Illustration by Tati Nguyễn
ADDICTION IS ONE of the biggest public health problems in our country, but success rates in attempting to treat it have been very poor. A major reason for this is that the very nature of addiction has been misunderstood, mostly because it has been confused with the physical phenomena of tolerance and withdrawal seen with some drugs, phenomena which are also called “addiction.” Those physical symptoms are real, of course, but the question is not what effects drugs have on the body. Rather, the question is why people compulsively repeat their addictive behavior despite its ruinous effects on their lives. We know that the repetition is not just a question of physical addiction, even for drug addictions, because there are many drugs that are used “addictively” (i.e., compulsively, without rational limits) which don't produce physical addiction (marijuana is an example). But even more important, people commonly switch from drug addictions to addictions that have no drug involvement at all, such as compulsive gambling, sex addiction, or compulsive exercising. This would not make sense if drug effects were the fundamental reason for addictive behavior.
In my clinical experience, addictions are neither more nor less than compulsions, psychological problems which we know how to treat. There are three major elements that I've found to be at the heart of all addictions.
I. Every addictive act is preceded by a feeling of overwhelming helplessness or powerlessness. The issues that lead to these overwhelmed states are unique to each person. That's one reason that individual psychodynamic therapy is frequently the most helpful treatment for people with addictions.
Addictive behavior functions to repair this helplessness. It does this because taking the addictive action (or—significantly—even deciding to take this action) creates a sense of being empowered, of regaining control over one's emotional experience and one's life. Drugs are particularly good for this purpose because they have the capacity to alter, and thereby reclaim control over, one's emotional state. However, nondrug addictions (gambling, exercising, compulsive use of the internet, etc.) can be shown to work in the same way, since it is the ability to intentionally do something that will alter and control one's emotional state that is important, not a physical drug action.
This reversal of helplessness may be described as the psychological function of addiction.
II. States of overwhelming helplessness produce a feeling of rage in response to having lost control. In psychodynamic terms, a loss of control is a blow to a person's sense of power and importance. That is a “narcissistic injury” because healthy narcissism (valuing yourself) is under attack by the feeling of helplessness. The fury that follows this is likewise called “narcissistic rage.”
Narcissistic rage is something that has been understood for a long time. It is characterized by powerful compulsive urges to act and, while one is in the throes of the rage, tends to overwhelm one's normal judgment.
These characteristics are identical to those that describe addiction. Indeed, narcissistic rage (at helplessness) provides an explanation of this well-known clinical description of addiction. And we can even take this one more step and say that it is narcissistic rage at helplessness that provides the drive behind addiction.
III. The final element in addiction is understanding why it takes the forms that it does. What does rage at feeling overwhelmingly helpless have to do with drinking, or gambling, or exercising? The answer is that each of these behaviors are substitute actions
“Every addictive act is preceded by a feeling of overwhelming helplessness or powerlessness. The issues that lead to these overwhelmed states are unique to each person. That's one reason that individual psychodynamic therapy is frequently the most helpful treatment for people with addictions.”
done instead of acting directly to reverse helplessness. We call such substitutes “displacements.” For example, if a man were flooded with feelings of intolerable helplessness when he was unfairly criticized by his boss, and he regularly dealt with such feelings by drinking instead of some more direct or rational way to express his feelings, his drinking would (temporarily) reverse his feelings of helplessness. He might say to himself, “I can't do anything about my humiliated and powerless feelings at work, but by God I can have this drink and make myself feel better and nobody can stop me! I'm in control of how I feel, not my damn work.” On the other hand, if, when he was criticized, he had instead marched into his boss's office and made his case for not being criticized, he would have reversed his helplessness by this direct act. And if he had done this, he would not have had to have a drink. He wouldn't have had a compulsion to act in a displaced way, driven by rage at his helplessness.
Addictions can in general be understood as displacements. That's how we name them! This man suffered with alcoholism, but if he regularly used another displacement to reverse his feelings of helplessness, such as driving to a casino to gamble, we would change his diagnosis to “compulsive gambling.” The well-known ability of many people to shift from one addiction to the other is due to this essential nature of addiction. The “new” addiction is simply a shift in the displacement they are using.
PEOPLE ARE ALL different, of course, so what makes a situation lead to intolerable feelings of helplessness depends on the individual emotional life of that person. But when patients understand the psychology of their addiction, including the kind of underlying issues that lead to their feeling intolerably helplessness, two things follow.
One, they can predict when their addictive drive will occur, sometimes far in advance, and long before the addictive urge is upon them. They can do that because they have learned the kind of things that will lead them to feel helpless. A good way to learn this is to look closely at the precipitants, the events that preceded the urge or even the thought to repeat the addictive behavior. These will all point in a single direction, which is the central issue with which the person has most trouble. And the second benefit of understanding addiction this way is that sufferers can (with some practice) discover better, more direct actions to deal with these issues.
As a result, patients can often bring their addictive behavior under good control even before they have fully worked out the issues behind it. Conversely, looking closely at the precipitants to each addictive thought enables patients to identify their overall emotional issues more quickly, since it is these central issues that lead to intolerable feelings of helplessness.
Naturally, there will be times when people suffering with addictions will need medical help, or brief hospitalization for detoxification. Residential treatments have been remarkably unsuccessful, and too often harmful by raising expectations (at a very high financial cost) despite evidence of their extremely low success rates. However, in dire situations, carefully selected inpatient treatment may be necessary.
But treatment with a knowledgeable psychodynamic therapist, who can help patients understand what drives their behavior and why, should be the backbone to dealing with this serious problem.
Lance M. Dodes, MD, is training and supervising analyst emeritus at the Boston Psychoanalytic Society and Institute and retired assistant clinical professor of psychiatry at Harvard Medical School. His theory of addiction has appeared in academic journals and three general-audience books.