't mean ignoring the addiction. But in order to treat it you have to understand the people who suffer with it. Since addiction is no more and no less than a psychological symptom, like other symptoms we all have, getting to know people with addictions and helping them to understand themselves usually turns out to be the best way to help them with their addictive behavior.

Unfortunately, the same therapists who think a person must "admit" his problem before embarking on treatment often also believe that there simply isn't time to treat addiction as a psychological problem, even though that is exactly what it is. The result is frequent treatment failures caused by treaters focusing exclusively on how bad their behavior is for their patients, trying to rationally convince them to stop that behavior, focusing on superficial advice ("Avoid walking into a bar"), or applying a 12-step approach whether it seems to fit that person or not.

The only thing we really have no time for is ineffective treatment. We should discard platitudes such as having to "admit" you have a problem before you can get better, and focus instead on making sense of this surprisingly understandable behavior. Perhaps if Mr. Myers understood that addiction is simply a comprehensible - and reparable - issue, he might be quite willing to talk with someone about the troubles he has suffered.


Is Anthony Weiner a Sex Addict?

And what would that mean, anyway?

Published on June 22, 2011

As the author of two books about addiction as well as a number of professional journal articles, I get a lot of questions from patients and colleagues alike about the nature of compulsive behavior -- what drives it, what gives it its power, and especially why so many people repeat destructive behaviors in the face of overwhelmingly bad consequences.

This question has resurfaced over the last couple of weeks as pundits and politicians began speculating about the motivations and psychology of Representative Anthony D. Weiner of New York. In case you have been on a news hiatus -- and who could blame you -- Congressman Weiner recently became engulfed in a scandal over some explicit photos he sent to various women over the Internet. When the story broke, allies and foes alike promptly demanded his resignation for what they deemed inappropriate behavior. Eventually the political pressure grew so great that Mr. Weiner was forced to resign from office.

Now, leave aside the question of whether a political figure's personal life is any of our business. I want to focus for just a second on the question so many people are asking: why? Why would a successful politician, media darling, and presumptive New York mayoral candidate sabotage his career in this way? Was it intentional? A cry for help? A daring bid to get caught? And why does this kind of behavior seem to be so common across the political spectrum? (See, for example, Messrs. Clinton, Spitzer, Schwarzenegger, Edwards, and Lee.) Is there something about politics in particular that rewards or invites sexual risk-taking, or is it simply the place where most of them get caught?

It is tempting to play parlor psychoanalyst and speculate about Representative Weiner's personal motivations, but of course such speculation would neither be fair nor appropriate. I have never met Mr. Weiner, nor would I presume to understand what goes on inside his head, let alone his marriage. But I can speak more generally to the question of why men in power may sometimes find themselves compelled to act out sexual fantasies that are almost certain to invite ridicule and recrimination.

Compulsion has certain qualities that are universal. Longtime readers of my work will recall my view that addiction arises from feelings of intolerable helplessness. This helplessness manifests differently for different people, of course -- it is subjective. But the common factor is its intolerable nature -- the kind of helplessness that goes straight to the heart of our sense of self. Most people act to repair these feelings directly when they occur, but addiction arises when this direct action is forbidden in some way -- considered by the suffering individual to be prohibited or taboo. The addiction then becomes a substitute remedy, a quick fix which works reasonably well in the moment, but which has devastating consequences over time.

In other words, addiction is neither a disease nor a pleasure-seeking behavior. It is an important act that serves a function, and understanding that function is the key to getting well.

So what does any of this have to do with Representative Weiner -- or for that matter, Clinton and the others? If their problem is not really an addiction, then maybe nothing. But it is not unreasonable to imagine that politics in general attracts more than its fair share of people deeply concerned about their value and importance. And their need for affirmation is just the sort of torment that is often driven by a deep sense of helplessness to be valued. Whether these feelings give rise to a compulsive quest for power or for sexual affirmation may not be much of a difference. I surely wouldn't be the first person to point out the strong association between power and sexuality.

As a touchstone for a broader discussion about the psychology of addiction, it bears repeating that all compulsive behaviors serve a purpose. On the surface, that purpose may look like sexual pleasure or a chemical high, but what underlies the behavior is inevitably a desperate need to repair feelings of helplessness. If someone doesn't feel enough of a powerful person, or enough of a worthy human being, he may find himself turning to reckless behavior without really knowing why. The best way to overcome any compulsion is to seek to understand its causes, and to discover more direct and healthy ways of addressing those feelings in the future.


The myth of impulsiveness in addiction

Addictions are the opposite of impulsive.

The often-stated notion that people with addictions are "impulsive" goes right along with the myth that addiction is pleasure-seeking or the result of some weakness of the mind. If you believed those myths then you would be willing to believe that addictive behavior is an unthinking, sudden act simply expressing an urge to instantly have what you want. But anyone who has experience with addiction knows that addictive acts are virtually never impulsive.

Addictive behavior occurs at the end of an emotional path, a journey that can take hours or even days. The first step in this journey is having the thought of performing the addiction -- drinking, for example. Moments to hours after having that thought, a person may make the decision to drink. But in between these steps there is often an internal struggle over whether or not to act. Sometimes, during that period the thought of acting seems to disappear or is pushed out of consciousness for a while. Then there is another delay. Even after the decision is made, the act has to be planned. Commonly, people wait to leave work at the end of the day to go get that drink, or have to get in the car and drive to a liquor store or a bar. There is then a wait for the waiter or the bartender to take the order and to have the drink brought over. Delays of this sort are present in every addiction. In compulsive (addictive) gambling, it is often necessary to drive a distance to the closest casino. Where I live it takes about an hour, but compulsive gamblers make that trip all the time. Likewise, there is planning and delay in contacting a drug dealer, or driving to where prostitutes hang out, or finding a time to be away from others to privately get on the Internet to watch porn. I have seen cases in which people with addictions plan their drinking or calling a prostitute or obtaining their drug days in advance. None of this behavior is impulsive

Real impulsive behavior is immediate. It is simply stimulus-response, like a biological reflex: see it, do it. Since it is literally unthinking, impulsive behavior has no planning. Indeed, if there were a delay or a need to plan the action, people would use their common sense and decide not to do dangerous or destructive acts.

Addictions are almost the opposite of impulsive action. When people with addictions feel an intense drive to eat or drink or gamble or watch pornography, we call such behaviors compulsions. (These psychological compulsions are different from the biological illness "OCD.") These compulsions are triggered by emotional factors and generally represent an attempt to regain a sense of control when people feel helplessly out of control. For example, after a devastating loss people sometimes irrationally clean and straighten up their house, unconsciously trying to re-establish order and control in their lives. In Shakespeare's play Macbeth, Lady Macbeth has a similar compulsion to repetitively wash her hands, to cleanse her of her guilt at having been complicit in several murders (symbolically "wash the blood off her hands"). Compulsions have meaning and purpose and can be understood. They are complex functions of the mind, rather than a simple impulsion to fill an immediate wish. Addictions are compulsions and they, too, are attempts to (temporarily) regain a sense of control when that sense has been lost or taken away. That is why addictions can tolerate delay: it is relieving just to have decided to perform the addictive act, since in making that decision one has already seized a measure of control. This is why it is so common for people to report that once they have decided to drink or gamble or eat, they feel better.

The fact that addictions are not impulsive underscores why they are not essentially a problem of brain chemistry. The "brain disease" chemical model requires that addictive behavior is driven by stimulation of the brain's pleasure pathway. That would fit the facts if people, like the rats on whom the brain disease theory is based, immediately scurried about seeking drugs when stimulated by cues. The rats are seeking pleasure and their response is active so long as their brain chemistry is stimulated. But a brain stimulation model is inconsistent with the delayed, meaningful, non-impulsive nature of addiction.

Knowing that addictions are not impulsive is another reason that people who suffer with addictions should not be seen as pleasure-seeking, weak or unthoughtful. They are just people who, along with all their perfectly good functioning, are troubled by a particular psychological symptom. That means they are pretty much like everyone else.


If you do something too much, is it an addiction?

Diagnosing addiction can be tricky


This week millions of families will gather together to celebrate a holiday, Easter or Passover. At some of these gatherings an uncle or cousin will talk too loud, interrupt too much or turn an innocent conversation about the state of the local baseball team into an ugly argument. He or she has had too much to drink. Do these people have alcoholism?

Of course, first you'd want to know if this was the only time they'd done this. Anyone can overdo behavior - drink, gamble, eat - without having an addiction. But what if this had happened before? How easy is it to make a diagnosis?

Actually, this may not be easy. Sometimes people overdo in certain situations, but the rest of their lives they're fine. Large family gatherings may be just that difficult kind of setting. It can produce the feeling, "Hey, it's just family! What a great time to toss out good sense, or even good manners!"

The setting you are in does affect self-control. This phenomenon is well-known to the gambling industry, for instance. If you've ever been in a casino you know that they have no windows and no clocks. The setting is designed to help you ignore the fact that time is passing. And the room is supplied with bright lights and exciting sounds, showing that somewhere somebody is winning a fortune. You are primed to feel that it's all fun here, a place to be carefree. And you don't have to worry about losing money because the casino has no money! There are just these colorful chips. How different they are from the hard-earned cash I worry about in my regular life. Finally, if this isn't enough to help ease your mind out of its normal routine, the casinos provide one other incentive. They give out free liquor.

So, setting can influence behavior. Therefore, if repetitive, excessive behavior is restricted to specific settings, it may not be an addiction at all. A famous example is the Vietnam soldiers I've described in earlier blogs, who used heroin because they were in a war zone but stopped when they returned home.

There are other non-addiction causes of excessive behavior. Habits are a good example. Habits are just automatic behaviors you perform without having to think about them. They can be stopped when you decide to pay attention to them because, unlike addictions, they have no deeper emotional basis. For example, one woman said, "I always had a candy bar after lunch. I figured it would add a pound or two but my weight is okay and it was just something I always did. Then my doctor told me I was pre-diabetic and had to watch my sugar intake. What a bummer. But I have a lot of willpower and let me tell you, that was the end of the candy bars." The key difference between habits and addictions is that habits, having no deeper emotional function, can be broken with willpower alone. Addictions, of course, cannot. But they can be easily confused unless you figure out what is driving the behavior.

Repetitive, excessive behavior can also be the result of trying to go along with the group. If "everybody is doing it" then you may do it too, against your better judgment. This is common among adolescents, where acceptance by the "in" group may feel critical. But adults respond to interpersonal pressure too, especially if it is a loved one who is encouraging you to drink or take drugs with him, or her.

If a behavior can be repetitive and excessive without being an addiction, how do you diagnose true addictions? Certainly, it's not enough that the behavior is destructive, since lots of repetitive non-addictive behaviors are destructive. Drinking and driving even without having alcoholism can still kill you. And to confuse matters, even though addictions always cause trouble for the people who suffer with them, the trouble may be small enough to go unnoticed for some time. A man who had millions compulsively gambled on the lottery, but never lost enough to make much difference in his life, at least financially.

If you can't reliably diagnose addictions from their outwardly observable effects, then it is clear that they have to be diagnosed from the inside out. Addictions are emotional mechanisms to manage overwhelmingly helpless feelings, as I've described in my books and this blog. If you want to diagnose addiction in yourself or others, you have to know the reasons for performing the behavior. Repetitive, excessive behaviors that are driven by an urgent need to reverse an overwhelming sense of helplessness are addictions. Addictions don't depend on the setting or a need to keep up with the group, and they're not habits that can be broken by willpower alone.

When the usually peaceful Uncle Max turns a discussion of the home team's pitching staff into an angry argument, he's had too much to drink. But we'd want to get to know him better, and maybe discreetly suggest to him that he give some thought to this himself, before settling on the conclusion that he has alcoholism. It's a big mistake to tell people that they have an addiction if they really don't. That's a quick way to stop being listened to. But it's a big mistake to fail to diagnose it, too. The best course of action is to learn more about the nature of addiction and learn more about the person (or yourself) that you are concerned about.

For more about diagnosing addiction and non-addiction causes of excessive behaviors, see my books, "Breaking Addiction: A 7-Step Handbook for Ending Any Addiction" and my earlier book, "The Heart of Addiction," both published by HarperCollins.


Breaking Addiction

It can be done, once you know how.


Let's face it; addiction treatment has not been very successful. But there is a clear reason for this: we haven't understood how it works. Once you do understand it, though, there are some critical steps you can take to break it. In my new book, Breaking Addiction: A 7-Step Handbook for Ending Any Addiction (HarperCollins, 2011), I describe those steps.

As previous readers of this blog know, true addiction (versus simple physical dependence) is neither more nor less than an emotional solution to manage feelings of intolerable helplessness. When people feel utterly trapped they have to do something, and if they feel they can't act directly to get out of the trap then they have to do something else. The "something else" is a substitute action or displacement. It is this displaced action that we call an addiction.

For example, Ron was sitting at his desk at 1 o'clock in the afternoon when a pile of new work was dumped on his desk. He already felt overwhelmed with all he had to do, and he'd promised his children that he'd come home and help them build a fort that evening. On top of that, he'd told his wife that tonight, for a change, he would come home early. He was trapped.

But Ron suffered with alcoholism, so at that moment when he felt helpless in the face of the work that was piled high on his desk, he decided that, by God, he was going to have a drink when he got out of work. Significantly, as soon as he made this decision he felt less pressured. He could and would do something that he knew would make him feel better. He had reversed his helplessness. And his solution, drinking, was driven by the furious intensity that anyone feels when utterly trapped. However, his decision to drink was not a direct response to the actual work problem. He didn't go to complain to his boss, or determine that he would do a less thorough job with his new tasks. His drinking (or even just his decision to drink) was a substitute activity driven by all the intensity of a person trapped in a cave-in. We have a name for such intensely driven substitute actions: "addictions."

Once you understand this is how addictions work, then there are steps you can take to combat the process. First, notice that the beginning of Ron's path toward drinking was hours before he actually drank, when he first thought about having a drink. I call this the "key moment" in addiction, and it is crucial to be able to identify it. Sometimes doing this is pretty easy, as in Ron's case. But the key moment can be harder to spot, because of your own defenses. For example, in another case in the book I describe a woman who became confused just when she felt most overwhelmed. This made it impossible for her to recognize when she felt anxious and despondent, just the moments that always led to her addictive behavior. Recognizing your defensive style is another of the steps in my book.

But what can you do when the addictive urge is upon you? The basic idea is fairly simple and I describe it in the book in Step 6, "Short-term Strategies for Dealing with Addiction." If addictions are just displaced actions -- substitutes for doing something to directly deal with the trap -- then it is only necessary to undo this substitution and take a more direct action. For instance, a woman with food addiction regularly went home and binged on junk food when she felt left out and unimportant, such as often happened to her in social settings. After she learned how her addiction worked, she was able to manage the next meeting of her pottery group very differently. She didn't have to do anything extraordinary; she just spoke up a bit about her concerns as a new member of the group, and when she got home she didn't need to eat. She had learned what made her addiction go and addressed it directly.

Another woman (whom I have described previously) felt she had to comply with her husband's demands to create a dinner for many guests on short notice. Usually, she meekly accepted these demands, and then took her Percodans. But when she was able to come up with a more direct solution ("I know I should have just told him to make his own damn dinner, but at least I figured out another way out"), and ordered take-out Chinese food, her addictive urge vanished! There was no magic here. She had just taken a more direct action to deal with her helplessness trap, so she didn't need her addictive act.

Sometimes, though, finding the more direct action is more complicated, such as when there is no clear action that will solve the problem. In the book I describe a man whose urge to use heroin became nearly overwhelming when he realized that his girlfriend was going to break up with him. Here, there was no clear direct action he could take to reverse the helplessness he felt. He needed to think about his helplessness trap in a different way: from the standpoint of what this loss meant to him, rather than just the loss of his girlfriend. I describe how to go about refocusing on your feelings, rather than only the external reality, in Chapter 6.

Step 7 in Breaking Addiction describes long-term strategies. These involve not just knowing how to identify the key moment on the path to addiction and how to manage the urges when they occur, but how to anticipate when they will occur and thereby avoid even having to reach the stage of intense feelings. When you have reached that point, the addiction is broken.

There has been a great deal of pessimism about breaking addiction. But we are embarking on a new era in understanding and treating this very common problem. There is now very good reason for hope.

Does addiction have to destroy love?

Not if you understand the psychology of addiction.

Phyllis and Peter had been married a few years when he started hiding "nip" bottles of vodka in the house. After Phyllis discovered them he lied, saying he had stopped drinking and she'd found the last of them. When a week later she found more bottles, she threw Peter out. "If it had only been his drinking," she said, "I could have stood it. But lying is different. A marriage can't exist without trust." Did addiction have to ruin this marriage?

The story of Phyllis and Peter is taken from my new book, "Breaking Addiction: A 7-step Handbook for Ending Any Addiction." The major issue between them is probably the most common way that addictions spoil relationships. Peter's drinking itself was a huge problem of course, but as Phyllis said, it was not the fatal one. Loss of trust was what would kill their relationship, and that would have to be repaired if this otherwise good marriage had a chance. Repairing trust would allow them to work together, creating the time and space needed for Peter to seek treatment for his addiction.

How can this happen if the person with addiction continues to lie?

The answer is that, when it comes to addiction, lying and general untrustworthiness are not quite the same thing. Although people with addictions often lie, nearly all the time their lies are about their addiction. Peter lied about his hidden liquor supply, and he had lied about going to bars on his way home from work, telling Phyllis he was just working late. But he didn't lie to her about anything unrelated to drinking. In fact, Peter was a very conscientious man, the sort of person who would return the money if he were given too much change at a store. Except for his drinking, it wouldn't cross his mind to lie to Phyllis. For the couple to survive, they would have to understand what the difference was between lying about addiction and lying in general.

First, let's consider what Phyllis thought Peter's lying was about. To her, it was a sign that he was excluding her from his life and was no longer treating her as his life partner. He was manipulating her and no longer respected her. Ultimately, his lying meant that he no longer loved her.

But from Peter's standpoint, his lying meant none of those things. He still loved his wife very much, but he was ashamed about his inability to stop drinking, and filled with guilt about hurting her repeatedly when he did. So, he came up with the only solution he could think of. He couldn't stop drinking, but what Phyllis didn't know wouldn't hurt her. He would be less ashamed and she would be less injured if he lied.

However, Phyllis regularly caught him in his lies, which made Peter feel even more guilty and ashamed. On these occasions, he promised never to drink again, and he meant it. But since he was unable to keep his promise, the problem escalated. Now he needed to conceal his drinking even more. In effect, the more he lied the more he needed to lie.

Peter felt trapped. As I've written about before in this blog and both my books, it is just this kind of helplessness that produces the impulse to addictive behavior. Peter's drinking had been, to begin with, a response to entirely separate issues in his life that led him to feel helplessly trapped. But now this new trap added to Peter's sense of overwhelming helplessness, and became a new precipitant to drinking. This new cycle of drinking, shame, lying, and more drinking was devastating, for both of them.

But here is the key point. Peter's drinking to begin with had been about issues within Peter, as is true about every addiction -- particular areas of his emotional life that led him to feel overwhelmingly helpless. His drinking was not about his feelings for Phyllis, even though she suffered terribly as a result. Exactly the same reasoning applies to Peter's lying. Although Phyllis suffered as a result of his behavior, the cycle of Peter's lying and drinking was not essentially about his feelings for her. Her interpretation of Peter's lying as a sign that he no longer loved or respected her, therefore, was not correct. There was an especially sad irony in this, because Phyllis's conclusion that Peter no longer loved her made her feel much worse.
The solution for this couple was to help them to understand both how addiction works psychologically, and how lying about addiction so often becomes part of the addictive cycle. As Phyllis was able to separate Peter's general trustworthiness and his usual respect for her from his addiction, her anger and hurt lessened. The furious tension between them subsided, and Peter was able to get into a good psychotherapy to address his addiction.
Phyllis and Peter found that the better you understand the psychology of addiction, the better you can repair not only addictive behavior but the damage to relationships caused by it.


Are people with addictions any “sicker” than anyone else?

Understanding the psychology of addiction provides the answer.

For the past few thousand years people have thought "addicts" were self-indulgent hedonists, lacking in the self-control present in healthy people. More recently people with addictions have been seen as psychologically "primitive," their addiction a sign of early developmental issues or a major personality disorder. None of this is true.

The first mistake, that people with addictions are self-indulgent or pleasure-seeking, arose from looking at addictive behavior instead of the psychology that causes it. As I've described in earlier posts and my book "The Heart of Addiction," addictive behavior is a temporary solution designed to reverse feelings of overwhelming helplessness. It is not at all motivated by a search for pleasure. In fact, it is almost precisely the opposite of a search for pleasure. This is because addictive behavior is always a displaced action, a substitute behavior taken by people when they feel helplessly trapped. Rather than doing something more direct to gratify a frustration, they perform another behavior: their addiction.

For example, in a case taken from my new book "Breaking Addiction" (coming out in March), a man with alcoholism felt trapped by having to work late doing an extra project, causing him to miss promised time with his children. When he learned of the extra work, his thoughts turned to stopping at a bar on the way home at the end of the day, and a few hours later he did just that. In driving to the bar he was in absolute control over his life, doing something he believed would make him feel better. Going to get a drink felt just the opposite of the trapped feeling he'd had at work; he had reversed his helplessness.

At the same time, the great intensity of his drive to drink was an expression of his fury at having been trapped. (In general, it is this rage at helplessness that is the powerful drive behind addictive behavior.) This man's addictive behavior was therefore not a gratifyingly direct response to his helplessness trap; it was a substitute. If he had responded more directly he might have, for example, refused to do the extra work at his job, or done it less thoroughly, or even just argued with his boss to let him go home earlier. The fact that instead of doing any of those things he drank, several hours later, meant that he displaced his response to feeling helpless in both time and space. Instead of marching into his boss's office he waited and went to a bar.

Far from enjoyably seeking gratification in an act of poor self-control, this man inhibited himself, rechanneling the great frustration he felt into a grim determination to drink later. Of course his drinking could be said to be out-of-control behavior, but looking at it from the inside out we can see it as a specific mechanism to manage intolerable feelings, an effort to maintain control against overwhelming powerlessness.

The second mistake, that people with addictions have major mental health problems or "primitive" characteristics, is also caused by a misunderstanding of addiction. Addictions are psychological mechanisms essentially identical to those symptoms we call "compulsions." Yet compulsions are present in people with all degrees of mental health. It makes sense, then, that addictions can be present in virtually anyone, without implying any particular psychological diagnosis. Nearly everyone has some emotional issues and some folks use an addictive mechanism to deal with them. That doesn't separate them from the rest of humanity. A related confusion is to say that some people have an "addictive personality." There is no such thing as an addictive personality because having an addiction is a compulsive symptom; it does not define an individual's personality.

The idea of "primitiveness" in addiction is a holdover from a time when people thought addictions had to do with the drive for food or oral gratification in young children. This notion was fostered by the fact that for most of human history addictions have been associated with drugs, which are usually consumed by mouth. It is only fairly recently that we have understood that addictions have nothing inherently to do with drugs, since they may be focused on non-drug activities such as gambling, food, sex, shopping, the Internet and so forth. The lack of any special significance of drugs in addiction is especially clear when you note that people with addictions commonly shift the focus of their addiction from a drug such as alcohol to a non-drug compulsive activity such as gambling, shopping or cleaning the house. Such shifts would be impossible if drugs or their effects on the brain were essential to the nature of addiction. (I've previously addressed the confusion in our terminology about the term "addiction" that leads many to think that brain effects of drugs cause addiction. The effects of drugs on the brain influence a quite narrow behavior, such as feeling an urge to drink a glass of beer when it is sitting in front of you. That urge may be a biologically conditioned response of the brain when presented with the stimulus of the beer. But, as in my example above, nearly all addictive acts are precipitated by emotionally-meaningful factors, not by the immediate presence of an addictive object, and are usually delayed in time. This usual addictive behavior is psychological in nature, not a physiologically-conditioned brain response.)

While some people who are quite ill psychologically have addictions, it is incorrect to generalize from these examples. As we all know, lots of people with addictions are highly capable, mature, responsible, empathic human beings. They suffer with a particularly maladaptive symptom, but we should not infer from this that they are in their essence different from anyone else.


Posted on Tuesday, February 8, 2011 at 12:01AM by Registered CommenterLance Dodes, M.D. | Comments1 Comment | References8 References