Physical Addictions and Psychological Addictions Are Not the Same

—You can be physically addicted to a substance without being psychologically addicted to it.

—Vets in Robins et. al (1975) study:  90% heroin-addicted do not become addicted to narcotics back in U.S.

—You can be psychologically addicted to a substance without being physically addicted to it, if you don’t use it often enough.

—Binge drinkers

—Weekend warriors

Treatment that only treats the physiology of addiction fails

—Detox programs unable to make people stop using. When physical addiction removed,  people relapse when they have a true psychological addiction which remains (an “addictive drive”, Dodes, 2002).

—Cross-addiction. Addicts often shift their addictive focus from substances to non-drug addictions, like when alcoholics become gamblers, or when people switch from one substance to a pharmacologically unrelated substance, like from cocaine to heroin, which also happens often. My female patient was a cocaine addict in the 1980s, until she quit and became alcoholic in the 1990s.

—Addictions occur regularly to substances that cannot produce physical addiction, like marijuana and LSD. People also get addicted to non-substances, such as gambling and sex.

—In another naturalistic experiment (besides returning Vietnam War vets), when the Surgeon General warned in the 1980s that cigarette smoking was dangerous to health, millions of people without an addictive drive were able quit.


—There is no single gene for alcoholism, the most carefully studied addiction (Dodes, 2002).

—One summary of multiple twin studies (Merikangas,1990) concluded that if one twin is alcoholic, the other twin is likely not alcoholic.

—The role of genetic factors is “minimal or nonexistent.” (Pickens, 1991).

—At most, genetic factors may influence susceptibility for some people; alcoholism cannot be directly inherited. (Foroud et al., 1999).

Alcoholism is therefore not a disease, at least not one caused by genetic factors, as AA has always maintained (Fingarette, 1988).

Biochemical Studies of Drug Action in the Brain: Newsweek and PET Scans

—Physiological brain changes caused by drugs cannot “create addiction in people without the psychology for it” (Dodes, 2002).

—Mechanisms and anatomical loci of action are present in addicts AND non-addicts, and so explain nothing unique to the brains of addicts.

—Sensitivity and subsequent responsiveness to drugs change, but this occurs in EVERYONE exposed to drugs, not just addicts.

How Is Addiction Best Understood if not as a Physiological Phenomenon?

—A type of Compulsion

—driven behavior which the person feels they MUST perform. The person feels he has no choice, no flexibility to act other than he does. Endlessly repetitive, unvarying behavior is the definition of psychopathology

“Unity of Addictions”

—The psychological structure of all addictions is the same. This is true whether the person is addicted to a substance or to other activities, such as  gambling or sex.

—Since all addictions are forms of compulsions, then, they are all treatable with psychotherapy.

Like compulsion, addiction is a compromise

—A compromise is a synthesis of 2 opposing tendencies. Each party gets something they want, but the outcome is a mix of the 2 sides, not a pure expression of either. Treatment involves disentangling the 2 sides.

—The alarm clock man (Dodes, 2002)

—A pure expression of one tendency in his feelings would lead to him setting his alarm clock getting to work on time.

—A pure expression of the second, opposing tendency in his feelings would be to complain to his boss about having to get up early, quitting if his boss held firm, etc.

Addictions, Compulsions, and DSM

  • DSM keeps addictions and compulsions separate because of superficial differences. Addictions (only) appear to be wanted or ego-syntonic, whereas compulsions appear to be unwanted or ego-dystonic.


  • The truth is fuzzier. Both addictions and compulsions are mixed. Addicts trying to stop using do not want their addiction, at least part of the time, so it has become ego-dystonic. Compulsives who cannot stop compulsive behaviors, e.g., hand-washing, often come to feel proud of symptoms.  They might come to see their hand-washing as a sign of cleanliness and goodness.
  • People go back and forth all the time in feelings about their compulsions and addictions. This is the definition of CONFLICT—mixed feelings, ambivalence.

The presence of inhibition

—Some thought, feeling, and/or action is always inhibited in a compromise.  Addiction is not pure pleasure.

—Often what is inhibited, the content of the inhibition, is some form of an aggressive impulse, as in the case of the alarm clock man. His superego, or conscience, objects to his anger at having to wake up early and blocks it from full expression.  The superego inhibits some forms these feelings might take, like the assertive act of complaining to his boss to change his schedule.

Just keep sending people to AA?

—In two studies (Fingarette, 1988) only 25% of alcoholics attending AA were attending meetings at 18-month follow-up.

—Of those 25%, only 25% remained “consistently sober”.

—Therefore, only about 6% of alcoholics attending AA were consistently sober at 18-month follow-up.

AA Does not Help Many People (cont.)

—Only the people who remain sober with AA’s help publicize their stories


—AA does not collect data on its effectiveness

—AA has no way of correcting or improving itself

Reasons AA helps when it helps

—AA fills the need for a nurturing other

— For addicts who feel empty and lonely, who have lost significant others, and for whom the bottle represented a lost significant other, AA may fill that hole in their lives

—Institutional transference

—It requires that alcoholics change their whole way of life—who they associate with, how they spend their leisure time, their relationships with themsevles and others, etc. (Fingarette,1988).

Why Not Treat Addicts with CBT?

—In a 2001 meta-analysis of 34 studies conducted in the 1990s on CBT treatment of depression, Westen and Morrison (cited in Dodes, 2004) found that “the short-term improvement commonly found with these treatments tends to disappear quickly over time” (p. 131).

—2001: Humphrey and Moos (cited in Dodes, 2004) found that one year after discharge from CBT inpatient programs, substance abusers were “no better off, and in some ways worse” (p. 131) compared to inpatients from simple 12-step programs.

—70% of patients from both groups continued having substance-abuse-related problems at 1-year follow-up.

There were no other options before

—Many psychodynamic clinicians would not treat addicts because addiction was conceptualized as being pleasure-seeking

—Addicts were told to renounce their pleasure-seeking activities first, then come back for therapy. Alcoholics might be sent to AA and told to return once they were sober.

—This approach is nonsensical, since we do not demand that patients with other symptoms give them up at the beginning of therapy. As long as the addiction is not producing a crisis requiring hospitalization, they can be treated.

—The addiction was considered to be  separate from the person’s other difficulties, which is untrue.

—My Cuban patient cannot assert herself with the men in her life—her father, her ex-husband, and her current husband.  Her problems with the affects of rage and helplessness, which are bound up in her alcoholism, are also part of a disturbance in his relationships with female significant others.

Level of Health as a Deterrent to Treatment

—Addicts were also thought by therapists to be too sick to treat.  But addiction by itself does not determine whether someone can be treated successfully; that depends instead on their general level of mental health.

—There are different types of addicts. Some are more treatable than others, as is true of any type of psychopathology.

—Contrast my Cuban patient, a relatively well-functioning woman with a family and gainfully employed, with another patient I treated, a gay Puerto Rican man one of whose symptoms was (especially when high on Ecstasy or Special K) paranoia that other people in nightclubs were talking about him and making fun of him. He was also gainfully employed, but he had no steady partner most of the time, and engaged in risky sex by working as a male prostitute on weekends.

—Another recent patient was a woman in her 30s from an affluent family. She was a crack addict and had a history of eating disorders. She was divorced. She quit treatment prematurely after becoming pregnant by and engaged to a man who also had a severe substance abuse problem, insisting that she would stay clean so as not to harm her baby.

Addiction as a Problem of the Ego

—Ed Khantzian proposed the self-medication hypothesis

—Heroin addicts, for example, experience tremendous rage, which they dampen by using drugs.

—Depressives use cocaine to flee from depression, which is their unbearable affect.

Khantzian and Mack (1983) also proposed that addicts suffer from “self-care” deficits in their egos caused by severe neglect during childhood.

—The cocaine addict I saw in the 1980s whose leg was chewed off by a dog while an infant.  He was caught smuggling cocaine into the U.S. inside his prosthetic leg.

Khantzian and Wurmser both addressed pathology of the superego, or conscience.

—“superego solvent”

—When the superego is too strict, the addict rebels against his inner conscience.  Task of therapy as with many non-addicts is to make the superego less harsh.

Lack of awareness of the Success of Psychodynamic Treatments

—As theory evolved over time, psychodynamic therapists accumulated a great deal of clinical experience with addicts.

—Johnson, 1992—treatment of an alcoholic man.

—Berger (1991) discusses successful txs.

—Wallerstein (1986) treated an alcoholic.

—Myers (1994) has treated sexual addiction successfully.

—Dodes (2003) has successfully treated compulsive gambling and sexual addiction as well as alcohol and substance abuse.

—Wurmser (1974)

—Must obtain systematic outcome data on efficacy of psychodynamic treatment. At present, it is often in the form of case studies, or conclusions reached on the basis of clinical experience.

Addictions: A Modern Psychodynamic View

Dodes (2002) clarified the relationship between addiction and the more familiar concept (and treatment implications) of compulsions.

He takes concepts familiar to clinicians such as inhibition and displacement and puts them together for the benefit of understanding and treating addiction.

The trigger for the addictive act is a discrete event. Clinicians search for it in a focused manner. Clinicians do not become discouraged by thinking that treatment will take years.

A displacement is a defense mechanism which “shifts the focus or emphasis in dreams and behavior, generally by diverting the interest or intensity (cathexis) attached to one idea onto another idea that is associatively related but more acceptable to the ego.”

Clinical Example of Helplessness and Rage

—My female patient received a court summons from her ex-husband. He wanted her to increase her child support for their children. My patient did not retain a lawyer and went to the proceeding alone. When her ex-husband began accusing her of making unreported extra money with side jobs, she became enraged and tried to defend herself, arguing with him. The judge silenced her and told her not to say another word.

Helplessness then followed by displacement

—The patient felt helpless in court because she could not defend herself. She became enraged.

—While still in court, she decided to drink afterwards. The decision itself to engage in an addictive act produces a sense of relief, even before the person picks up his first drink.

—Her rage was the antidote to her helplessness. She sought the opposite of helplessness, or omnipotence, a feeling of being all-powerful (like “Superman”, she once told me).

Abstinence from Alcohol

—My female patient has relapsed between 5-10 times in approximately 8 months of treatment.

—She was drinking several times per week when treatment began, with health concerns and worries over her husband leaving her.

Most Recent Relapses

—Occurred on a Friday night when she had 2 drinks after arguing with her husband about whether she should attend a work party at which he knew she would drink.

—She picked up her teenage son afterwards, making her husband feel she was drinking and driving with her kids in the car again.

—She maintained that she ate a lot, and that given her large frame the 2 drinks did not affect her.

—On Sunday, two days afterwards and still fighting with her husband, she got angry about something she had to do for work and drank a six-pack of beer.

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