Psychodynamic Approaches for Treatment of Drug Abuse and Addiction

Theory and Treatment

David Potik

• Verlag: Routledge
• Jahr: 2020
• ISBN:
  9780429657030
• Auflage: 1
• Thema: Psicologia
• Thema: Psicoterapia

This book provides clinicians and students with insights on the use of psychodynamic therapy to treat drug abuse and addiction, combining theory with clinical case material.

The perspectives of analysts such as Abraham, Rado, Zimmel, Tibout, Wurmser, Khanzian, Krystal and McDougall are reviewed alongside original and more recent conceptualizations of drug addiction and recovery based on Kleinian, Winnicottian and Kohutian ideas. The case material deals with clinical phenomena that characterize working with this complex population, such as intense projective identification, countertransference difficulties and relapses. The theoretical analysis covers a range of concepts, such as John Steiner's psychic shelters and Betty Joseph's near-death-addiction, which are yet to be fully explored in the context of addiction. Prevalent topics in the addiction field, such as the reward system, the cycle of change and the 12-step program, are also discussed in relation to psychodynamic theory and practice.

Written by an experienced therapist, Psychodynamic Approaches for Treatment of Drug Abuse and Addiction is useful reading for anyone looking to understand how psychodynamic thought is applicable in the treatment of drug abuse and addiction. It may also be of some relevance to those working on treating alcohol use disorders and behavioral addictions.

Chapter 1

An historical overview of psychoanalytic perspectives on drug abuse and addiction – Part 1

“I have carried out experiments and studied, in myself and others, the effect of coca on the healthy human body”.

(Freud, 1884\1975, p. 58)

The addiction field is situated in the edges of psychoanalytic thought and practice from its earliest days. For more than a century, analysts dealt with complex mental conditions, such as psychoses, severe personality disorders and regressive states (Bion, 1967; Kernberg, 1984; Searles, 1979; Winnicott, 1955), whereas the status of the addiction field was of a stepbrother or a stepsister who is never considered part of the family. Perhaps this status has become fixated because of Freud’s assertion that drug abusers are not appropriate candidates for analysis since difficulties which will appear during the treatment will lead to further abuse (Loose, 2000).

During his life, Freud presented several ideas about drug abuse and addictions. He saw addiction as a substitute for the primary addiction – masturbation and noted that oral fixations have a central role in the development of behaviors, such as drinking alcohol or smoking nicotine (Freud, 1905/1975). In “Civilization and Its Discontents” (Freud, 1930/1961), he claimed that alcohol and drug use enable relief for the suffering of law-abiding people who obey society’s laws and restrictions. In a certain sense, this argument is heard today by many law-abiding people who view cannabis use as a natural escape from the daily grind.

Freud investigated the influences of cocaine toward the end of the 19th century in a period in which pharmaceutical companies tried to promote this drug as a panacea for mental and physical malaises (Markel, 2011). The reports on self-experiencing with cocaine reveal that he felt sexual arousal, vitality and vigor, and Gay (1988) suggests that Freud used it for coping with depressive moods. Following the death of one of his friends after prolonged cocaine abuse, Freud changed his mind about the beneficial use of cocaine (Markel, 2011), and turned to other research directions. At that stage of his life, Freud saw his future career as studying the medical uses of cocaine (Volkan, 1994), and perhaps had it not been for his friend’s death, things would have turned out differently for psychoanalysis.

Loose (2000) provides a comprehensive review of a few significant articles about psychoanalytic thinking and addictions, which were published until Freud’s death. He terms this period as the drive theory period because the impetus of most of the contributions was on the libido and on the psychosexual stages theory (Loose, 2000). Loose does not mention additional periods in psychoanalytic writing about addictions, and, in my opinion, there are additional periods that are characterized by the emergence of different ideas concerning theory and treatment of drug abuse and addiction. Those ideas appeared against a background, of scientific, social and historical changes.

The first period – from the emergence of psychoanalysis to World War II

The first article in the psychoanalytic literature which focused on addiction is that of Carl Abraham, in which he argued that alcohol use influences on sexual impulses because it removes defences and inhibitions and causes increased sexual activity. This article was not based on analysis of patients with alcohol use disorders but on observation of men’s behavior in pubs. There, Abraham saw men falling on each other’s necks and exhibiting emotion, and, consequently, he deduced that alcohol use enables inhibitions release, which causes the rise of latent homosexual impulses to the conscious (1908/1979). According to this claim, alcohol use is the result of an oral conflict as alcoholism represents a regressive oral tendency (Volkan, 1994). Among individuals who are not homosexuals, the homosexual component of the sexual instinct had undergone sublimation by the influence of education and the society. In contrast, among addicted individuals, alcohol becomes a substitution for genital intercourse, and so alcohol becomes associated with perversion (cited in Levin, 1987).

Abraham did not claim that all men have homosexual identity, but rather that latent homosexual impulses that exist among males tend to appear during drunkenness (Loose, 2000). Lack of sexual activity or abstinence from it leads to a search for sexual gratification, which belongs to an earlier stage of infantile sexual development (Abraham, 1908/1979). Therefore, individuals who suffer from drug use disorders and addiction look for drugs and alcohol because of an oral fixation, as the substances are used as substitutions for the gratification of infantile sexual wishes. According to drive theory, those individuals cannot contain any frustration and demand immediate gratification, and even prefer it to the gratification obtained from interpersonal interactions (Loose, 2000).

Besides emphasizing the idea that alcohol is a psychoactive substance which temporarily neutralizes the repression mechanism and allows repressed material to arrive to the conscious, Abraham also notes that external factors such as genetics and the environment do not provide a convincing explanation for alcoholism, and there is a personality factor which should be explored (Abraham, 1908/1979). An interesting conclusion which arises from this article is that already at the beginning of the 20th century, prevailed the stereotypic gender that manhood is associated with drinking large amounts of alcohol.

Sandor Rado is the next significant analyst who wrote several articles about addiction in different periods. In the beginning, he assumed that addiction is a substitute for sexual activity since it enables immediate gratification, which bypasses the erogenous zones (Rado, 1926). Meaning, drug abuse creates sexualization of the body since it provides a certain orgasm, and people become addicted since they can gain oral sexual gratification whenever they desire. Rado termed this process alimentary orgasm and noted that this orgasm is experienced by the baby during breastfeeding in pre-genital stages.

In his next articles, he introduced elements that in later years will be attributed to ego psychology (Loose, 2000), and self psychology (Ulman & Paul, 2006). First, he argued that an individual does not become a drug addict because he uses drugs but because he has an urge to use them. The main factor of addiction is craving, and addicts can switch among different types of drugs and go from using one drug to another (Rado, 1933). Second, Rado distinguished between two main drug categories according to their influence: hypnotic, which ameliorate pain and stimulants, and sedative drugs, which provide euphoria and pleasure. Third, he provided a psychological explanation for the specific choice of drug abusers in specific drugs and added that those who suffer from depression would search for stimulant drugs, which will provide to the ego a high self-value (Rado, 1928).

Fourth, he related to drug addiction as pharmacothymia and described a process in which the ego is captured by a pharmacothymic regime that destroys the natural ego organization (Rado, 1933). Reality’s frustrations hurt the ego’s omnipotence, and narcotic drug addiction allows the ego to regain elation, omnipotence and “its original narcissistic stature” (Rado, 1933, p. 8). Besides, Rado described a personality factor which he termed the ‘action self’, and which represented the individual’s image of himself. The action self is nourished from pleasures and successes, and when one cannot gain them in his daily activities, he turns to drug abuse (Rado, 1969).

Rado never relinquished the drive model and noted that addiction is rooted in attempts to gratify archaic oral cravings, but simultaneously he noted that those cravings are associated with the need for safety and preservation of self-value. In his last article on this subject, Rado (1957) offered a general theory about the etiology of addiction and noted that it constitutes an inferior substitution for sexual gratification, as addicted individuals are characterized with ego deficits and recurrent self-regulation attempts as a malignant form of reparation.

Rado did not present with a clear and organized theory of addiction, but rather diverse ideas which are associated with different psychoanalytic schools of thought. Rado’s contribution, as well as that of most of the psychoanalytic writers in this period, is mostly theoretical yet highly significant. During four decades, he offered analysts different ideas to use in the treatment of individuals who suffer from drug abuse and addiction. In addition, Rado aspired to create bridges between the psychoanalytical world and the scientific world and was one of the most prominent figures who promoted an adaptational psychodynamic approach.

To summarize his contributions, first, he noted that drugs do not only affect the erogenous zones but also the entire body and added that there are neural operating systems (Rado, 1969). Those assumptions appeared a few decades before the rise of neuroscience. Most impressing, in one of his later contributions, he noted that addiction is associated with regulation, reward and punishment (Rado, 1957). Three years before the publication of this article, Olds and Milner (1954) implanted electrodes in different areas of rats’ brains and managed to discover a system whose unique function is creating a rewarding effect on behavior.

Second, his ideas correspond with the concept of addiction as a disorder that is characterized by a recurrent search for gratification despite the destructive consequences is the accepted view of this disorder in the scientific world today (Volkow, Koob, & McLellan, 2016). Third, Rado was also one of the first analysts who offered a distinction of drug types according to their mental effects. Although Loose (2000) argues that this distinction is quite simplistic since it is based on the pleasure principle (searching for pleasure and avoiding pain), in my opinion, Rado laid the foundations of self-medication theory, which will be delineated years later by another analyst. Fourth, the idea that drug abuse assists in boosting self-esteem was also ahead of its time and will be elaborated in the future by ego and self psychology analysts. Unfortunately, Rado, one of the most conspicuous analysts that Budapest produced (Gay, 1988), did not receive enough recognition for his contributions to the addiction field.

The addiction phenomenon received attention also on the other side of the continent. Edward Glover, a British psychiatrist and psychoanalyst who was also one of the pioneers of forensic psychiatry, published a few articles on the aetiology of drug addiction. The subject of his first article was alcohol addiction and he claimed that alcohol abuse and addiction enable the addicted individual infantile impulse gratification (Glover, 1928). Concerning drug addiction, Glover (1928) noted that some addictions originate in early developmental stages, whereas the origin of other addictions is in the oedipal drama. He thought that individuals use drugs progressively for both controlling and releasing aggressive impulses, and conceptualized the drug as an object with sadistic qualities which lives both in the external reality and in the body of the user.

There are clear associations between aggression and addiction. The internal world of drug addicts contains much aggression, and they live on the verge of psychosis (Glover, 1932). Drugs assist drug addicts in coping with paranoid and sadistic impulses (Glover, 1932), and ease the existence in a chaotic reality. In the phantasy world of drug addicts, drugs could kill, punish or cure bad internal objects, as they have a simultaneous effect on objects projected to the external world.

Although, one of her bitter opponents in later years, the resemblance to Melanie Klein’s ideas is quite evident. In addition, the link between Kleinian ideas and ego psychology ideas is also evident in these conceptualizations, as Glover is one of the first analysts who claimed that drugs assist in ameliorating or avoiding mental pain. In other words, he points on the ability of drugs to regulate internal and external aggression, and suggests (as Rado did) that addiction is not an attempt to escape from reality but more of the ego’s attempt to defend the individual’s psyche. Although Glover did not treat drug abusers, he noticed that addiction has a unique course that is situated in the transition stage between neurosis and psychosis. Actually, this important contribution which linked addictions and borderline mental conditions (Glover, 1932), was a head of its time, and years later Krystal and Kernberg would present similar ideas.

Otto Fenichel, an Austrian analyst, referred to addictions in his comprehensive book about the psyc...

Inhaltsverzeichnis

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgments
• Introduction
• 1 An historical overview of psychoanalytic perspectives on drug abuse and addiction – Part 1
• 2 An historical overview of psychoanalytic perspectives on drug abuse and addiction – Part 2
• 3 Drug addiction ≈ the paranoid-schizoid position
• 4 Recovery and reparation ≈ the depressive position
• 5 Lapses and relapses
• 6 Therapeutic issues: internal destructiveness, countertransference and projective identification
• 7 Methadone maintenance treatment (MMT) as transitional phenomena
• 8 Towards independence: detoxification during opioid maintenance treatment
• 9 Drug abuse and addiction in the view of self psychology
• 10 The 12-step program
• Index