The truth is indeed sobering A Response to Dr. Lance Dodes (Part Two)

By Michael G. Brock, MA, LLP, LMSW

“Do you have something better?”

The second question the interviewer asks regards Dodes assertion that, “addiction is a psychological challenge, not a disease,” and that as such it could be overcome with insight-oriented therapy. Lavitt cites the poor track record insight therapy has with treating addiction and asks what would be different this time. Dodes’ first response is that one might criticize the choice of wording in that part of the book:

“It was unintentional to suggest that is the way to treat everybody. However, I will stand my ground about the idea behind it: To call addiction or alcoholism a disease, doesn’t help understand it, and I have always felt it confuses matters. Second of all, I don’t think it’s accurate because we know that people can switch from addictively or compulsively using alcohol to addictively or compulsively gambling or addictively or compulsively having sex or shopping. We know that because it really happens in the real world.

“So what is the disease? If the disease is that you have compulsions that shift from one thing to another, I don’t need to call that a disease because I already know what that is. It’s called a compulsion and it’s been well-studied for over a hundred years. It does have a psychological basis. Your point that it’s [insight-oriented therapy] been studied and it doesn’t work well is true. But I’m not sure it has been well-studied[i]. People have been studying and using cognitive-behavioral therapy, but the kind of treatment I’m talking about hasn’t existed. It really hasn’t been studied and I wish somebody would study it.”

There is a brief section at the end of the interview where Dodes gives a summary of the kind of therapy he is proposing, and it is clearly insight-oriented. Interestingly, he dismisses cognitive-behavioral therapy, but cognitive-behavioral therapy has become the predominant or preferred method of therapy for most psychological problems today because it is generally much more usable than the insight-oriented approach. You might say it is more psychologically sound. This may be because it is solution oriented rather than problem oriented. When I do therapy with an addict, I’m going to remain as concrete and behavior-oriented as possible. Helping him find an event in his life that triggered his addiction doesn’t give him an answer, it gives him an excuse and a reason to feel sorry for himself. He’s already good at that. I want him to take responsibility for himself. I know that sounds like a cliché, but if it is one it’s because it’s a necessary part of change and growth.

AA’s “Serenity Prayer[ii]” tells him to divide the world into what he can do something about and what he can’t, and to focus on what he can change. He can’t do anything about the past, except make amends for his own behavior. (Predictably, Dodes doesn’t like that process.) Psychiatrist Abraham Low had an answer for patients who wanted to know the why of their mental health condition. He would tell them, “Why is temper at the illness.” It’s the patient’s way of saying, “I don’t want this condition.” Too bad; you’ve got it. Deal with it. Tough love is still love; pity is condescension.

They have a saying in AA that, “You can live your way into right thinking, but you can’t think your way into right living.” Dr. Abraham Low, the founder of a self-help group called “Recovery Incorporated (now Recovery International),” and the person credited by Albert Ellis with being the founder of cognitive-behavioral therapy, said that a “nervous patient” must learn to “move his muscles to reeducate the brain.” This is a complete reversal of the notion that one can gain insight into one’s dysfunctional behavior and then logically chart a course of behavior that will achieve the desired effect through healthy behavior.

The insight oriented way of thinking makes much more intuitive sense, I will admit. It just doesn’t work. I would also agree with Dr. Dodes that the disease of alcoholism, like the disease of addiction in general, and the disease of obsessive-compulsive disorder (a totally separated and unrelated condition to addiction) are essentially conditions that have a psychological basis. In calling alcoholism a disease, Bill Wilson, who was educated as a lawyer and had no medical or psychological/mental health training or licensure, relied upon the theories of his friend and physician Dr. Silkworth. Silkworth’s idea was that alcoholism was an “allergy of the body and an obsession of the mind.”

Actually, it is neither.[iii] There is no evidence that an alcoholic responds differently physically to alcohol than other people, with the notable exception that once a person has developed a high tolerance to a drug, they seem to regain that tolerance very quickly once they resume using their drug of choice. This same phenomenon holds true of other addictive behaviors, suggesting the grooves may be worn, not in any physical pathways, but in some intangible psycho-spiritual pathways.

As differentiated from compulsive behaviors, however, addictive behavior is pleasure driven and becomes increasingly destructive in outwardly observable ways. Compulsive behavior, such as cleaning your house over and over (the example given by Dodes) may prevent one from doing more productive things with his time, but it is rooted in a perfectionism that can never quite be satisfied, and brings the OCD suffer no pleasure. Indeed, the more times they repeat the compulsive behavior, the more tense they are likely to feel.

Similarly, the so-called alcoholic obsession of the mind, is in fact a fantasy of the pleasure that the person will experience once they engage in the addictive behavior. A true obsession, on the other hand, is repeating a thought over and over (often connected with a compulsive behavior), though the repetition brings the obsessive no pleasure at all. I’m not sure if anyone has ever satisfactorily explained what goal the obsessive hopes to achieve through this behavior, but again, the focus seems to be relief from discomfort if they can “get the thought right.” It seems to me that true obsession might be an effort to change things beyond the power of the person to control by thinking about them.

But whether or not alcoholism is considered a disease or a psychological challenge is a moot point. What is important is that the condition has certain recognizable features. Most definitions include: increased tolerance, loss of control, and withdrawal. It is also frequently progressive, resulting in increasingly uncontrolled behavior and serious consequences. Disease or not, clients are responsible for their behavior under the influence, and also for what they have to do to get their drug of choice. They are legally and morally responsible, and responsible to their own conscience. They are also responsible for getting the help they need to overcome the problem.

“Disease” may be a convenient fiction, but it helps to explain to an addict why the condition progresses, and why it is hard to beat without help. One of my clients had a drinking career lasted only 9.5 years, but during that time he went from drinking a few beers on the weekends to a fifth of liquor daily. But not every problem user of a substance has a high tolerance, and few people (only those with more advanced conditions) have major withdrawal symptoms. The chief symptom of addiction is loss of control — the inability of the alcoholic to predict his behavior after the first drink, along with the inability to make a firm decision not to take the drink.

Significantly, loss of control is gradual for most people — almost imperceptive — and that is one of the things that make the condition so insidious. The alcoholic doesn’t lose control of how much he drinks every time he drinks unless he’s living under a bridge, in which case he’s not seeing either myself or Dr. Dodes. He begins by losing control gradually, once in a while he drinks too much. “If you’d just set a limit,” his well-meaning friends and family tell him. And he doesn’t use bad judgment every time he drinks, just once in a while. “Just don’t get behind the wheel when you have too much; get a designated driver, or call me, I’ll pick you up…”

One of the things I ask my clients is, “If you drink two beers every day, but 1% of the time you lose control, and when you lose control you get behind the wheel and get arrested, how many DUIs do you have at the end of a year?” The answer is, of course, 3.65. Three and a half DUIs is enough for you to be charged with a felony and do prison time in Michigan. I guarantee that if you get three in one year you will do time and be without a license for a long time once you get out. You will most likely lose your job, possibly your marriage, your self-esteem/respect, your financial resources, and anything else you value. This is from one percent loss of control — but most of my clients have less than that. They might pick up a DUI every five to ten years, but the third one is still a felony, or the first if he kills someone.

Dr. Dodes says we should not expect alcoholics to achieve and maintain permanent abstinence, but should look for improvement and “harm reduction.” We should not be too critical of persons who are unable to remain completely abstinent. Isn’t it obvious why those in the recovery and treatment fields (to say nothing of those people who have lost loved ones to drunk drivers) find this kind of talk exasperating? Equally disconcerting is that he does not differentiate between addiction and compulsion, which are two very different conditions.

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 Early in the interview, Dodes said that AA succeeds because it’s become accepted as the standard and so now it is the default position for anyone making a treatment referral of a problem drinker. That such a phenomenon exists is hard to dispute. When Eric Clapton released one of his best albums, Derek and the Dominos, it didn’t have his name on it and he had to do a promotion campaign telling people that “Derek is Eric” before the record became successful. I guess he wanted to see if he could sell a lot of records on merit alone, and I guess he decided he couldn’t. So yes, past success is one huge determiner of future success.

However, there have been and are many 12-Step programs that have attempted to emulate the success of AA. Some of them may work, but many are less effective and less popular than other methods for treating these conditions. Weight Watchers, for example, has more sound behavioral principles for treating overeating that Overeaters Anonymous. It is goal oriented (goal weight), behaviorally specific (certain amounts of certain foods), measurable (they make members get on the scale), and sustainable (If they do it forever, they stay thin forever). I used a modified WW program to lose and keep off 50 lbs. (minus the meetings, the weighing of food and counting of points, and with daily weigh-ins at home). If I had never gone to Weight Watchers, I might never have been able to design my own version once I was ready to lose the weight.[iv] But I don’t see much change in friends or clients who attend OA and would never make that referral.

Similarly, I’ve always been convinced that Abraham Low could have been to mental health self-help what AA has been to substance abuse self-help if he had been a little more politically savvy, had not died suddenly and prematurely, and had the marketing skills of Bill Wilson. Good ideas don’t always find their way to an audience, but, because of their simplicity and specificity to depression, anxiety and OCD symptoms, Low’s ideas[v] are much more tailored to the needs of those with mental health problems that Emotions Anonymous’ 12-step approach.[vi]

It is truly amazing that someone repackaging Freudian ideas as a treatment for addiction could ever find an audience. Dodes slams AA because the scientific support is bad, but he puts forth his own solutions, for which the scientific support is even less encouraging, or, if you accept his position, there is no science at all, either good or bad. Here I have to agree with Dodes; if it weren’t for his credentials, the resentment of people who are being forced to participate in a quasi-religious recovery program (which most AAs are not particularly happy about, by the way) and the undying prejudice in the scientific community against the efficacy of anything with any degree of spiritual content, it is unlikely that anyone would give Dodes theories serious consideration.

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When I was new in the treatment field I would often have what I thought were very productive sessions with clients regarding what fundamental issues needed to be addressed and changed. They would frequently express quality insights and I would mentally congratulate myself on having facilitated that insight. However, it was usually the case that the client had reverted to his old defensive posture by the time of the next meeting and we would wind up going over the same ground again. If the client had not instituted any positive behavioral changes, the insight was lost.

I came at length to agree with a colleague who once told me that insight is for the therapist, the client needs a behavioral plan. After months or years in therapy, many of my clients were pretty cognizant of the underlying factors feeding their addictions. However, it hadn’t altered their behavior. I came eventually to understand that only after there is some success with changed behavior will a client internalize the insight corresponding to that behavior.
Another point about addiction is that it has to be a program of prevention, not one of cure. Once the fantasy process has started it is just a matter of time until the addict begins to use his substance. Crucial to that process is the ability to engage in self-talk which will enable the addict to truly believe that he is doing himself a favor by being sober and opening up all kinds of positive possibilities. In this way he can counter the feeling-generated thought that he is denying himself something by refraining from drinking or using a drug. Both the AA program and Abraham Low’s cognitive-behavioral method of self-help contain a plethora of one-liners the sufferer can offer himself to get through a day. AA says: “one day at a time; easy does it; one’s too many, a thousand’s not enough; don’t get to hungry to angry, to lonely or too tired; let go and let God.”

Note the similarity to Low’s Recovery Inc. language which says: “Take things in part acts; don’t limit how much discomfort you can bear; feelings are not facts; nervous symptoms are distressing but not dangerous.” Whether someone is suffering a panic attack, or facing an uncomfortable social event, they need a short positive thought, not a complicated insight to get through the moment. This is why AA is actually much more psychologically mainstream than the groundbreaking, but now outmoded Freudian method of psychotherapy. The confused person needs something clear, specific and behavioral to help him override the powerful, but momentary onslaught of negative emotions.

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Dodes further states that he wants to “muddy the waters” a little more by explaining harm reduction as a goal, vs. the permanent abstinence proposed by AA. There is certainly a great deal of evidence in anyone’s treatment practice that people often get well/recover by degrees. People may be in and out of therapy and/or AA for a long time before establishing permanent sobriety and noting quality improvement in their lives. However, that path to permanent abstinence is one way recovery can proceed.

Another path that people sometimes follow is much more sinister and destructive. This is one where the client cleans up long enough to get people off his back before surreptitiously beginning to drink on the sly. If he were truly able to control his drinking in the manner he intended, he would not wind up returning to treatment or AA because of some new trouble his drinking is causing, or some repetition of his old behavior. I have watched many such people over a period of decades, and it never ends well. And I’ve had a few clients who said they had gone from excessive drinking to controlled drinking, but I’ve never seen them maintain that over a long period of time. Moreover, I wouldn’t just take their word for it.

If there are clients out there who can gradually reduce their drinking from harmful excess to socially acceptable, non-harmful limits, then Dodes may be more apt to see them than I. He is more likely to have clients who are economically well-off enough to see him multiple times a week for years, and it may be that kind of intensive contact can have the kind of results he is claiming. However, these are also people who are seeking treatment on their own and not being pushed into it by a third party, such as the court, an employer, or a wife. Self-motivated people are every therapist’s dream. It may be the case that anyone who is willing to go to any length will find the right combination, the length that they need to go to in order to achieve a productive life and a modicum of happiness.

It might also be said that this kind of therapy that goes on for years may be a kind of dependency in itself, albeit a less harmful dependency than substances. Woody Allen can joke about being in never ending therapy, but how many people can really afford it? And can that therapy itself be avoidance of moral issues the person needs to deal with? I love Woody Allen, I think he is America’s most important filmmaker, but I saw a moral evolution in his films that stopped at a certain point. In Broadway Danny Rose Allen’s character tells Mia Farrow’s Character that guilt has a useful purpose, “It’s important to feel guilty, otherwise you’re capable of terrible things!” But the main character in Crimes and Misdemeanors gets away with murder.

I see a lot of people who have remained permanently abstinent for years after months or years of therapy and/or AA had terminated, but their policy was to remain sober. I’ve also seen a lot of them relapse after years of abstinence and have some kind of trouble. It could be argued that the ones who regain the ability to drink socially don’t get into trouble and come back, but how do you really measure that? And why would you try to teach that to people, if failure meant a major setback to them and the people in their lives?

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[i] A central point of Dodes book is that the science supporting AA is bad. Here he is not questioning the methods of those who have studied the application of insight oriented therapy to substance abuse, but claims there are subtle differences in the kind of insight oriented therapy he provides, verses what has been studied; therefore the research cannot be relied upon. However, he has no problem recommending a therapy that is supported by no scientific research.

[ii] The prayer is generally attributed to Christian theologian Reinhold Niebuhr, but may have originated as far back as roman times with Boethius, the Roman philosopher (480-524 A.D.)

[iii] The Mayo Clinic website has this:
http://www.mayoclinic.org/diseases-conditions/alcoholintolerance/basics/definition/con-20034907 Alcohol intolerance can cause immediate, unpleasant reactions after you consume alcohol. The most common signs and symptoms of alcohol intolerance are nasal congestion and skin flushing. This condition is sometimes inaccurately referred to as an alcohol allergy. Alcohol intolerance is caused by a genetic condition in which the body is unable to break down alcohol. The only way to prevent alcohol intolerance is to avoid alcohol altogether. In some cases, what may seem to be alcohol intolerance is caused by a reaction to something else in an alcoholic beverage — such as chemicals, grains or preservatives. In other cases, reactions are caused by combining alcohol with certain medications. In rare instances, reactions to alcohol can be a sign of a serious underlying health problem that requires diagnosis and treatment.

[iv] For more info, check out my article, A Psychologically Sound Diet, on the Internet.

[v] As expressed in his major text, Mental Health Through Will Training, available through Recovery International in Chicago Ill

[vi] Low thought his self-help method should be helpful for dissociative disorders as well, but in my view it isn’t particularly. It seems to require more cognitive clarity than these patients can muster. I don’t know that there is anything for Schizophrenia that can restore a person to normal functioning, though medications clearly help with stability.

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Michael G. Brock, MA, LLP, LMSW, is a forensic mental health professional in private practice at Counseling and Evaluation Services in Wyandotte, Michigan. He has worked in the mental health field since 1974, and has been in full-time private practice since 1985. The majority of his practice in recent years relates to driver license restoration and substance abuse evaluation. He may be contacted at Michael G. Brock, Counseling and Evaluation Services, 2514 Biddle, Wyandotte, 48192; 313-802-0863, fax/phone 734-692-1082; e-mail, michaelgbrock@ comcast.net; website, michaelgbrock.com.