Psychodynamics of drug dependence

201 Pages·2000·0.62 MB·English

PSYCHODYNAMICS
OF DRUG
DEPENDENCE
US DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE • Public Health Service • Alcohol, Drug Abuse. and Menial Health Administration
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The NIDA Research Monograph series is prepared by the Division of Research of
the National Institute on Drug Abuse. Its primary objective is to provide critical re-
views of research problem areas and techniques, the content of state-of-the-art
conferences, integrative research reviews and significant original research. Its
dual publication emphasis is rapid and targeted dissemination to the scientific
and professional community.
Editorial Advisory Board
Avram Goldstein, M.D.
Addiction Research Foundation
Palo Alto, California
Jerome Jaffe, M.D.
College of Physicians and Surgeons
Columbia University. New York
Reese T. Jones, M.D.
Langley Porter Neuropsychiatric Institute
University of California
San Francisco. California
William McGlothlin, Ph.D.
Department of Psychology, UCLA
Los Angeles. California
Jack Mendelson, M.D.
Alcohol and Drug Abuse Research Center
Harvard Medical School
McLean Hospital
Belmont. Massachusetts
Helen Nowlis, Ph.D.
Office of Drug Education. DHEW
Washington. DC.
Lee Robins, Ph.D.
Washington University School of Medicine
St Louis. Missouri
NIDA Research Monograph series
Robert DuPont, M.D.
DIRECTOR, NIDA
William Pollin, M.D.
DIRECTOR, DIVISION OF RESEARCH, NIDA
Robert C. Petersen, Ph.D.
EDITOR-IN-CHIEF
Eunice L. Corfman, M.A.
EDITOR
Rockwell Building 11400 Rockville Pike Rockville. Maryland 20852
PSYCHODYNAMICS OF DRUG DEPENDENCE
ACKNOWLEDGMENTS
Chapter 4, “Mr. Pecksniff’s Horse? (Psychodynamics in
Compulsive Drug Use),” by Leon Wurmser, is taken in
slightly altered form from THE HIDDEN DIMENSION:
PSYCHOPATHOLOGY OF COMPULSIVE DRUG USE to
be published by Jason Aronson and used with their kind
permission. The appendix for chapter 5 is reprinted with
the permission of International Universities Press, Inc.,
from the Journal of the American Psychoanalytic Associa-
tion, Vol. 21, No. 2, 1973.
Further reproduction of chapter 4 and the appendix for
chapter 5 is prohibited without specific permission of the
copyright holder. All other material contained in this
volume is in the public domain, and may be used and re-
printed without special permission. Citation as to source,
however, is appreciated.
Library of Congress catalog card number 77-77369
DHEW publication number (ADM) 77-470
Printed 1977
NIDA Research Monographs are indexed in the Index
Medicus.
iv
FOREWORD
Over the past two decades research in drug dependence has
focused primarily on individual drugs-their pharmacokinetics, bio-
chemical structure and physiological effects-or on their social im-
pact, indicated by demographic variables used in epidemiologic
studies and as parameters in treatment systems. Missing has been
an equivalent emphasis at the level of the individual person, focused
on the structure and dynamics of the total personality. We have
adequate conceptual rubrics for capturing physical data and socio-
logical data, but a comparative dearth of reliable rubrics for the
data in between, at the level where a person directly experiences
drug dependence.
We need research at this level in order to identify high risk traits
that signal predilection to drug dependence, to organize traits for
diagnosis, to indicate differential treatment regimens. Demographic
variables such as age, sex, socioeconomic status, “religiosity,”
parental drug use, appear to be significant indicators of varying
degrees of drug abuse predilection. However, we don’t know why
among people similarly at risk to a given drug, some will and some
won’t become drug dependent. Differences in personality may
make the difference.
The effort to identify these key personality traits is part of a
larger effort by the Division of Research to widen the focus of our
research efforts, from the cellular to such issues as why people
become enmeshed in other compulsive dependencies that are akin
to drug dependence.
A central concern, for all of these as with drug dependence, is
to discover the part played by a person’s own psychodynamics. It
is at this level that a person most plausibly can exercise control over
his or her own life. But we are far from understanding how these
factors lead to or defend against symptomatic compulsive behavior
in different people. The papers in this monograph are a pioneering
effort toward this objective.
William Pollin, M.D.
Director, Division of Research
National Institute on Drug Abuse
v

PREFACE
The explanatory power of the new psychology of the self is no-
where as evident as with regard to these four types of psychological
disturbance: (1) the narcissistic personality disorders, (2) the per-
versions, (3) the delinquencies, and (4) the addictions. Why can
these seemingly disparate conditions be examined so fruitfully with
the aid of the same conceptual framework? Why can all these
widely differing and even contrasting symptom pictures be compre-
hended when seen from the viewpoint of the psychology of the
self? How, in other words, are these four conditions related to each
other? What do they have in common, despite the fact that they
exhibit widely differing, and even contrasting, symptomatologies?
The answer to these questions is simple: in all of these disorders the
afflicted individual suffers from a central weakness, from a weak-
ness in the core of his personality. He suffers from the conse-
quences of a defect in the self. The symptoms of these disorders,
whether comparatively hazy or hidden, or whether more distinct
and conspicuous, arise secondarily as an outgrowth of a defect in
the self. The manifestations of these disorders become intelligible
if we call to mind that they are all attempts-unsuccessful attempts,
it must be stressed-to remedy the central defect in the personality.
The narcissistically disturbed individual yearns for praise and
approval or for a merger with an idealized supportive other because
he cannot sufficiently supply himself with self-approval or with a
sense of strength through his own inner resources. The pervert is
driven toward sexual enactments with figures or symbols that give
him the feeling of being wanted, real, alive, or powerful. The delin-
quent repeats over and over again certain acts through which he
demonstrates to himself an escape from the realization that he feels
devoid of sustaining self-confidence and of sustaining ideals. And
the addict, finally, craves the drug because the drug seems to him to
be capable of curing the central defect in his self. It becomes for
him the substitute for a self-object which failed him traumatically
at a time when he should still have had the feeling of omnipotently
controlling its responses in accordance with his needs as if it were a
part of himself. By ingesting the drug he symbolically compels the
mirroring self-object to soothe him, to accept him. Or he symbol-
ically compels the idealized self-object to submit to his merging into
it and thus to his partaking in its magical power. In either case the
ingestion of the drug provides him with the self-esteem which he
vii
PSYCHODYNAMICS OF DRUG DEPENDENCE
does not possess. Through the incorporation of the drug he supplies
for himself the feeling of being accepted and thus of being self-
confident; or he creates the experience of being merged with a
source of power that gives him the feeling of being strong and
worthwhile. And all these effects of the drug tend to increase his
feeling of being alive, tend to increase his certainty that he exists in
this world.
It is the tragedy of all these attempts at self-cure that the solu-
tions which they provide are impermanent, that in essence they
cannot succeed. The praise which the narcissistically disturbed in-
dividual is able to evoke, the mergers with idealized others which he
brings about, the sexualized reassurances which the pervert procures
for himself, the loudly proclaimed assertion of omnipotence forever
repeated through his actions by the delinquent-they all give only
fleeting relief. They are repeated again and again without producing
the cure of the basic psychological malady. And the calming or the
stimulating effect which the addict obtains from the drug is similarly
impermanent. Whatever the chemical nature of the substance that is
employed, however frequently repeated its consumption, however
cleverly rationalized or mythologized its ingestion with the support
from others who are similarly afflicted-no psychic structure is
built, the defect in the self remains. It is as if a person with a wide
open gastric fistula were trying to still his hunger through eating.
He may obtain pleasurable taste sensations by his frantic ingestion of
food but, since the food does not enter that part of the digestive sys-
tem where it is absorbed into the organism, he continues to starve.
The enriching effect of the insights supplied by the psychology
of the self upon the data obtained within different psychological
frames of reference can be demonstrated with special clarity with
regard to the examination of the family background, of the child-
hood situation of the future addict. It is evidently of great impor-
tance in the present context to determine certain details concern-
ing the behavior of the addict’s parents when he was a child. We
might ask, for example, whether they had been lenient or strict, or
whether their identities (e.g., as male and female; or, occupationally,
the mother as a housewife, the father as a truckdriver, etc.) were
hazy or well defined. Yet, having obtained the answer to these and
similar questions, we will look at the significance of the socio-
psychological data concerning parental behavior with different
eyes when we examine them against the background of our knowl-
edge concerning the factors that contribute to the child’s ability to
build up a strong and cohesive self and, in the obverse, concerning
the factors that stand in the way of this crucial developmental task.
Just as we know, from the point of view of the physiologist, that
a child needs to be given certain foods, that he needs to be pro-
viii
PREFACE
tected against extreme temperatures, and that the atmosphere he
breathes has to contain sufficient oxygen, if his body is to become
strong and resilient, so do we also know, from the point of view of
the depth-psychologist, that he requires an empathic environment-
specifically, an environment that responds (a) to his need to have his
presence confirmed by the glow of parental pleasure and (b) to his
need to merge into the reassuring calmness of the powerful adult-
if he is to acquire a firm and resilient self. It is not enough to ob-
tain answers to questions such as whether the mother’s attitude
toward toilet training is strict or lenient, for example, or whether
the father’s work-identity is clearly defined or not. The crucial
question concerns the adequacy or inadequacy of the parents as the
self-objects of the child, i.e., the adequacy or inadequacy of the
parents at a time when they are still performing for the child the
psychological functions of self-esteem regulation which the child
should later be able to perform on his own, the adequacy or inade-
quacy of the parents at a time in other words when the child still
experiences them predominantly as extensions of himself or experi-
ences himself still predominantly as part of their strength. The
crucial question then is whether the parents are able to reflect with
approval at least some of the child’s proudly exhibited attributes
and functions, whether they are able to respond with genuine enjoy-
ment to his budding skills, whether they are able to remain in
touch with him throughout his trials and errors. And, furthermore,
we must determine whether they are able to provide the child with
a reliable embodiment of calmness and strength into which he can
merge and with a focus for his need to find a target for his admira-
tion. Or, stated in the obverse, it will be of crucial importance to
ascertain the fact that a child could find neither confirmation of
his own worthwhileness nor a target for a merger with the idealized
strength of the parent and that he, therefore, remained deprived of
the opportunity for the gradual transformation of these external
sources of narcissistic sustenance into endopsychic resources, i.e.,
specifically into sustaining self-esteem and into a sustaining relation-
ship to internal ideals. Thus, in asking the crucial question concern-
ing the factors in childhood which lead to the addiction-prone
personality, we will say that, in the last analysis, and within certain
limits, it is less important to determine what the parents do than
what they are.
Heinz Kohut, M.D.
Institute for Psychoanalysis
Chicago
ix