Addiction or Compulsion or Habit?

By Lance Dodes 05/26/16

Psychotherapy for people with addictions.

Addiction or Compulsion or Habit?
Why can't you stop?

The inclusion of Gambling Disorder in DSM adds fuel to the fire of the ongoing debate about the differences between substance use disorders—firmly established as “true” addictions—and other potentially pathological behaviors that may be best classified as habits or compulsions. Although the debate is in some ways theoretical, these questions raise important considerations with respect to insurance reimbursement and, more importantly, clinical practice. Any problematic behavior included in the debate can have a significantly deleterious impact on relationships, careers, health status and overall psychological functioning. Psychiatrist Lance Dodes has been a long-time critic of 12-step based orientations to addiction, the idea that addiction is a brain disease, and other longstanding views about addiction and its treatment. Here, he argues that there is no fundamental difference between addictions and compulsions, and argues the case for in-depth psychotherapy as the gold standard of treatment for both…Richard Juman, PsyD

Addictions are Compulsions

"Addiction" is the word we use to describe a repetitive behavior that is unwanted yet cannot be stopped by willpower or simple decision-making. It is different from physical dependence (unfortunately also called "addiction") because physical dependence can happen to anyone and is treatable by detoxification, unlike true (psychological) addiction which occurs only in those who develop it as a symptom to manage difficult feelings, and is entirely independent of physical drug effects. True addiction is, therefore, identical to the behaviors we call "compulsions," which are also unwanted repetitive behaviors that cannot be stopped by willpower or rational thought.

Compulsive behaviors, like compulsively having to clean the house, exercise, or gamble, have always been understood to be psychological symptoms—complex emotional solutions to emotional distress. We have understood the psychological mechanism behind compulsions for over a hundred years, and they have been repeatedly shown to be treatable in psychotherapy (as long ago as 1945 the eminent psychoanalyst Otto Fenichel described such successful treatment by psychoanalysis in his textbook of psychoanalysis). (As an aside, I need to clarify that I am not speaking here about the diagnosis "Obsessive-Compulsive Disorder" or OCD, which is very different since it has a biological, not psychological, cause and is treatable with SSRIs, unlike psychological compulsions or addictions.)

Although addictions and compulsions are the same psychologically, we call some compulsive behaviors "addictions" for historical reasons, since for most of human history people thought addictions were caused by drugs and ignored the fact that the urge to compulsively repeat any behavior is the same for both drug and non-drug behaviors, and the fact that folks regularly shift their compelled behaviors from a drug addiction, such as alcoholism, to non-drug behaviors like gambling. Once we recognize that addictions are no more and no less than compulsions, it highlights an egregious error we've made for the past century: we don't treat them in the same way.


Treatment for addiction has been generally unsuccessful throughout history. A major reason is precisely the failure to appreciate that addictions are compulsions. Consequently, while we have been able to treat other compulsive behaviors by understanding how they work within each individual and resolving the issues that produce the symptom, we have invented nonsensical and largely ineffective approaches. We try to motivate people to stop by reminding them of the dangers of their behavior. We try to treat them as if they have a moral or spiritual failing. We give them lectures about addiction, as if they have an educational deficiency. Rehabilitation centers offer absurd "treatments" for addiction like riding on a yacht, grooming a horse, or doing "trust falls." Imagine doing any of those things for somebody with a hand-washing compulsion. Imagine telling someone with a compulsion to repeatedly clean the house or play games on the Internet that he or she should take a fearless moral inventory of himself. When people simply don't know or understand human psychology they are like physicians from hundreds or thousands of years ago, trying to treat illnesses with bloodletting or drilling holes in the skull. Those treaters were doing their best, but they simply didn't understand the nature of the symptoms they were treating. 

Psychotherapy, however, has itself had a bad reputation for treating addiction in the past. The problem has not been psychotherapy itself, though. Rather, it is that therapists didn't understand how to helpfully focus their treatment on the addiction as a psychological symptom while also still treating the whole human being. I've devoted many years to trying to address this problem and my first two books (The Heart of Addiction and Breaking Addiction) describe a new way to understand the psychology behind addiction as the compulsion it is and consequently define a new path to treating it in psychotherapy. It turns out that with better awareness of what we're treating, the compulsive behaviors we call addictions are just as treatable as the rest of the universe of compulsive behaviors—exactly as we'd expect. This doesn't mean there is a magic or instant cure for addictive behaviors, any more than for other compulsions. But it means we can approach them knowledgeably and use the perfectly good ability of people who suffer with addictions to do what other people can do. After all, folks suffering with addictions are every bit as capable as anyone else of being introspective, understanding the emotional factors that precipitate addictive thoughts, and working out the issues behind them. Denying psychotherapy to people just because their particular symptom is an addiction is both ignorant and prejudiced.

Treatment Goals

Even once we agree that people with addictions deserve the same sophisticated treatment we would offer anyone else, there is still a question of what the goals of the therapy should be. In any psychotherapy, the goal is to help people change, to grow emotionally, so not only are they free of their current symptoms but they have greater capacity to deal with all of their feelings, thoughts, and relationships. The hope is to come out of therapy free of the limiting conflicts, fears, inhibitions, and confusions that have interfered with happily living their lives. So, obviously, we should have the same goals for people whose symptoms include an addiction. But at the same time, when treating a symptom that is dangerous, it has to be given attention from the start, and it has to be kept in focus. The need for this kind of focus isn't limited to addiction, of course. It applies to treating people who have suicidal thoughts, people in emergency situations who need help making crisis decisions, people with major psychiatric disorders such as schizophrenia who are at risk of relapsing into psychosis, and so on. The good news is that paying close attention to an addiction, specifically looking at the feelings that precipitate addictive actions, is actually a wonderful way to explore people's overall emotional lives. Understanding the emotional details behind addiction helps the treatment of the whole person at the same time that treating the whole person helps the management and resolution of the addiction. It is one reason that psychotherapy is especially important for people with addictions.

But there is another problem. When we treat a person with, say, a phobia about flying in airplanes, or the kind of compulsive housecleaning I mentioned above, or even someone who makes repeated suicidal gestures, we are accustomed to keep working in the therapy even while the behavior continues. It would be insane to stop the treatment just because the symptom hadn't yet disappeared. But with addiction, the world tends to demand instant results.

Patients actually are the least likely to make this mistake, in my experience. They generally can see the need for ongoing therapy quite well, and how the therapy is making progress. But their families and friends think that if they are still drinking or using drugs or gambling after a long time in psychotherapy, then the treatment must be failing. This view places harmful pressure on the patient as well as the therapist, and sometimes good therapies are stopped because of the anxiety of family members. The best way to manage this problem is to educate family, friends and even other caregivers. They need to understand that the therapist is not ignoring the addictive behavior—quite the contrary, he or she is closely monitoring both the behavior and its precipitants—but that good therapy for everyone takes time. They need to understand that although there is no magic cure, there is successful treatment.

Finally, during an ongoing therapy there might be times that a brief hospitalization is needed, either for detoxification or just to have a break from a pattern of addictive use. The latter is almost always best done in a short stay in a supportive environment, generally no more than 10 days (and certainly not in an expensive luxury rehab whose "treatments" with horses and gourmet food are nonsensical and unjustifiable expenses). Any inpatient stay must also always be individualized. There is no medical or psychiatric condition in the world that requires an exact, predictable number of days in the hospital. The current practice that hospitalization should be 30 days, or some other fixed number, is both absurd and harmful.

In the end, just as for anyone else who is capable of thinking about himself or herself, psychotherapy that is guided by a modern understanding of the psychology behind addiction is often the best way to achieve both lasting emotional growth and protection against future addiction relapses.

Lance Dodes, M.D. is a Training and Supervising Analyst Emeritus at the Boston Psychoanalytic Society and Institute, member of the faculty of the New Center for Psychoanalysis (Los Angeles), and retired assistant clinical professor of psychiatry at Harvard Medical School. He is the author or co-author of many journal articles and book chapters about addiction and the author of three books: The Heart of Addiction (HarperCollins, 2002), Breaking Addiction: A 7-Step Handbook for Ending Any Addiction (HarperCollins, 2011), and The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry (Beacon Press, 2014; senior author). Dr. Dodes has been elected a Distinguished Fellow of the American Academy of Addiction Psychiatry.

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Lance Dodes, M.D., is a Supervising Analyst Emeritus with the Boston Psychoanalytic Society and Institute and a retired assistant clinical professor of psychiatry at Harvard Medical School. He is the author of several books about addiction and alcoholism, including, The Sober Truth. You can find him on Linkedin.