The Heart of Addiction

How psychology drives addictive behavior.

The right and wrong way to measure progress with an addiction

As usual, it’s more complicated than it appears

Everybody takes for granted that progress in addiction means abstaining from, or at least cutting down, addictive behavior. This is the standard of measurement for addiction treatment facilities and research outcome studies. But this is naive, since progress can be occurring before any change in behavior, and behavior can change without any real progress. Worse, using addictive behavior as the measurement of progress can make addiction more painful and harder to treat.

 

First some background. As readers of this blog know, addictive actions are the result of an emotional process – an attempted solution to feeling helplessly overwhelmed. Addictive behavior is therefore a symptom – a very destructive one, but a symptom nonetheless. In psychology and medicine we regularly treat symptoms, of course. But the primary focus of any treatment must be on root causes, when we know how to treat them. Before antibiotics were discovered, for example, treatment for tuberculosis consisted of exposure to fresh air and rest because this approach improved its symptoms. “Progress” in those days meant less coughing and fewer night sweats. But this symptomatic treatment did nothing to kill the bacteria that cause TB. The disease was very much alive inside, and frequently returned with a vengeance.

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In addiction, we are still defining progress by symptom reduction even though we now have much better knowledge about its emotional cause and treatment. It’s no wonder that treatment programs that spend patients’ valuable time trying to motivate them to change their behavior fail so often. Like TB, the emotional nature and process of addiction remains alive no matter how encouraged, uplifted, and educated about addiction they are.

 

Besides failing to address the real causes of addiction, this symptomatic approach creates its own problems. When treatment programs (or individual treaters) measure their own success by the amount of addictive behavior of their patients they create a destructive feedback loop. In order to improve their “success” numbers they must push for behavioral change all the harder, whether or not their patients are learning about the kinds of overwhelming helplessness that precipitate their addictive urges. It is the same problem we hear about in the business world, when companies focus on reporting a profit every quarter rather than living with a temporary deficit because they are investing in improving their product. When the business fails, we often hear from executives about the pressure they felt to maintain the appearance of doing well.

 

A similar effect occurs in individuals. If you are in a good psychological therapy where you are looking closely at the immediate and deeper emotional precipitants of addictive behavior, both you and your therapist should understand that progress consists of doing this work. In the course of any psychotherapy symptoms disappear and return. Too often, people in treatment feel they are failing because their behavior has not turned off like closing a spigot. It is a tragedy when people drop out of good treatment because they measure progress on the basis of symptomatic behavior. Of course, good treatment never means ignoring addiction. Quite the contrary, as I’ve described many times in this blog and both my books, it is just those moments of feeling you have to get a drink, or eat, or gamble, that are the best opportunities to figure out the underlying emotional causes of the behavior and how addiction works in you. And, if addiction is ever unmanageable or too dangerous to be allowed to continue, hospitalization is appropriate until the situation stabilizes. But that is emergency care, and should not interfere with therapy that is making true progress.

The issue arises in spades with family members. If addictive behavior continues during a psychologically-knowledgeable therapy, family members often become suspicious that the treatment is not working. In the worst cases, they stop supporting the treatment. It helps if family members can learn about the psychological nature of addiction.

 

Finally, when researchers use addictive behavior to measure treatment effectiveness, they make it all the harder to allow for creative growth in the way the addiction treatment industry works. True, it’s tougher to measure internal emotional change. But anyone with psychological training knows that that’s where all meaningful progress is. Researchers need to look beyond behavior if the industry is to be convinced to adopt newer approaches to treatment.

 

If measuring progress by the amount or frequency of addictive behavior is misguided and hurtful, how then do you know if you are making progress? If you are dealing with an addiction yourself, or in therapy, when you are able to see the themes in your life that always precipitate addictive feelings and are working to find ways to manage or resolve these themes when they arise, you are getting better.

 

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

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