The Sober Truth (14 page)

In fact, there is probably some genetic influence on addictions, but this shouldn’t be surprising. Many human conditions, like peptic ulcer disease or hypertension, have some genetic loading, meaning that genes confer some degree of increased susceptibility without the condition being directly heritable. Given the way addiction works psychologically, it could be possible that some decreased biological tolerance of certain emotions could lead to a variety of symptoms, including addiction. But nobody in human history has ever walked into a bar because a gene told them to.

Now let us return to the compulsion model. The idea fits neatly with much that has been written about addiction for centuries. People have understood the basic nature of compulsions for a long time, even before modern psychology. William Shakespeare provided an especially clear example in
Macbeth
: Lady Macbeth demonstrates literature’s most quotable compulsion when she wails “Out, damned spot!” while ceaselessly washing her hands. The “spot” that she imagines is the blood of people she has murdered, of course, and her compulsive behavior is universally comprehensible in human terms: a symbolic gesture to undo her guilt. Because she can’t actually reverse the murders, the compulsion becomes a stand-in for the act itself: cleanse the hands if you can’t raise the dead. In psychology, there is a word for an action like this that substitutes for a more direct behavior: a
displacement
.

It is understood in psychology that all compulsions are displacements. One of their defining features is how irrational they seem; in the inner world of our minds, the direct act and its substitute may be adequate surrogates, but to everyone else they can seem crazy. Yet compulsions can be relieved by undoing the displacement. If a real Lady Macbeth had dealt with her guilt more directly (that is, by confessing to the victims’ relatives, or asking for forgiveness, or even just coming to some peace by thinking through her behavior), then she might have been liberated from the need to endlessly repeat her handwashing.

Once addictive behavior is defined through the prism of compulsive behavior,
⁹
it can be treated just as psychotherapists would treat any emotionally driven compulsion, using talk therapy to root out the deeper meanings and purposes behind the behavior.
¹⁰
(Again, I am making a distinction between chemical OCD and psychological compulsions, which are wholly different in their origin and treatment.) There is no longer any reason to appeal to a Higher Power, to think of addiction as its own “disease,” or to rely solely on fellow addicts for relief. No one would ever treat a housecleaning compulsion by relying on the been-there-done-that counsel of recovering housecleaners or suggest that compulsive housecleaning is a spiritual problem.

The easiest way to explain the psychology of addictions, as I have uncovered it over the past twenty-five years, is to show it. The following vignette is a short version of a case story that originally appeared in my book
The Heart of Addiction
.
¹¹

For personal reasons that echoed from her past, Marion felt unable to defy her husband’s insistent demands. But this inability to speak up left her with a terrible feeling—an agonizing sensation, like being caught in a trap. She would have liked nothing better than to tell Gerry to make his own damn dinner. But she felt she just couldn’t. Like anybody faced with a sense of overwhelming helplessness, she had to do
something
to get out of the trap. And for her, that something had always been taking her pills.

This is what addiction is about.

When Marion took her pills, she felt better. Yes, the medication had a soothing effect, but that wasn’t the whole story. She noticed that she started to feel better long before the drug could possibly have an effect; Marion felt better even before she took the pills. Indeed, like every addict I have ever met, Marion started to feel better at the moment she
decided
to take the drug. How could this be possible?

The answer is deceptively simple: she had already solved her problem. Of course, she hadn’t done anything about the dinner or about Gerry. But she had solved her internal problem—the sense of intolerable helplessness. By deciding to take a pill, Marion had chosen to do something within her own control, something that would make her feel better. Gone was the unbearable sense of powerlessness, replaced by a liberating sense of control. This phenomenon repeats across all addictions. And this fact helps us to see the first piece of the addiction puzzle:
The psychological function of addiction is to reverse the sense of overwhelming helplessness
.

This may sound counterintuitive at first. After all, we know that addiction regularly leads people to experience more, not less, helplessness in their lives. But that’s because of the awful consequences of addiction, and consequences have little to do with the act in the moment. The drive to reverse utter helplessness is an explosive force, the natural human rage to fight against being trapped. We know this kind of anger has the capacity to overwhelm a person’s judgment while she is in the throes of it. Emotions this strong have compelled many people to do things they later regretted terribly.

I often use the example of people caught in a cave-in to illustrate the experience of utter helplessness that precipitates addictive acts. When two hundred tons of rock suddenly fall between you and daylight, you might try to stay calm. But it won’t last forever. The time will come when you begin pounding at the rocks, clawing at the boulders and hurling yourself against the walls with enough abandon that you might even break a few bones. This is
normal
, an understandable reaction with evolutionary survival value. Nobody would accuse you of being self-destructive for breaking your wrist in an intense effort to get out of the cave.
¹²
And this rage at helplessness boils up equally when people feel emotionally trapped, like Marion. It is what gives addiction its most defining characteristic: an enormous intensity that overrides every other concern and good judgment, and that often seems impossible to stop by either the person herself or those around her. And so this delivers the second piece of the puzzle:
If reversal of helplessness is the
function
of addiction, then the powerful
drive
behind addiction is rage at that helplessness
.

But there is one remaining question in Marion’s story. We know the function of her addiction and the drive behind it, but why pills? Why do people do things that have no realistic chance of solving the problem? Pills are just one example; others have a drink or go out looking for sex. And this brings us back to where we started: with the idea of displacement. Marion couldn’t take the direct step of standing up to Gerry for complicated reasons of her own. Yet she had to do
something
. So what she did was a displacement, a substitute action. This is the final piece of the puzzle:
Every addictive act is a substitute for a more direct behavior
. This fact leads to one of the important parts of a modern treatment of addiction: If addicts can learn to address their rage at helplessness directly, then it manifests simply as an assertive act. When people act directly, there can be no addiction.

Marion provided a very clear example as she and I worked through her feelings. One day she came in for an appointment and told me that Gerry had done the same thing again—called in the middle of the day to tell her to make dinner for business guests that evening. She said, “I know now what I should have done. I should have told him he could make his own damn dinner. But I just couldn’t, so I agreed. The next thing I know, I was going to get my pills.” She looked at me and grinned. “But I didn’t take any!” It turned out that she found another way: “I knew I had to do something about the damned dinner. Then I thought of it: I called up a Chinese restaurant and ordered take-out.” She laughed. “And you know what? As soon as I decided to order the food, my urge to take the pills totally vanished.”

Marion’s solution wasn’t perfect; she knew that the best thing clearly would have been to stand up to her husband. But ordering Chinese food was far more direct than taking Percodan, and the insight that allowed her to understand why she had the urge to take her pills would eventually lead her to defeat her addiction permanently.

As a final side note, this model of addiction also explains why people are able to switch addictions so readily from alcohol to gambling to sex and so on. Although different “addictions” may appear to be wholly separate problems, they are, in fact, just different outward manifestations of the same mechanism. This awareness is often extremely helpful for people as they switch from one addictive focus to the other. Instead of believing they have several diagnoses, they can simply note that the focus of their need to reverse helplessness has changed. (One wonders how this perspective might have helped Bill Wilson, who famously beat drinking, but struggled for the remainder of his life with sexual and smoking compulsions.)

Understanding the psychological contours of addiction also provides a road map for how to treat it. No longer is it necessary to adopt special spiritual beliefs or join a cohort of people who all suffer with the same problem. Unlocking addiction brings it back down to earth. The problem becomes ordinary, no more or less manageable than any psychological challenge; it needs no special category; it is a psychological problem and can be managed as such.

People who have this symptom can learn how it works within them and develop the agility to solve the issues that lie behind it. For instance, once people view their addiction as a mechanism to solve feelings of overwhelming helplessness, then it becomes critical to identify what is overwhelming for them—what sort of events or feelings carry powerful emotional significance. Being stuck on a call with the bank is frustrating for everybody, but for someone who used to spend hours every week as a child waiting to speak to his estranged father by phone, it carries a particular resonance and power.

Addictive thoughts are never random. To unlock this puzzle, addicts must focus on when the addictive thought first appears. This is the key moment, the pivot point on which everything else turns. By analyzing what happened immediately before this moment—what was just felt or just thought—they can shine a light on the central issue. Yes, each moment is different, and no two people are the same. But we can be certain that they all have something in common: a unifying theme of helplessness about particular issues that are crucial to them. Anyone can learn to recognize these issues for him or herself. Once known, they become far easier to master. People find that they can pause and develop perspective on what is happening. Marion, for instance, knew that her problem was being excessively meek, and this allowed her to pause long enough to understand why she suddenly had the urge to take her pills. Once she realized what was happening, she was able to devise a more direct action to deal with the helplessness. She also gradually found that she could anticipate when the next addictive urge would occur, because she knew what circumstances led to these feelings.

There is always a more direct response to helplessness; this is the lesson to be learned from understanding addictive acts as displacements. It would be beyond the scope of this book to describe all the different ways helplessness can manifest and all the ways people can address these feelings in constructive ways (but many examples can be found in
Breaking Addiction
).
¹³
For now I will simply say that addiction can be understood, managed, and ended through learning about oneself. People can do a lot on their own, but it is often faster and more helpful to explore these kinds of underlying issues with a professional. For working out these issues permanently, a good psychotherapy is the best approach.

Understanding the nature of addiction helps us clarify why AA, and AA-based rehab programs, have had such limited success. Programs that apply community-based encouragement and little or no individualized care are poorly designed to treat emotional symptoms, including addictive behaviors. It is also easy to see why activities like massage, horses, lectures, and yacht trips don’t seem to make much of a dent either. Like the TB sanitaria of the late nineteenth century, 12-step treatments are trying their best to solve a problem whose fundamental essence they do not understand. The fact that a small percentage of people nonetheless become devoted members of 12-step approaches and do well, therefore, raises an interesting question. As we will see in chapter 7, this phenomenon actually makes perfect sense through the prism of a psychological understanding of addiction.

THE ACCOUNTS IN THIS CHAPTER tell us a few things about what works and what fails in 12-step treatment, and why. As part of the process of writing this book, I invited (through my blog on
Psychology Today
) firsthand accounts, both positive and negative, of readers’ experiences with 12-step programs.
¹
This book’s writing deadline and space requirements limited the number of interviews I could conduct as well as the total number of accounts that could be included. There was no selection process in choosing the narratives in this chapter; they are simply the reports of the first ten people who responded and gave permission to use their stories in the book. After the deadline I received a number of further accounts; except for a couple of deeply negative reports of people’s 12-step experiences, they were remarkable in citing the same combination of positive and negative factors seen in the stories below. These reports tell us much about AA that most people don’t hear in popular media.