Substance Abuse as Symptom

A Psychoanalytic Critique of Treatment Approaches and the Cultural Beliefs That Sustain Them

Louis S. Berger

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134881093
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

What can psychoanalysis contribute to an understanding of the etiology, treatment, and prevention of substance abuse? Here, Louis Berger contests both the orthodox view of substance abuse as a "disease" explicable within the medical model, and the fashionable dissenting view that substance abuse is a habit controllable through the "willpower" fostered by superficial treatment approaches. According to Berger, substance abuse is first and foremost a symptom. He argues that it is only by grasping this fact that we can understand why standard approaches to treatment and prevention have failed. Berger invokes a wide spectrum of recent analytic insights about infant and child development, the psychology of narcissism, and primitive character disorders in making the case that substance abuse masks serious preoedipal (or "midrange") psychopathology. Such psychopathology, operating at both cultural and person levels, explains why certain individuals become dependent on illicit drugs; it is equally revelatory of why the substance abuse "establishment" -- and society at large -- continues to misconstrue the nature of the problem and to proffer ill-conceived and ineffective remedies. After thoroughly examining the motives, conscious and unconscious, that maintain "mainstream" myths about substance abuse, Berger points the way to alternative approaches to prevention and treatment.

Part One

In contrast to the personality structure of the fin de siecle patients whose investigation led Freud to his formulation of the dichotomized psyche and later of structural conflict, the prevalent personality organization of our time is not typified by the simple horizontal split brought about by repression. The psyche of modern man—the psyche described by Kafka and Proust and Joyce—is enfeebled, multifragmented (vertically split), and disharmonious.

(Kohut, 1984)

Most men are so thoroughly subjective that nothing really interests them but themselves. They always think of their own case as soon as ever any remark is made, and their whole attention is engrossed and absorbed by the merest chance reference to anything which affects them personally, be it never so remote: with the result that they have no power left for forming an objective view of things, should the conversation take that turn; neither can they admit any validity in arguments which tell against their interest or their vanity. Hence their attention is easily distracted. They are so readily offended, insulted or annoyed, that in discussing any impersonal matter with them, no care is too great to avoid letting your remarks bear the slightest possible reference to the very worthy and sensitive individuals whom you have before you; for anything you may say will perhaps hurt their feelings. People really care about nothing that does not affect them personally.

(Schopenhauer, 1890)

Chapter One
Introduction

Psychoanalysis and Compulsive Drug Use

One day during a Green Bay Packers offensive slump, head coach Vince Lombardi called a team meeting. “We’re going back to basics,” he said. “Back to fundamentals.”

”Now this,” he said, holding up a ball, “is a football.”

”Hold on, coach,” interrupted split end Max McGee. “You’re going too fast.”

The Illustrated NFL Playbook (1982)

These days, the “war” on alcohol and drug abuse swirls all around us. Polls indicate that the general public sees that war as a top national priority.¹

The media are dominated by it. Each day brings sensational headlines about some aspect of this war—arrests, scandals, legislation, medical findings, international military or police action, and so on. The impact of drug and alcohol use on the economy, on crime, and on public health is widely discussed with great concern. Current plans are to spend over $10 billion over the next year at the federal level; annual costs of the drug situation to the nation have been estimated at over $47 billion.² This preoccupation with substance abuse hardly needs formal documentation.

How is one to cope with this complex and costly situation? The consensus is clear: enforce the law, interdict, rehabilitate users, and prevent the abuse through education and information dissemination, which will make citizens more aware of the consequences of drug use. The trouble is that these approaches, singly or in combination, have not worked—neither now nor in past “wars against drugs.”³ In spite of occasional optimistic, even Pollyannalike, reassurances, there is no evidence that the standard approaches and measures are effective, except here and there, in isolated, relatively minor ways. On the contrary, not infrequently one hears just the opposite, that the drug scene is getting worse, that law enforcement agencies are openly admitting their inability to have a significant impact, and so on.⁴ Drug abuse remains a top problem.

Occasionally, a few lone voices suggest that the wrong war is being fought, that the basic problem stems from our foreign policy, from “crack capitalism,” or from America’s bottomless appetite for drugs, or from general mental health problems. For example, the House Narcotics Committee chairman, Representative Charles Rangell, has said that “there is nothing in the strategy [the president’s drug war battle plan] addressing the root causes of drug abuse—lack of education, housing, employment, poverty” (Kelley, 1990, p. 1 A). On the whole, though, the standard version of the “war” has wide support. One senator has characterized President Bush’s proposed plan as “the kind of get-tougher approach that the public is crying out for.”⁵

It would seem that we have here a peculiar situation: policies that have a demonstrated history of failure are receiving more and more support. At the same time, proposals for approaches that lie outside the mainstream are being rejected out of hand. The prime example is legalization. In any of its variants, this alternative approach is seen as radical and inevitably raises a public outcry.⁶ Because of this negative reaction, it follows that in a culture such as ours where popularity, reelection, and following behind public opinion are the standards of conduct for elected officials, unorthodox or unpopular proposals which call cherished doctrines into question will receive little support from politicians or others in power, regardless of the proposals’ merit.⁷ In sum, the ongoing and accepted policy is to continue with the same set of approaches, but more intensively—with more funding, harsher criminal penalties, and so on.

Does psychoanalysis have anything to offer to ameliorate this situation? Psychoanalysts have long been interested in substance abuse. Analytic work in this area began in the 1880s with Freud’s studies of cocaine use. It was continued by early analysts such as Abraham, Federn, Fenichel, Glover, Kardiner, Rado, Sachs, Simmel, and Tausk; and more recently by, for example, Farber, Greenacre, Khantzian, Krystal, Raskin, Rosenfeld, and Wurmser.⁸

Within this psychoanalytic tradition, compulsive drug use has generally been viewed as a symptom of severe psychopathology, as “a final common pathway for many different types of individuals with varied personalities and psychiatric diagnoses” (Kaufman, 1985, p. 11). Therefore, analysts’ principal concerns about this class of symptomatology have been essentially the same as their concerns about any other problem behavior: to understand the underlying pathology psychoanalytically and to find effective therapeutic approaches.

Patients with significant drug addiction problems who are seen in analysis or psychoanalytic therapy typically are identified as persons with severe personality disorders. Consequently, most clinical and theoretical analytic work pertaining to substance abuse is set within this wider clinical context. In other words, psychoanalytic thought and practice concerning substance abuse tend to overlap or become subsumed into the study and therapy of severe personality disorders. For example, Wurmser’s approach to the conceptualization and treatment of drug abuse focuses on severe borderline pathology; Khantzian’s, on ego pathology; Krystal’s, on “alexithymia”; or, Farber’s, on disorders of the will.⁹ To be sure, in some instances analysts may need to modify concepts and treatment so as to take into account certain practical considerations that are salient, perhaps even unique, to the treatment of substance abusers.¹⁰

My interest is in seeing whether there are other ways in which a psychoanalytic framework can make a contribution. I wish to apply that framework at two different levels of the problem, to two different subject areas—one general, the other, circumscribed. The first application will be at the cultural level, while the second will be at a clinical level, at the level of individual therapy. Concerning the first of these two levels, the premises I will try to develop and support are that there is a pervasive and severe cultural psychopathology; that this pathology accounts for a number of aspects of the substance abuse scene, aspects ranging from why there is a rampant problem in the first place to the persistence of misguided approaches to solutions; and that a remedial approach, if it is to be sound and effective, will necessarily have to address a wide range of underlying issues. In other words, I will attempt to set and to examine the drug problem in the wider context of general sociocultural psychological symptoms and problems, by my drawing on analytic thought and accumulated clinical wisdom to accomplish that goal.

Such extraclinical applications of an analytic perspective are not popular among clinicians: “The task of extracting from psychoanalysis implications for social change is one which Freud himself mostly shied away from” (Ingleby, 1980, p. 69). Ingleby goes even further:

Psychoanalytic theory is easily used to adapt the individual to his social role, and in this guise it may become absorbed effortlessly into the repertoire ot ‘welfare’ services. Analysis for the interesting rich; drugs for the boring remainder…. Unfortunately, since psychoanalytic theory has from the beginning been in the hands of therapists, its social dimension has become submerged and obscured. (Ingleby, 1980, p. 68)

There is, however, a minority tradition of analysts who do address wider social ills from a clinical framework. Freud might have shied away from advocating social change, but he did write analytically about social issues—war, group psychology, religion, government.¹¹ In the 1920s “there arose the corpus of ‘Freudo-Marxism,’ which includes Reich, Fenichel, Fromm, Horkheimer, Adorno and Marcuse…. Since the war, the same challenge has been taken up by many others, including Habermas, Michel Schneider, Deleuze and Guattari, and Lacan” (Ingleby, 1980, p. 69).¹² The list can be extended: Rangell (1976) has written about the ubiquitous presence of corruption in our society; Eissler (1975), about very general social pathology; Searles (1972), about the rape of the environment; Wachtel (1983) and Fine (1981, chap. 9), about consumerism; Fornari (1975), R. R. Holt (1984), Kovel (1983), and Ladan (1989), about nuclear war; Farber (1966), about generalized addiction phenomena; and Kovel (1984) and Frosh (1988, chap. 5), about racism.

The reconceptualization of substance abuse within a wider sociocultural context, then, is the first domain to which I wish to apply an analytic framework. The second domain is narrower, clinical. I have mentioned that, by and large, analysts do not consider substance abuse as a separate category of pathology and do not advocate any specialized diagnostic or therapeutic approach.¹³ Nevertheless, as I shall argue in Part II, there are clinical contributions from analysis that, although not unique to substance abusers, deserve to be explored further because they become particularly salient for this class of patients.

The clinical topic that will be my point of departure in Part II is “analyzability,” the suitability of patients for analytic therapy or analysis; it has been, and remains, an important subject for analysts. Of course, the question of which therapy and therapist are best matched to the needs of any given candidate for psychotherapy is not restricted to analysis; it is— or at least it should be—of interest in any psychotherapeutic context, including the treatment of substance abuse. As it happens, although it has had a checkered history within the mainstream substance abuse treatment establishment, matching now has once again come into vogue in that industry; currently, the question of which kind of therapy is suitable to which kind of addicted patient is receiving a good deal of attention in the mainstream literature on substance abuse, as we shall see in Part II.

As I have mentioned, for analysts, analyzability—a special case of matching—has been a subject of considerable interest and study over many decades. In my opinion, when viewed from the perspective of, and compared with, that body of analytic work, the approaches to matching proposed, studied, and implemented in the drug rehabilitation treatment industry seem simplistic, deficient, and impoverished.¹⁴ If that is the case, it seems reasonable to suppose that the richer, more clinically sophisticated analytic approaches to matching could have something to offer to the substance abuse treatment industry. The analytic framework’s unique perspectives and complexity may allow less mundane, more apt and useful characterizations of patients, therapies, and therapists than has been possible within the limited theories and concepts (typically, based on some variant of twelve-step programs) that are employed in most drug rehabilitation work.

The clinical explorations of Part II take these issues as the point of departure. It should be apparent that analyzability, or, more generally, matching, will very quickly bring most major clinical issues into the picture as well. One can hardly expect to speak about matching without also considering psychopathology, patients’ motivations, therapeutic action, outcome criteria, therapist characteristics, and so on. Thus, though matching might at first glance seem a specialized or narrow topic, actually it can serve as an entry to a comprehensive examination of clinical issues.

I have mentioned the two major contexts within which I will consider drug abuse from an analytic perspective: cultural pathology and matching. A third way in which an analytic framework can influence one’s thinking about substance abuse concerns ontological and epistemological issues. Along with some others,¹⁵ I believe that analytic thought is a good deal more radical in what it implies for normal science (to use Kuhn’s familiar term) than usually is recognized, even by analysts themselves.¹⁶ While most analysts, especially in this country, want analysis to be a science that in principle is like any other science, there is another point of view. It leads to quite different conceptions of what our world may be like and how we may come to know something about it:

Psychoanalysts familiar with the work of Hans Loewald, Roy Schafer, and others know how much this [traditionally scientific] concept of psychoanalysis is currently being revised. We are arriving at a post-Strachean, post-Rapaportian vision of Freud and of experience, not altogether different from Derrida’s interpretation. (Kerrigan & Smith, 1984, p. viii)

Ironically, most critical studies of psychoanalysis by philosophers (e.g., Grunbaum—see Wallace, 1989) have failed to appreciate the epistemological and ontological unorthodoxies and heresies latent in that framework. It is well known that such philosophical studies usually have faulted analysis for not living up to traditional scientific criteria (e.g., for not being logically consistent, not having operationalizable concepts, not having theories that can be verified or disconfirmed); in addition, analysts who are dedicated to conforming to these standards of scientific respectability and rigor have tended to abet such typical criticisms.¹⁷ Be that as it may, while they continue to pervasively influence my thinking (clinical and other), these radical aspects of analysis will, for the most part, remain latent and tacit in this book; their most prominent explicit appearance will be in chapter 8, when I examine the ground of a therapeutic framework that I develop. Their background status should not obscure their importance for this work, however.

Let me return now to the first issue, the matter of reconceptualizing approaches to dealing with drug addiction. To begin to move away from the traditional, mainstream views and values concerning substance abuse and its treatments toward another view that can emerge when abuse is seen against the wider backdrop of pervasive, ubiquitous sociocultural psychopathology, we will find it useful first to articulate, and then to scrutinize, the widely accepted ideas about what substance abuse is, how it should be prevented, and how it should be treated. It will be convenient to use as a vehicle for the discussions one root metaphor—the medical model of addiction—that pervades the mainstream views concerning the nature, treatment, and prevention of substance abuse. Accordingly, that metaphor is the leading thematic focus of the first part of this book.

Chapter Two
The Medical Model and Its Implications

When any wrong statement is made, whether in public, or in society, or in books, and well received—or, at any rate, not refuted—that is no reason why you should despair or think that there the matter will rest. You should comfort yourself with the reflection that the question will be afterwards gradually subjected to examination; light will be thrown upon it; it will be thought over, considered, discussed, and generally in the end the correct view will be reached; so that, after a time—the length of which will depend upon the difficulty of the subject— everyone will come to understand that which a clear head saw at once.

In the meantime, of course, you must have patience. He who can see truly in the midst of general infatuation is like a man whose watch keeps good time, when all clocks in the town in which he lives are wrong. He alone knows the right time; but what use is that to him? for everyone goes by the clocks which speak false, not even excepting those who know that his watch is the only one that is right.

(Schopenhauer, 1890)

The Disease

Characteristics

There is a very general, widely shared model that underlies the mainstream perceptions of and...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Part I
• Part II
• Notes
• References
• Index