I recently completed a review of 50 years of scientific articles about addiction treatment for my book, The Sober Truth. The science shows what most people already know: despite having a standard, nearly every approach to addiction treatment has been a spectacular failure as far back as we can measure.
In the 1990s the largest study of addiction treatment ever conducted, Project Match, examined the three main treatments, all of which remain the standard today: 12-step facilitation therapy, cognitive behavioral therapy, and motivational enhancement therapy. The study found that every one of them was ineffective. It was clear that there was something wrong with the way we were treating addiction. Even more important, it was apparent that there was probably something wrong with the way we understood the very nature of addiction.
I will describe a new way to explain addiction, and a new way to treat it based on this understanding. First, we know that traditional approaches to treatment have been based on one or a combination of several theories:
1 Addiction is due to a moral or spiritual problem, and should be treated by improving one’s connection with God or a higher power.
2 Addiction is due to ignorance and should be treated with lectures and education about how drugs work and the dangers of using them.
3. Addiction is due to a lack of motivation to abstain and should be treated by enhancing one’s motivation.
4. Addiction is due to faulty thinking and should be treated with corrected cognitive approaches to one’s behavior.
All of these theories overlook something that is clear once we stop thinking of addiction as somehow different from every other human behavior. Addictive behaviors do not occur at random. They are powerfully-impelled actions driven by overwhelming feelings at the moment they are enacted. They are generally precipitated by emotional distress. They are actions taken even when people are fully aware of their disastrous consequences and are trying their best not to perform them.
They are, in short, identical to another well-known kind of behavior: the psychological symptoms we call “compulsions.” Indeed, although addictions are frequently more dangerous than other compulsive behaviors, they are fundamentally neither more nor less than compulsions.
We have known for a long time that compulsions, such as feeling an intense need to clean the house again and again, or buy more and more clothes even when they’re not needed and can’t be afforded, or repetitively exercising beyond any real need for health, can be treated in a good psychotherapy that explores the emotional roots behind the symptom. (This kind of common psychological compulsion should not be confused with the biological illness “OCD” (Obsessive-Compulsive Disorder), which is easily distinguishable clinically, does not have a psychological basis, and can be well-treated with SSRI drugs.)
If these behaviors – compulsively cleaning or exercising or shopping – were directed at obtaining and using drugs, we would be quick to label them addictions. Indeed, some addictions are named compulsions, such as “compulsive gambling.” The fact that we don’t think of all these compulsive/addictive behaviors as the same is simply a historical error.
Part of the reason for this error is that the name “addiction” was first applied to drug-related behaviors, and we became stuck on the idea that drugs were an integral aspect of addiction. And, of course, some drugs used in addictions (but not all) can produce physical dependence, and that fact seemed extremely important, and it set drug addictions apart from non-drug compulsive behaviors.
It wasn’t until late in the 20th century that researchers, and the public, began to pay attention to the fact that people regularly switch from drug addictions to non-drug addictions. (For example, 40 percent of compulsive gamblers have alcoholism.) If non-drug compulsive behaviors could substitute for drug compulsive behaviors, how different could they be? When you put this together with the fact that drug addictions are almost always precipitated by emotionally significant events, just like every other psychological symptom, it is clear that we’ve made a big mistake to separate addictions from other psychological symptoms. (In the past 20 years, a new misunderstanding of the nature of addiction has arisen, from studies with rats. This idea is that addictions are caused by brain changes which are themselves caused by use of drugs. I will explain why this is mistaken in a future article.)
A New Way to Understand the Psychology of Addiction.
If we are going to effectively treat the basic nature of addiction, we need to know its psychology. I have devoted most of my career to this, and described a new way to understand the psychology of addiction in my first two books, The Heart of Addiction and Breaking Addiction. Here is a summary:
- Every addictive act is preceded by a feeling of overwhelming helplessness or powerlessness. The particular situations or feelings that produce this helplessness are different for different people. Addictive behavior reverses these underlying feeling of helplessness. The behavior is able to do this because taking an addictive action (or even deciding to take this action) is a way of doing something that the person expects will make him feel better, in an act that is completely in his own control. Hence, this action creates a sense of being empowered, of regaining control against helplessness. The reversal of helplessness is the psychological function of addiction.
A consequence of this for the treatment of addiction is to focus not on the addictive act itself, but on the feelings and events that preceded the very first thought of enacting an addictive behavior, when the sense of being utterly trapped arose. I call that point in time the “key moment” in addiction. It may arise shortly before the action, but often occurs quite long before it. For example, at 1 p.m. a man thinks of having a drink after work. He waits until 5 p.m. when he does go to a bar. To figure out the issues behind his addiction, the moment to focus on is not when he had the drink, but what was happening just before 1 p.m. that led him to feel overwhelmingly helpless.
- The states of helplessness which precede addictive urges are always associated with a great anger – basically the normal rage anyone feels when utterly trapped. It is this rage at helplessness that is the powerful drive behind addiction. It explains why addictions have such an unstoppable quality: “Nobody and nothing is going to stop me (not even myself)!”
A therapeutic consequence of this is that people suffering with addictions can learn that their inability to keep themselves from repeating harmful behavior is an understandable psychological process, not a sign of spiritual or moral weakness, or cognitive illogic.
In addictions, the emotional function (reversing helplessness) and the drive (normal rage at feeling trapped) are always expressed in a substitute action (technically called a “displacement”). All addictions are displacements, or substitutes, for taking a more direct action. It is the displacement nature of addictions that causes them to look the way they do.
- For example, a person with alcoholism who is cut off in traffic and is infuriated by this (because it leads him to feel terribly disempowered) feels an intense compulsion to start drinking, turns off the road, and heads for a bar. He is attempting to solve the problem of feeling helpless by taking an action that is completely in his control and that he expects will make him feel better. But, this action is actually a substitute for a more direct response. If he had vigorously honked his horn and made an insulting gesture, and/or written down the license plate number of the other driver and resolved to report him, or any of a variety of other more direct responses, he would have been much less likely to feel the impulse to have a drink.
In treatment of a person with an addiction, it is important to locate the more direct actions that could have been taken. Along with this, it is important to explore why those direct actions felt impossible at the time.
Here’s another example. A woman with addictive use of a painkiller was desperate to remain a member of a particular group of women. When the group made a decision with which she strongly disagreed, she felt she couldn’t speak up without losing her friends, then went home and took her pills. In therapy, she was able to identify the issues behind her fear of speaking, and could easily come up with direct ways she could have expressed herself that were less frightening. At a later meeting of the group, she did so, and felt no need to take her drug. Over a little while longer, knowing the issues behind her repeated addictive urges, she found that she could anticipate when her feelings of helplessness would arise, so she could avoid being blindsided by them again. She was able to master her addiction. Ultimately, she worked out why she had fear of being rejected if she expressed herself. At that point, her addiction was gone from her life.