I recently finished reading a fascinating book, The Sober Truth, by Lance Dodes, which focuses a critical look at the treatment of addictions, particularly inpatient rehab centers and 12-step groups. I’m sure this book will prove to be very controversial, especially in addiction circles, as its main premise is there is no evidence that 12-step groups, or inpatient rehabs (which are mostly modeled on the 12-steps) are more effective than no treatment at all in helping folks to overcome their addictions. In all, research shows that only 5% of those who regularly attend a 12-step fellowship are able to abstain fully from alcohol or drugs in the long-term, which is about the same percentage of those who quit on their own.

As a sexologist, my expertise is not in addictionology, but where my practice does intersect the addiction field is in the area of sex addiction and sexual compulsivity.  There is currently tremendous debate whether out-of-control sexuality is really an addiction or a compulsion. For more on this, check out this article which covers recent research in this area. Interestingly, in The Sober Truth, Dodes states that all addictions, yes ALL addictions, and this includes all manner of drug addictions and alcoholism are really compulsions, not addictions.  To illustrate his point, Dodes differentiates between physical addictions, where the human body has built up a tolerance and would go into withdrawal if the substance is removed, and the psychological or emotional aspect of the addiction, which looks very similar to a compulsion. Dodes states that it is quite possible to develop a physical addiction without emotional dependence, as well as emotional dependence without physical addiction. For example, many folks with chronic pain may develop a physical addiction to painkillers, but without all of the signs of emotional dependence. For these folks, it is much simpler to kick the habit if they don’t need it emotionally. On the other hand, many people develop habits which serve emotional needs, such as gambling, shopping, workaholism, and yes, sex, but without the manifestations of physical addiction.

Kicking an emotional habit is much more difficult than overcoming a physical dependence. The rise of heroin addiction in the 1970s provides a perfect illustration of these two different kinds of “addictions”– emotional and physical.  Soldiers returning from the Vietnam War in the 70s were often arriving hooked on heroin, which they used on the front to cope with the horrors of war. At the same time, rates of heroin addiction were rising in cities across America amongst civilians who had never had to endure any of the atrocities that the soldiers experienced. In this way, the soldiers were dealing with external pain (the horrors of war), while the civilian addicts were struggling with internal (or emotional) pain. Interestingly, once the war was over and the external stress removed, the soldiers demonstrated very high rates of recovery from heroin addiction and were likely to stay off the drug long-term. However, the civilians showed poor recovery rates, as they were likely to still be struggling with the internal difficulties that fueled their addiction. This case illustrates the key point that the main deterrent to recovery is not physical addiction, but the internal, emotional causes of the addiction.

Dodes goes on to state that most folks who identify as alcoholics or drug addicts are not really physically addicted to the substance, but are instead acting on emotional stressors. In fact, they don’t even need to take the drug to feel better; just deciding to take the drug appears to provide great emotional relief. This is very similar to someone suffering with compulsions– think OCD. The individual uses obsessions (thoughts) and compulsions (behaviors) to soothe anxiety. The person who compulsively checks the door or the stove knows that the door is locked and the stove is off, but the act of checking provides a sense of relief. For this reason, Dodes believes that most addictions are truly compulsions, and should be treated as such.

For Dodes, the most powerful emotion that addicts experience is helplessness, and then subsequent rage at feeling so ineffectual. The compulsivity stems from seeking substances (or other behaviors such as gambling and sex) which provides relief from this internal storm. I’m not quite sure about this theory, since I believe that helplessness is not a core emotion but may consist of other emotions such as fear and shame, but I do agree with Dodes on the primal role that emotions play in compulsive behaviors.

I’m not going to go into the argument about rehab centers and 12-step fellowships because I think it veers away from the core idea of differentiating physical addiction from the emotional, compulsive aspects of these behaviors. And specifically, when it comes to sexuality and sex addiction, there is absolutely no proof at all of the physical aspects of addiction such as tolerance or withdrawal. So then what are we left with? The compulsivity. And the problematic emotions at the core.

For more on the connection between emotions and sexuality, click here and here and here and here.