The Heart of Addiction

How psychology drives addictive behavior.

Treating Addiction a New Way

Understanding the psychology of addiction makes it controllable.

In my last post I briefly summarized the psychology of addiction. I said that treatment of addiction has had generally poor results because its very nature, its psychology, has not been well understood. Of course, this raises the next question: How does understanding its psychology allow people to control their addictive behaviors? Here is an example, taken from my book, “The Heart of Addiction.” It is the follow-up to the story of Marion whom I introduced last time.

Marion addictively used the drug Percodan. She lived with, and passively put up with, a domineering husband. On one occasion, when he called and demanded she drop everything and prepare a dinner for him and several business associates, she had quietly agreed, then immediately took some Percodans. I described her addictive action as a reaction against an overwhelming sense of helplessness. Taking her drug (or even just deciding to take it) reversed her helplessness. This worked because even though she had been powerless to stand up to her husband, now she could, and would, do something that was completely in her control, something she believed would make her feel better. In taking this action she empowered herself. And this action was driven by an intense rage at her helplessness. I pointed out that it is this powerful rage at helplessness (which is itself a normal response to feeling completely trapped) that gives to addiction its “addictive” qualities: its enormous intensity, blindness to consequences and apparent loss of judgment. Nobody has good judgment in the throes of rage at being overwhelmingly trapped.

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Marion’s story also showed the final piece of the psychology of addiction. When people cannot respond directly to situations of feeling overwhelmingly helpless, they sometimes take a substitute action (a “displacement”) that provides them the sense of taking control of their lives. In Marion’s case, since she felt she could do nothing to deal with her husband directly, she turned to her usual displaced action: taking her pills. It is this final, displaced action that we call an addiction.

In treatment, Marion began to understand all of this. Of course, some of her treatment involved solving the underlying problem of why she was so passive to begin with, which had resulted in her repeatedly feeling so helpless. But even before she had worked out this deeper problem, she could see that her addiction was an attempted effort to reverse the feelings of helplessness that had always plagued her. In fact, she could see that her addictive urges arose precisely in those situations in which she felt the most helplessly trapped. Armed with this knowledge, she began to be able to anticipate when her addictive urges would occur, and to plan in advance to deal with these situations differently so she did not use her pills. She made progress.

Then, one day her husband again called her in the middle of the day to demand she make dinner for him and some others, that evening.

Marion now knew that, to prevent another episode of her addiction, she needed to respond directly to her husband, perhaps telling him to make his own damn dinner. But she couldn’t -- not yet. She found herself drifting over to the medicine cabinet where she kept her Percodans. Then she stopped. She hadn’t been able to stand up to her husband, but maybe she could come up with some action that would deal more directly with her helplessness. Then it hit her. She walked to the phone and ordered takeout Chinese food for dinner. At that moment, her addictive urge vanished.

Marion had found a more direct way to reverse her helplessness, so she had no need to perform her displaced action, her addiction.

Over time, she became better and better at picking up the situations in which she felt overwhelmingly helpless and finding ways to deal with them. Her addiction gradually faded.

Everyone is different. The kind of thing that made Marion feel overwhelmingly helpless is different from what makes others feel so helpless. This is one reason that treatment for addiction must always be individualized. But the underlying psychology of addiction, the way it works, stays the same. Once people understand it they find they no longer need to march blindly into their addiction again and again. They can become the master of their addiction, not the other way around.

Lance Dodes, M.D., is an assistant clinical professor of psychiatry at Harvard Medical School.

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