The Heart of Addiction

The Heart of Addiction claims to be "a new way of thinking" about addictions. However, rediscovery of an old, important, but little used perspective for treating the addicted patient might be a more accurate description.

Lance M. Dodes, the author, is a psychoanalytically trained psychiatrist who has been treating addicted patients in a variety of settings for many years. To this reviewer, who began treating addictions during psychiatric training in the late 1950s, this book exemplifies the idea that "what goes around comes around." Fortunately, this update of a historic psychiatric-psychoanalytic perspective on addictions—that the addiction represents an attempt to deal with an unresolved neurotic conflict—has value for our times. It tilts against "just say no" foolishness and argues against the reductionism of the one-size-fits-all approach used by some Alcoholics Anonymous (AA) groups and other 12-step groups.

Dodes argues that every true addiction represents an attempt on the part of the patient to regain lost control. The addictive process—substance use, gambling, shoplifting—is used as a substitute for mastery over the unsolvable problem. The problem might be rooted in the present—perhaps in an unhappy marriage or career—but most often has its roots in an unresolved childhood conflict. The approach proposed, and exemplified in a number of useful case vignettes, is to develop a therapeutic alliance, to explore conflicted areas in the patient's life, to find the source of the sense of helplessness that the addictive process solves for the moment, and to help the person move on. Would Freud argue with this formulation?

The Heart of Addiction never proposes psychoanalytic treatment. Indeed, it never mentions it. Rather, the book describes a method of psychotherapy that is readily recognizable by practitioners of psychodynamically oriented psychotherapy.

Dodes argues that all "true addiction" is psychological; it is displaced helplessness and is separate from and independent of physical dependence. He sees physical dependence as more easily treated than psychological addiction. In pursuing this line of reasoning, Dodes minimizes the role of genetics and dependence. In reviewing the evidence for such a role, he concludes that such evidence is scant and finds the psychological dimension of helplessness to be controlling.

Dodes analyzes the AA model and finds it wanting. A bit of history might be helpful here. When AA was created in the 1930s it acknowledged that psychiatric disorders often co-occurred with alcohol abuse. It respected the role of medicine and psychiatry. It added the self-help group and a set of rules for recovery to provide social and spiritual support. However, over the next 50 years AA narrowed from the broad base created by its founders. It tended to become a one-size-fits-all group support structure and shunned all psychiatric medications on the grounds that they were addictive. This is the AA that Dodes rightly criticizes.

We cannot leave it at that; another point must be added. AA groups are essentially autonomous, and in the past decade or two many of them have broadened their approach. Some AA groups welcome medications and psychiatric treatment, as long as the doctor does not tell the patient to stop attending AA meetings. In sum, AA and other 12-step groups, such as Narcotics Anonymous (NA), help some people but not others, and the fit between a patient and a specific group must be considered.

Dr. Dodes addresses his book to people who believe they may have an addictive disorder, or to family members who are trying to understand a relative who is in trouble. He provides a rich series of examples of individuals whose addiction was closely tied to issues of psychological conflict, and it is likely that many readers will benefit from the case examples. The book might be particularly useful for someone who has not been helped by the 12-step approach or who finds that approach to be personally unacceptable. For these reasons, The Heart of Addiction may be a useful book for many people who need help. However, it is regrettable that, in order to make his legitimate case about the importance of psychodynamics in understanding how unresolved conflict and helplessness can lead to an addiction, the author has excessively deemphasized the important role of physical addiction and of genetic risk factors.