HippoPress

August 1, 2002

Lance Dodes:
On the 'power' of addiction

By Lisa Parsons
HippoPress.com

Addiction is about helplessness, says Lance Dodes, M.D., a Boston psychiatrist, in his new book, "The Heart of Addiction" (2002, HarperCollins). Dodes (DOE-dess), a Dartmouth graduate, teaches at Harvard Medical School and directs the Boston Center for Problem Gambling. He has treated hundreds of addicts and directed various alcoholism treatment units in New England.

Dodes says the most common phrase uttered by alcoholics about to take a drink is "Aw, F*** it." For example: Joe owns a business and employs his nephew. The nephew misbehaves. Joe's gut says to fire the nephew. Joe's brain tells him he must never turn away family. Joe feels trapped and helpless. Later, unaware of the connection, Joe goes on a drinking binge preceded by an angry "Aw, F*** it."

People with addiction, believes Dodes, need to feel less powerless. This seems to conflict with the Alcoholics Anonymous credo that alcoholics need to admit they are powerless over alcohol (see sidebar on page 17). Dodes finds value in AA, but takes issue with this tenet.
HippoPress talked with Dodes about his work.

HippoPress: Are you redefining addiction?

Lance Dodes: Yes, I think so. One of the problems with current definitions is that they're always based on external consequences ... is it taking up most of your time, has it hurt your relationships, that sort of thing. And that's OK, but it's actually more sensible, if you can do it, to diagnose addiction from the inside out because that really has to do with the essence of addiction ... I'm saying that addictions are compulsive behaviors like other compulsions and that they have a specific kind of psychological basis ... And that psychology, as far as I've been able to tell, is true in hundreds and hundreds of people with different kinds of addictions ...

In his writing, Dodes explains: "an underlying psychology of addiction can be understood and described (but) everyone is unique in the specific concerns and problems that he or she deals with through addictive behaviors. This is why any approach to self-understanding or treatment must be individualized ... "

HP: So understanding is necessary, understanding what's driving someone's addiction. Is it sufficient?

LD: I think that it's sufficient when it's an emotional understanding ... what happens is that people learn about themselves ... not just intellectually but ... they feel the feelings, they can feel them in the key moments when they start to feel an addictive urge, and once ... they know what the addiction is about, they get choices.

The need to honor emotions is key for Dodes, who writes: "The AA injunction to avoid being tired or hungry might be useful to some people by giving them a sense of well-being ... But ... avoiding noticing when you are angry, or trying not to feel angry when you are, is just the kind of thing that can launch the drive toward addictive behavior." (p. 62)

He also writes, "A response to act against helplessness is at heart actually quite normal. It is just that when the response is addiction, the results are typically disastrous ... "

HP: Take me through the process of someone who winds up in a hospital in Boston with an alcohol problem. What kind of treatment are they offered?

LD: It's changed. Twenty years ago there were many inpatient rehabilitation programs, which lasted from two to five weeks. They don't exist anymore because of the insurance restrictions, so mostly people just go in for detoxification, so the stays are very brief. But if people do stay-and there are still one or two places that do some rehabilitation programs-nearly all of them are basically AA model programs ... it's a very closed system ... And one of the problems is that, you know, then patients get blamed when they don't get well ... My purpose is not to bash AA; it's just that it's such a mistake for people to think that it's the (only) right treatment ... the patients don't know other treatments and people are, you know, badly being hurt by this."

In "The Heart of Addiction," Dodes explains which AA tenets trouble him:

"The myth of hitting bottom implies that people are too stupid to learn from experience ... There is no need to 'hit bottom,' in any sense, before taking control of your life."
AA's injunction to surrender your power "is clearly not for everyone. However, along with other AA concepts, the 'surrendering' notion is often described as the only way to address alcoholism ... and that is a myth that is both wrong and hurtful."
The obligation to count how many days you've been sober " works for some but is hurtful to many ... " Dodes objects to the moralistic overtone and calls it "nonsensical" to think that if you have one drink after a year's sobriety you are sent back to Start.

HP: Does AA need to question itself more?

LD: I've talked to lots of people from AA and I have to say I'm not against these people-I mean one of the nice things about AA is that it can be extremely supportive ... it's lovely that people can go and be with a group of people who all share the same problem and who are going to be on your side; that's lovely, but it's nonspecific.

In the 19th century, medicine treated tuberculosis by sending people to spas, which was lovely, and some people actually got better. But when they discovered that tuberculosis was caused by a bacterium, well, then we had a better treatment, so people don't send folks to spas anymore. Unfortunately we're still in the spa stage with addiction.

HP: Why haven't I seen the link made between addiction and helplessness before?

LD: Just as the people who are mostly treating addictions don't have much psychological training, the reverse unfortunately is also true.
When I was studying psychiatry, when I was a resident, I didn't get too much training in addiction ... I think there've been very few people who have been trained in both fields, so they haven't been looking.

HP: How did you become a specialist in addiction?

LD: It was partly by accident, I suppose. When I finished my training I took a job as director of psychiatry at a small hospital and they had no addiction program at all but they had trouble filling their beds, so they wanted suggestions about how to fill the beds and so I suggested we start an addiction unit ... Once I got involved in it I became interested, because it just was very poorly understood from a psychological standpoint. And ... some of the people who were very interested in understanding it happened to be in the Boston area ... people like Ed Khantzian ... he's also a psychoanalyst and also interested in addiction, and a couple other people. So I learned from them and I stayed with it.

HP: Any other points you'd like to make?

LD: I just want to stress that ... I would like to see a change in the dialogue in this country about addiction ... The way the courts handle addiction cases, very often people are mandated into treatment and the treatment is almost 100 percent an AA-oriented treatment, and in that sense the government itself has put its imprimatur on AA and that's just a mistake. What they should be doing is referring people for a careful evaluation of what the issues are and then having a treatment prescribed, which might include AA but might not, or might be a combination of things. But we're funneling people through a system that can do good for some people but also can do harm and it's just not appropriate for many.

Lisa Parsons can be reached at hippo@hippopress.com

The 'life design' of AA

By Lisa Parsons
HippoPress.com

You don't join AA by paying dues or signing a membership card. You just show up.

Meetings happen around the city every day-almost 100 each week-in churches, hospitals and function halls. There is a type of meeting for nearly everyone: West Side, Sunday morning, noontimers and Pinardville groups for example.

"It's a very un-organized organization," says one member who declined to give his name but volunteers for AA administrative work.

There is no official spokesperson for AA. There are a lot of pamphlets, books, and tapes, labeled "AA General Service Conference-approved."

But no one-the literature is adamant about this-speaks for AA. Nor does anyone tell anyone else what to do. The pamphlets say "based on AA experience," and "the explanation that seems to make the most sense to most AA members is...," and "there are, of course, no musts in AA."

There are, however, strong suggestions, the strongest of which is to follow The 12 Steps, first published in 1939 by the founders of AA.

Step 1, for example, says: "We admitted we were powerless over alcohol-that our lives had become unmanageable." One longstanding AA member and office volunteer explains: "The idea is to let go of your attempt to control."

Step 4 says to make "a searching and fearless moral inventory of ourselves." Step 5 has you admit your wrongs, to God and yourself.

But AA also proposes that alcoholism is not a moral failing, and the office volunteer emphasizes self-acceptance as the key to recovery. So is AA moralistic or not?

"The moral inventory," says the AA volunteer, "is not to identify sin, it's to identify what are all the games we've been playing because we don't accept ourselves."

"It's analogous to going into your garage that you haven't cleaned in 10 years and putting everything into neat trash buckets. The fifth step is like opening the garage door and inviting your sponsor in...

The sixth step, you take those trash buckets out, and if you let go of them, the majority of them get picked up by the trash guy. You then go back into the garage. You used to think you were the things you were putting into the trash."

This non-spokesperson says professional psychology has only a small role in alcoholism recovery; he thinks the fellowship of other alcoholics is paramount. That's what the meetings are all about.

Other steps involve making amends and making contact with a higher power. Step 12 says to "carry this message to all alcoholics."

You may have heard the notion that alcoholics don't get better until they've hit bottom. The non-spokesperson says, "You need to declare a bottom." Asked whether people are ever "recovered" or are always "recovering," he replies, "It's arguable."
He talks about alcohol as anesthesia, and emphasizes the importance of acknowledging feelings.

"AA," he says, "is a life design."

Lisa Parsons can be reached at hippo@hippopress.com