The Heart of Addiction

How psychology drives addictive behavior.

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.

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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.

 

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

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