The Heart of Addiction

How psychology drives addictive behavior.

The Worst Addiction Advice You Can Get

On the insanity of stopping addiction before you treat it

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.

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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.

 

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

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