An Interview with Dr. Lance Dodes

Lance Dodes does psychiatry the old fashioned way: He listens to people and tries to figure out what’s going on with the aid of his psychoanalytic training. Educated at Dartmouth and Harvard Medical School, the 62-year-old doctor has an extensive private practice and is an assistant clinical professor of psychiatry at Harvard. Having directed substance abuse treatment at various hospitals, and having worked with hundreds of addicts of all kinds, he clearly has the credentials to be a recognized expert in his chosen specialty of addiction.

His 2002 book The Heart of Addiction (Harper) has been called “revolutionary” by some, while others have not exactly welcomed his challenge to previous paradigms. The addictive act, he says, is a compulsive displacement; that is, a substitute action which the addict uses to ameliorate chronic feelings of helplessness in certain situations that he believes are impermissible to address directly. “Addictive behavior functions to repair this underlying feeling of helplessness. It is able to do this because taking the addictive action (or even deciding to take the addictive action) creates a sense of being empowered, of regaining control–over one’s emotional experience and one’s life.” 

While the particular situation that makes one feel helpless is specific to each individual, all addicts rage against helplessness, which is “the nearly irresistible force that drives addiction.” Pretty much any behavior can become an addiction, but when the addict learns to address the underlying situation directly–in other words, to stop displacing–the addiction no longer compels and the addictive act becomes unnecessary.

I remember reading these and other insights one afternoon while on a hunting and gathering expedition at Borders. “Wow,” I thought, “the Rosetta Stone of addiction. This is something new.” As I finished the book at home, I further thought, “I need to interview this guy.” And I did, at his office in Newton Highlands, a suburb full of trees outside Boston. 

Charles Young: How did you get started in addiction studies?

Dr. Dodes: I got into it by accident. I was director of psychiatry at a hospital, and they wanted to add addiction treatment. Since I was to be head of it, I had to learn more about it, after what I had learned at medical school. I began my psychoanalytic training about the same time, so I was interested in integrating what I was learning about psychology with what I was learning about addiction. It turns out that there are relatively few people who are both well trained in psychology and interested in addiction.

CY: What did you find interesting about addiction, as opposed to something like bipolar disorder?

DD: Well, I was seeing a lot of people who had addictions, but maybe you’re making a good comparison. I’m not particularly interested in bipolar disorder because it is understood to be a biological problem with the brain. An addiction, on the other hand, is a psychological problem. Most people in the field of psychoanalysis, like the general public, probably have a misunderstanding that addiction is somehow related to the drug’s effect on the brain or to the brain itself. So they avoid it, because the addict doesn’t seem to be as appropriate for psychological treatment as, say, someone who is having difficulty with relationships. One of the points I try to emphasize in my book is that addictions aren’t very different at all from other psychological problems. It’s the same thing as my being interested in obsessive compulsive disorders, which I am, because that basically is the same problem. Physical addiction–becoming tolerant to a drug and having withdrawal when you stop using–is relatively unimportant. 

Perhaps you saw the HBO special Addiction a couple of years ago. That was basically a NIDA (National Institute on Drug Abuse) production, and it got a very wide audience. Their view is that addiction is a type of brain disease, and it is based on studies of rats. They took rats and physically addicted them to drugs like heroin and showed that the rats’ brains had changed after chronic exposure. At a subsequent time, when they exposed the rats to the drug or drug paraphernalia, this set off the same sort of dopamine discharge that the rats originally got from the heroin or whatever the drug was. So the rat’s brain is conditioned to over-react, and it has a permanent hyper-responsiveness to the drug and things associated with the drug. Thus NIDA claims addiction is a chronic brain disease, which is why the addict can’t stop. That’s the official government position.

Why that’s wrong is this: We’re not rats. Even though it’s true that we and the rats share the same limbic system, the pleasure pathway of the brain, we also have a big brain on top of it. If you ignore human psychology, if you ignore everything that makes us different from rats, you miss the boat. When you actually look at people with exposure to an addictive drug over a long period of time, they don’t necessarily become addicts. There was a famous study of Vietnam veterans who had long-term exposure to heroin in Vietnam that should have changed their brains and made them addicts forever. And it didn’t. They just stopped using when they got back to the United States. And that’s just one example. It’s also true of people with long term exposure to cocaine and alcohol. So NIDA is just wrong. It won’t pay attention to these data, and it has quite a bit of power as a government agency. 

CY: How have people reacted to your book?

DD: Some people just understand the whole thing immediately. Some sort of get it and sort of don’t. And some are antagonistic. The antagonistic ones believe that it’s an attack on AA to have a different view than they do. I always go out of my way to say that I have no quarrel with AA. It’s life saving for a small percentage of people, which is great, but it isn’t the answer for everyone else. 

CY: You quibble in the book with some of the AA slogans, but your basic insight that addiction is a displacement for feelings of disempowerment fits in well with the program. AA is an egalitarian environment where an alcoholic can quickly feel useful to his fellow alcoholics, thereby dissolving the rage at helplessness.

DD: I agree. But I can just tell you my experience. If I go on a radio show and they have call-ins, I guarantee that one out of four or five callers will be mad at me for writing a book that isn’t AA doctrine. Elsewhere, at treatment centers, people are open and receptive but hesitant to change as an organization. I would have hoped that if people found that this is a good idea, they would make changes in their treatment, even if they don’t make it the center of their program. It’s difficult in any field when you bring in something new.

CY: It seems like the first important thing in your treatment is recognizing the decision to drink, which is largely unconscious and delivers the first feelings of empowerment.

DD: I’m writing another book now, the follow-up to The Heart of Addiction. It gives a step-by-step approach to treatment, which is not the way the first book was organized. The first step is really recognizing that you have an addiction, and then you need to see at the earliest possible moment that you have made the decision to drink. That’s where it is most useful to focus your attention, not on the actual addictive behavior. You want to go backwards from the moment of the addictive act to when the decision was made, which can be hours or days before. Most of the time, when people talk about alcohol, or whatever it is, they discuss the effects of their drinking–understandably, because the effects are so devastating. But it doesn’t help much. What helps is looking at the cause, not the effect. So then it’s a question of what to do in that key moment. What was going on in your life at that point–and there is always something going on–that set off the compulsion? And finally, what else can you do instead of the addictive act? 

CY: So you recognize when you made the decision to drink, and then you need to figure out why this thing that inspired you to drink is so meaningful?

DD: Yes.

CY: That means the psychoanalytic approach?

DD: Well, there’s an immediate course of action and a long term course of action. Take an example from The Heart of Addiction, the woman who was addicted to Percodans. Her husband had a habit of calling up at the last minute and demanding that she make a large dinner for him and his business associates, and she’d say, “Yes, dear,” and then she’d go make dinner and take the pills. After a while in treatment, she realized that she needed to re-empower herself after being so meek with her husband. One day she went to the medicine cabinet and was asking herself, “Should I or shouldn’t I take the pills?” and she came up with a new solution: She ordered out for Chinese food. She said to me, “I know what I should have done. I should have told my husband to go jump in the lake and make his own dinner. I still can’t do that, but I found a different way of handling it.” That was the intermediate solution–getting his dinner but not making it.

CY: It was half a displacement.

DD: Yes, half a displacement, but a big improvement. She wasn’t taking the pills. What’s important to me in that story was at the point she decided to order the Chinese food, she no longer needed to take the Percodans. She found something else to do. If you talk to the NIDA people about that, they have no explanation. For her, it was one of those intermediate points where she might not have done enough psychotherapy to know where the feeling of disempowerment came from, but she could recognize the situation. In fact, you can learn to anticipate those situations, which my patients do regularly, and then you can get some help. The woman in this case could stop taking the pills before she had it worked out why she was so meek in the first place.

CY: There are feelings of being disempowered, and then there is the reality of being disempowered. If you’re financially dependent on an arrogant husband or an abusive boss, aren’t you in reality limited in your choices?

DD: Yes, but that isn’t why she was meek. It wasn’t a financial issue for her; it was a psychological issue, which went back to her relationship with her mother. She had a very demanding mother, and as a child was willing to do anything to hold onto that relationship. That was the template for her relationship with her husband. 

CY: In the United States right now, aren’t we dealing with a kind of mass disempowerment? High unemployment, huge numbers of foreclosures and bankruptcies, colossal income disparities.

DD: Well, this is a very interesting question. It’s true that there is more alcoholism in poor communities than in rich communities. Why? The point you are making. Poor people are actually less empowered. They are in a bad situation in reality. 

When I was on staff at hospitals, I used to work with a lot of people who had spinal cord injuries. And what was so striking was seeing two people with the same devastating injury and two completely different reactions. Talk about being helpless. But your reaction still depends on who you are. As a culture, we tend to admire someone who reacts “well.” We like the paraplegic who’s a fighter, who makes a life for himself and doesn’t let the wheel chair hold him back. We all admire that, and I have no objection. But what about the guy who is paraplegic and his life goes down the tubes? He sits at home. He’s depressed. He has no relationships. We don’t admire him. Well, what’s the difference? It’s what they had inside them, what was given to them. Maybe the guy who did well had loving consistent parents and a home where he was respected, so he had enough in him to manage catastrophe. The other guy maybe had none of that. He started out injured, so for him the catastrophe was overwhelming. I don’t admire him any less. It has nothing to do with admiration.

CY: Where does the second guy get his empowerment?

DD: He doesn’t. He gets depressed. Let’s say he becomes an alcoholic. That would certainly fit. But he doesn’t have to become an alcoholic. Alcoholism is just a symptom. It’s one version of psychological adaptation. Maybe he has no addiction. Maybe he’s just miserable. He’s certainly not a coward. Maybe he becomes agoraphobic and stays inside his house. Or he might develop paranoia. There are many psychological ways of dealing with issues, and symptom formation is one. One possible symptom formation is compulsive behavior, like addictions.

CY: When you say in your book that addiction is not a moral problem, what do you mean?

DD: It’s just a symptom. There’s no such thing as a moral problem with a psychological symptom. It’s an adaptation to life that has gone badly for you. If people are hurt by your addiction, I can’t deny that there is morality involved, but that is a byproduct. It’s important, but that’s not the addiction. The addiction is a psychological issue.

CY: You don’t have quarrel with the state taking away the license of somebody who is driving drunk?

DD: No, but I don’t see that as a moral issue either. It’s a public safety issue. I’ll give you an example. I testified in court on behalf of a man who I won’t name. He had a gambling problem and he’d done some illegal financial dealings. The judge asked me, “What do you think we should do with this person?” And I said, “I don’t see any point in putting this man in jail. You may need to because of the law, but it doesn’t serve the public interest. He’s not going to learn anything there. If I ruled the world, I would put him in treatment.” It’s a different issue if you’re a sociopath. That’s a serious, untreatable disorder, and there’s no point in trying.

CY: Are there certain jobs or cultures where drinking is more common? It seems like so many of the writers and musicians I know have had an addiction of one kind or another.

DD: I don’t know what the statistics are on that, but I’ll tell you my bias. We hear about celebrities getting arrested for drunk driving, or dying of an overdose. We don’t hear about everyone else who isn’t in the public eye. I’m not at all sure that there isn’t an equal amount of drinking in every field of endeavor. We do know that cultures who introduce alcohol at an early age as a normal part of family life seem to have less alcoholism, so there are cultural factors. Some companies have a tradition of going out every night for a drink after work.

CY: I met a guy once who was telling me how brutal the drinking was in the furniture upholstery business.

DD: Yeah, it’s everywhere.

Charles M. Young has written lots of articles for Rolling Stone and has played bass for Iron Prostate, the Dry Heaves and the Whistling Boogers.