Abstract
Lance Dodes on Jeffrey Roth
In his review of Howard Markel’s An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine (JAPA 59/6), Jeffrey Roth writes that a modern view of addiction shows it to be the result of neurobiological processes in the brain. This is an error. The ideas to which he refers arose from experimental studies with rats, but have been amply shown to be inapplicable to humans (Dodes 2009, 2011). Rats’ brains are altered by exposure to drugs, heroin for example, making them more responsive to subsequent exposure to heroin or a related environmental stimulus. Upon such exposure, they immediately seek more heroin because the reward system of their brains is stimulated by release of dopamine in the area of the nucleus accumbens. The animals’ response is immediate and unmodulated by higher psychological processes, which are not present in rats. This hyperresponsiveness is said to be the source of future drug-seeking behavior in what animal researchers have called a “chronic brain disease.” Humans, on the other hand, have repeatedly been shown to fail to react this way. High exposure to heroin over long periods of time leads to a physical dependence but does not turn people into addicts, as first demonstrated by Robins, Helzer, and Davis (1975), and as seen in people with years of exposure to nicotine and alcohol (millions quit smoking after the Surgeon General required warning labels on cigarettes despite having been physically addicted to nicotine, and the majority of Americans drink regularly without becoming alcoholics). Nor do people with addictions have immediate drug-seeking behavior following exposure to salient environmental cues. The most common pattern of drug use in human addicts is significant delay after the first thought of performing the behavior (think of the time it takes to drive to a casino, or obtain a drug supply), a phenomenon common in psychological processes but inconsistent with immediate release of dopamine as found in rats. Humans also regularly substitute non-drug compulsive behaviors (e.g., cleaning or shopping) for drug addictions. Most important, addiction in people is virtually always triggered not by external stimuli but by psychologically meaningful factors, and is treatable in psychotherapy or psychoanalysis once the psychodynamic mechanism of addiction is understood (Dodes 1990, 1996, 2002, 2011). In many instances, the addiction urge vanishes once it is understood to be a displacement from a more direct, but forbidden, response to overwhelming feelings. Taking more direct action is a common and helpful result (Dodes 2011). Of all therapists, psychoanalysts should be the most aware that addiction is neither more nor less than a psychological symptom, a compulsion that is well within the mainstream of psychoanalytic purview and treatment (Dodes 2003).