Edward J. Khantzian, M.D., and Catherine J. Treece, Ph.D.

CHAPTER 2 of NIDA Monograph 12: Psychodynamics of Drug Dependence

BACKGROUND

Until recently, attempts to apply psychoanalytic theory to an understanding and treatment of drug dependence have been limited, and when attempted, have proven inconsequential. Self-help and methadone maintenance approaches, which developed and proliferated in the 1960’s, provided the mainstay of treatment for compulsive and chronic drug use.

The promise that these two new modalities seemed to offer, corresponding with rising alarm about a drug problem in this country of “epidemic proportions,” resulted in the development and expenditure of enormous resources at the Federal, State, and local levels to enlist large numbers of patients in treatment and rehabilitation. Unfortunately, the hope that vast expenditures would result in speedy cures and expeditiously eliminate the problem has proven illusory.

The development of this monograph represents a modest but significant departure from these recent trends. In April of 1976, the Division of Research, Clinical-Behavioral Branch, under the leadership of Drs. Pollin, Renault, Julius and Blaine convened a group of psychoanalysts, psychiatrists and psychologists who had demonstrated an interest in understanding substance use from a psychodynamic point of view.

The participants were charged to reexamine psychoanalytic theory and its relevance for understanding opiate addiction. There was also an implied hope that some practical treatment applications could be garnered from such an exercise. The preliminary results of this effort are represented by the content of this monograph. We believe it represents a good beginning.

With the interest and support of NIDA, the participants of and contributors to the first Technical Review in 1976 and to this monograph, have, in our estimation, demonstrated the value and utility of developing and expanding on previous applications of psychoanalytic
theory to problems of substance use.

The study of addiction as a human process begs for a depth psychology. We are convinced that psychoanalytic theory continues to be the most enabling and useful depth psychology at our disposal to understand the human mind and behavior, including addictive behavior. Psychoanalysis does not invalidate other psychological methods of understanding, but rather attempts to account more adequately for the complexities of human behavior in terms of dynamic, economic, structural, developmental and adaptational
factors.

For the unversed in psychoanalytic theory the contents of this monograph might seem too complex, obscure and far removed from an everyday understanding and management of drug-dependent individuals. We believe that the theoretical formulations developed
in this monograph reflect rather than obscure the complexities of the drug problems with which we work.

We also believe that diligence in trying to comprehend this theoretical point of view will help to organize clinical observations and apply them more meaningfully and consistently in work with patients. In turn, hopefully, our theory will more likely reflect data and observations obtained from what our patients tell us and what they experience.

Clearly, the clinical observations about drug-dependent patients and the theoretical discussions in this monograph suggest a number of avenues for further exploration and research.

We believe that this beginning effort to involve psychoanalysts in national efforts to address problems of opiate addiction represents a promising vista for the development of a more dynamic clinical approach and a richer theoretical understanding of drug dependence.

The intention of this chapter is to provide an updated review of the literature and to provide an overview of this monograph, stressing areas of agreement and complementarity, as well as unresolved differences, among the contributors.

THE LITERATURE - AN UPDATE

Yorke (1970) and Khantzian (1974) have recently reviewed the early psychoanalytic literature on addiction. They have both concluded that the limitations of an excessively drive-oriented model prevented these early authors from fully developing and utilizing many important clinical observations.

Thus, there was an excessive emphasis on the libidinal gratification provided through drug use to account for the addict’s involvement with his drug. Similarly, in their overemphasis on the symbolic meaning of the drug and how it was used, they failed to make distinctions between various classes of drugs and their distinctive psychopharmacologic effects.

Khantzian notes that Rado (1933, 1957), in particular, and Savit (1954), Fenichel (1945) and others, seemed to appreciate underlying depression and tension as motives for taking drugs. However, in his review Khantzian concludes that these themes are not well developed and that too much emphasis is placed on pleasurable and regressive aspects of drug use to explain the compelling nature of addiction.

Although Glover (1956) also failed to appreciate the specific effects of different drugs and excessively stressed symbolic factors, Yorke and Khantzian have both noted that he better appreciated the adaptive, “progressive” use of drugs to cope with and defend against powerful, overwhelming and psychoticogenic rage and aggression.

The work of Chein et al. (1964) and the previous related work by Gerard and Kornetsky (1954) marks a significant shift in the psychoanalytic literature. Studying adolescent addiction in the ghetto rather than adult addiction in the analytic office provided new perspectives on which to build.

In addition to appreciating the specific psychotropic effects of opiates, their work more adequately focused on the addict’s ego and superego pathology, problems with narcissism and other psychopathology. They delineated some of the major difficulties that addicts have in engaging their environment, and stressed how their use of heroin was “adaptive and functional,” helping them to overcome crippling adolescent anxieties evoked by the prospect of facing adult role expectations with inadequate preparation, models, and prospects.

Subsequently, Hartmann (1969) developed similar themes through the study of other populations of adolescent drug users, focusing on the use of drugs, particularly by those with passive tendencies, to avoid active mastery of adolescent tasks in which narcotics were used to provide a passive regressive solution to intra-psychic conflicts associated with the adolescent phase of development.

Wieder and Kaplan (1969) elaborated further on this point of view, emphasizing that preadolescent developmental conflicts left certain individuals specifically vulnerable to problems of anxiety, depression, and physical discomfort during adolescence. In such cases drugs seemed to provide the means to induce a desirable ego regression. Specific drugs were understood to be related to stage-specific developmental conflict.

Opiates, for instance, were said to produce a state reminiscent of a blissful closeness and union with the mother, which resulted in avoidance of separation anxieties aroused by the adolescent dependency crisis.

Despite a superficial resemblance to earlier formulations that stressed regressive pleasurable use of drugs, their work represents an important advance and elaboration of trends set in motion by Gerard and Kornetsky in the 1950’s which utilized recent developments in ego theory enabling Wieder and Kaplan to appreciate that individuals self-select different drugs based on personality organization and ego impairments.

Their emphasis on the use of drugs as a “prosthetic,” and their focus on developmental considerations, adaptation and the ego, clearly sets their work apart from earlier simplistic formulations based on an id psychology.

Based on this and other recent work that considers ego and adaptational problems of addicts and following lines pursued by Wieder and Kaplan, Milkman and Frosch (1973) empirically tested the hypothesis that self-selection of specific drugs is related to preferred
defensive style. Using the Bellak and Hurvich Interview and Rating Scale for Ego Functioning, they compared heroin and amphetamine addicts in drugged and non-drugged conditions.

Their preliminary findings supported their hypothesis that heroin addicts preferred the calming and dampening effects of opiates and seemed to use this action of the drug to shore up tenuous defenses and reinforce a tendency toward withdrawal and isolation, while amphetamine users used the stimulating action of amphetamines to support an inflated sense of self-worth and a defensive style involving active confrontation with their environment.

Similarly, Hendin (1974), using psychological testing and interview data, concluded that heroin as well as barbiturates acted to assist in withdrawal and to avoid intimacy and thus defend against overwhelming destructive impulses.

In contradistinction, the works of Wurmser (1972, 1974) and Khantzian (1972, 1974, 1975) suggest that the excessive emphasis on the regressive effects of narcotics in these studies is unwarranted, and that in fact, the specific psychopharmacologic action of opiates has an opposite, “progressive” effect whereby regressed states may be reversed. Wurmser believes that narcotics are used adaptively by narcotic addicts to compensate for defects in affect defense, particularly against feelings of “rage, hurt, shame-and loneliness.”

Khantzian stresses drive defense and believes narcotics act to reverse regressed states by the direct antiaggression action of opiates, counteracting disorganizing influences of rage and aggression on the ego.

Both these formulations propose that the psychopharmacologic effects of the drug can substitute for defective or nonexistent ego mechanisms of defense. As with previously mentioned recent investigators, Wurmser and Khantzian also consider developmental impairments, the severe, predisposing psychopathology, and problems in adaptation as central issues in understanding addiction.

Radford, Wiseberg, and Yorke (1972) reported detailed case material that supports the findings of Wurmser and Khantzian that opiates can have an antiaggression and antiregression action or effect. They further observe that opiate use cannot be exclusively correlated with any particular patterns of internal conflict or phase-specific developmental impairment.

Despite differences in emphasis, the work of Gerard and Kornetsky, Hartmann, Wieder and Kaplan, Milkman and Frosch, and Hendin shares in common a stress on opiate use as an attempt to correct impaired or defective ego functions and thereby assist the individual to cope.

It is also recurrently evident in the work of these investigators that this attempt is only partially successful at best. Their findings repeatedly seem to suggest that adopting passive solutions through opiates induces a self-perpetuating tendency for maladaptive and pathologic ego and drive regression.

This apparent contradiction between the adaptive and maladaptive effects of opiate use implied in these formulations awaits further clarification.

Krystal and Raskin (1970) are somewhat less precise about the specific effects of different drugs, but allow that they may be used either to permit or prevent regression. However, their work does focus much more precisely on the relationship between the affects of pain, depression, and anxiety, and drug and placebo effects.

Addicts’ difficulties in recognizing and tolerating painful affects are explored and greatly clarified. The tendency for the affects of depression and anxiety to remain somatized, unverbalized and undifferentiated in addicts, results in a defective stimulus barrier and thus leaves such individuals ill-equipped to deal with their feelings, and predisposes them to drug use. Their work also focuses in greater depth on the major problems that addicts have in relation to positive and negative feelings about themselves and in relation
to other people.

Krystal and Raskin believe that addicts have major difficulties in being good to themselves and in dealing with their positive and negative feelings toward others because of rigid and massive defenses such as splitting and denial. They maintain that drug users take drugs not only to assist in defending against their feelings, but also briefly and therefore “safely” to enable the experience of feelings like fusion (oneness) with loved objects, which are normally prevented by the rigid defenses against aggression.

The problem of ego regression among narcotic addicts has been addressed by Zinberg (1975) from a rather different perspective than most of the other authors cited here. Zinberg minimizes factors of psychopathology and proposes an alternative explanation for the uniformly regressed appearance and behavior of addicts.

Zinberg develops his thesis around the concept of relative autonomy of the ego. He suggests that the enforced social isolation and deviant status of illicit narcotics users result in a sufficient reduction of balanced input from external reality as to undermine the ego’s relative autonomy from the id, and simultaneously affect superego structures which are maintained by social supports.

The cyclical nature of addiction in which the user continuously cycles from high to low and back again serves to keep drive tension high which results in increased dependence on the environment for
obtaining drugs and for whatever is left of coherent social relations, thus weakening relative autonomy from the environment.

Under such conditions, Zinberg notes, the ego could be expected to undergo a regressive process resulting in the “typical impulse-ridden, psychopathic junkie” who is the subject of most clinical studies.