Etiology of Compulsive Drug Use
J. AMER. PSYCHOANAL. ASSN., 22:820 (APA) (1974)
LEON WURMSER, M.D.
UNTIL NOW, THERE HAS BEEN very little systematic exploration into the etiology of drug abuse. Glasscote et al. (1972) described the situation most aptly:
It may be fruitless to make the effort to identify a group of universal causes of susceptibility. In any case, while there has been some interest in determining what drug users are like, by means of interviews and standardized tests, there has been little systematic effort to delineate and quantify causes. On the other hand, there has been much hypothesizing about the conditions, events, and circumstances that lead to drug abuse, most of which fall into three categories: the physical, the internal or intrapsychic, and the social and environmental [p. 19].
A study to fill at least part of the gap is envisioned here: viz., to delineate in a systematic way the etiology of drug abuse on the basis of large-scale clinical experience with all types of this phenomenon.1
Inasmuch as most "drug abusers" are inaccessible to psychoanalysis proper, it is not surprising that, despite the huge upsurge over the last decade of drug abuse in general, and of intensive, compulsive drug use in particular, only a few psychoanalytic studies have appeared which could try to explore in depth the possible etiology of this illness. The contributions of Chein et al. (1964), Krystal and Raskin (1970), Wieder and Kaplan (1969), Dora Hartmann (1969), Savitt (1963), Panel (1970), Zinberg and Robertson (1972), and Khantzian et al. (1974) are notable examples. Earlier works—the essays of Rado (1926), (1933), (1963), Glover (1928), (1932), Savitt (1954), Limentani (1968), and the comments of Fenichel (1945), although still very interesting, seem outdated and barely applicable to most categories of drug abuse seen nowadays.
The question we intend to answer, then, is: What are the causes of drug abuse? This in turn raises the further question of what exactly is meant by "drug abuse." The term is so wide and imprecise, contains such a hodgepodge of clinical and social phenomena, and is so dependent on the bias of the observer, that a systematic study of its etiology would be as vast and comprehensive as an inquiry into the etiology of fever. It will therefore be necessary to define what we mean before embarking on our investigation.
Some Basic Distinctions and Definitions
The usual definition of drug abuse is based simply on sociolegal criteria. According to Jaffe (1965), it is: "the use, usually by self-administration, of any drug in a manner that deviates from the approved medical or social patterns within a given culture" (p. 285). Jaffe narrows this broad definition by focusing on those "drugs that produce changes in mood and behavior." Similarly, Glasscote et al. (1972), apply the term drug abuse "to illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at a minimum, culture alien" (pp. 3—4).
Such sociolegal definitions obviously carry strong connotations of moral judgment and are based on specific ethical values. I believe a further delimitation can be made if the problem is viewed psychiatrically: drug abuse is the use of any mind-altering drug for the purpose of inner change, if it leads to any transitory or long-range interference with social, cognitive, or motor functioning or with physical health, regardless of the legal standing of the drug. Here, the judgment is based on impaired functioning and thus on an observable medical criterion, vague though it might still be.
For most purposes, however, even this definition is unsatisfactory because of its breadth. For a careful study of etiology, we had better set apart all those occasional or irregular drug users in whom the impairment is merely transitory; this latter group seems particularly heterogeneous and contingent. Our starting point is thus the discernment of two groups placed on the two extremes of a continuum. At the one end, we have the experimenters or casual users who represent the vast majority of participants in drug abuse (according to both definitions given above)—probably 90 per cent.
They present, medically and psychiatrically, very few and rare problems. Yet, much of the public's attention, the law's concerns and energies, the preventive efforts, are dedicated to these people. The experimenter takes a mind-altering drug a few times and feels he does not really need and require its effect. Out of curiosity, and just as much in order to avoid shame by not conforming with the adolescent peer group, he wants to prove that he has partaken of the initiation, that he knows what it is all about.
At the other end of the continuum, we have the compulsive drug abuser. He is the real problem. To him applies the statement that drug use is just a symptom of deep underlying problems. Only those relatively few experimenters proceed to compulsive drug abuse who carry the set of profound deficiencies and conflicts that we are going to explore in this study. It is the compulsive drug abuser who feels that the drug-induced state relieves him of what bothers him and gives him what he is missing, so that he feels unable to renounce the "high," regardless of dangers and threats he is usually fully cognizant of.
In the broad area between these two groups we encounter the so-called recreational user of drugs like alcohol or marijuana. For many recreational users the goal is merely relaxation, not intoxication; the amount of the active substance is so small that no interference with motor or mental functioning is noticeable. In many more so-called recreational users, the goal is indeed occasional or frequent intoxication.
They usually claim that their temporary abdication of rational controls is an entirely free, noncompulsive activity. I have not reached any final conclusion about this group, but on the basis of my clinical experience, I would associate the first type of recreational users, the relaxers, with the experimenters, the second type, those striving to get "stoned," "high," or "down," with the compulsive users.2
We turn now to this problem of "compulsive drug abuse" (cf. also Jaffe, 1965); (Glasscote et al., 1972).
Of course, the question arises: how far is this compulsiveness of a physical nature? Is that not just what led to the prohibition of these drugs in the first place—that they induce inevitably or at least very often a physiologic dependence which henceforth cannot be broken?
If we carefully study, on the one side, history and treatment experience and, on the other side, the interesting observations in medically and psychiatrically induced addictions, (e.g., when opiates were used to treat melancholics), we are forced to assign very little valence in the long range to this factor of physical dependence. In other words, as Hamlet said, "the readiness is all."
Those who work closely with compulsive drug users observe time and again that if their drug of predilection is taken away (or more precisely, if their drug effect of choice is removed), they sooner or later tend to substitute other symptoms. Neurotic depression and suicidal attempts, acts of violence, stealing, running away, severe attacks of anxiety, found prior to the use of drugs and sometimes accompanying the full-blown drug use, once the resorting to drugs is blocked, frequently reappear in exacerbated form and are often more destructive than drug use itself.
Still more frequently, we encounter the replacement of a suddenly unavailable type of drug by a pharmacologically completely unrelated class: i.e., patients deprived of narcotics typically resort to alcohol and sedatives (especially barbiturates), which have no bearing on any physical withdrawal phenomena, but solely on the psychological need for a drug-induced relief. In other words, compulsive drug use is merely one symptom among others, the expression of an underlying disturbance, not the illness itself.
One implication of this observation is, of course, that the really difficult task in treating these patients is not the withdrawal from drugs, but the coping with the emotional need to use a drug, to use any drug, and to use many other equally harmful external means, to find relief. In other words: I have never yet seen a compulsive drug user who has not been emotionally deeply disturbed, who has not shown in his history the ravages of borderline, or even psychotic conflicts and defects.
Only secondarily do we encounter the devastations caused by the drugs themselves. We may go one step farther: Not only do we encounter many other signs of pervasive severe psychopathology—most frequently of the borderline type—but the very criterion used to single out this group as compulsive drug users, namely "compulsiveness," leads us straight into the tangled thicket of how to define psychological health and illness, since this observable quality of compulsiveness or peremptoriness has been used by several psychoanalytic theoreticians (notably Waelder, 1936) and (Kubie, 1954) to define illness:
"The essence of normality is flexibility in all of these vital ways. The essence of illness is the freezing of behavior into unalterable and insatiable patterns. It is this which characterizes every manifestation of psychopathology, whether in impulse, purpose, act, thought, or feelings" (Kubie, 1961, pp. 20—21). Our "habitu?s" are, without exception, paradigms for people overwhelmed with such "unalterable and insatiable patterns."
Hierarchy of Causes
Even if we select an apparently homogeneous group, e.g., narcotics addicts, we still are bewildered by the variety of causes and, correspondingly, the vast array of proffered, discussed, and disputed cause-and-effect relationships. We may try to discern layers of causes (or, to be more precise, layers of reasons [Schafer, 1973, p. 268]), ordered according to causative specificity, and start off with a superficial distinction between two factors that always appear to be present:
The first is a psychological hunger or "craving," which we might describe as the addictive search—an entire group of activities, predating, accompanying, and following the compulsive drug use; they all are used to provide external relief for an internal urge of overpowering drivenness. We refer to activities such as irresistible violence, food addiction, gambling, alcohol use, indiscriminate "driven" sexual activity, or running away. The second factor is the more or less contingent, even accidental entrance of various drugs, in forms of both accessibility and seduction. This factor we shall call the adventitious entrance of drugs.
Behind this phenomenological distinction we can perceive a logical and historical structure of causes which we now examine, viewing them as a hierarchy of causes of various specificity. As is very often the case with such differentiations, what in this analysis is torn asunder into various groups and layers of reasons is in reality a continuum, ranging from high to low specificity.
Freud (1895) distinguished four types of causes for an emotional disorder: (a) precondition; (b) specific cause; (c) concurrent cause; and (d) precipitating cause. This distinction seems to have been an original contribution of Freud to the philosophy of causation. With it, he tried to apply the basic concepts of accidental, necessary, and sufficient causes—which had originated with Aristotle and had been developed by d'Alembert, Leibnitz, and Schopenhauer—to the problems of motivation, in particular, to the causation of emotional illness. He used a precursor of this four-part model in Draft B (1893), replacing it later on by the concept of the complementary series (Sherwood, 1969).
I was not able to consider all the philosophical roots, merits, or weaknesses of this model as a basic logical concept, but I feel it may serve us heuristically better than other models of causation. Some of the following layers will be explored more in detail later on.
a. A cardinal, indispensable, but broad layer of reasons is the precondition: "The factors which may be described as preconditions are those in whose absence the effect would never come about, but which are incapable of producing the effect by themselves alone, no matter in what amount they may be present" (Freud, 1895, p. 136). Applied to our problem, these inevitable preconditions can be located in a life history of massive narcissistic disturbances and in a rather specific pattern of family pathology.
I describe this in more detail below (cf. also Wurmser, 1972a), (1972b). Here, it should be only stated that the narcissistic conflicts referred to pertain to massively overvalued images of self and others. The term narcissistic is used in the (precise) psychoanalytic sense of Freud (1914), Kohut (1971), (1972), Kernberg (1970), and Pulver (1970), namely, to denote an archaic overvaluation of the self or of others, a host of grandiose expectations, and the abyssmal sense of frustration and letdown if these hopes are shattered.
b. "The specific cause is the one which is never missing in any case in which the effect takes place, and which moreover suffices, if present in the required quantity or intensity, to achieve the effect, provided only that the preconditions are also fulfilled" (Freud, 1895, p. 136).
Most people would now be inclined to seek the specific reason for compulsive drug use in the temptations by peers or pushers. I believe this would be misleading; it is, though semantically correct, clinically and theoretically wrong. We earlier differentiated "addictive illness' and "adventitious" appearance of the drug, and can now repeat that we find an emotional illness brewing independently, whether the drug enters or not. The specificity for its outbreak in manifest form lies in an experience of overwhelming crisis, accompanied by intense emotions like disillusionment and rage, depression, or anxiety, in an actualization of a lifelong massive conflict about omnipotence and grandiosity, meaning and trust—what we have just described as a narcissistic conflict.
This actualization inevitably leads to massive emotional disruption and thus to the addictive search. In other words, if we focus on the illness "addictive syndrome," the specific reason is a more or less acute external and internal crisis bringing about an exacerbation of a narcissistic disturbance. We may call this a "narcissistic crisis." In contrast, if we focus on the symptom "drug abuse," we are wiser to talk about precipitating, rather than specific reasons, a category I shall mention shortly. Even without the advent of the drug itself, we still have the characteristic seeking for a way out, for an escape, a driven desperate attempt to find a crutch outside of oneself.
Much vaguer and several steps removed are the reasons ("causes") that litter the literature, all of which we can put in the next category. Their nature is very unspecific, broad, of little predictive value. They are shared by many who do not join in the illness, and vice versa. Yet, they indeed are the only reasons (and indeed "causes") which epidemiological and sociological studies are apt to find. The statistical methods employed by these disciplines tend to bring out the background factors leading to heightened incidence, but not the more specific correlations.
c. "As concurrent causes we may regard such factors as are not necessarily present every time, nor able, whatever their amount, to produce the effect by themselves alone, but which operate alongside of the preconditions and the specific cause in satisfying the aetiological equation" (Freud, 1895, p. 136).
The most general of these concurrent reasons are widespread value conflicts in our culture and basic philosophical questions about the limitations of human existence. One crucial element is the conflict between democratic philosophies, postulating the dissolution of most external representatives of the superego, the increasing abolition of the restraining powers of authority and tradition, of external structures and restraints, and totalitarian philosophies, imposing the most tyrannical forms of such authority and power. Drugs are for many the shibboleth of liberation from authority, a symbol of protest and extreme privacy ("doing one's own thing").
A second element is the paradox with regard to mastery and domination of our outer and inner life: most of the ancient dreams of mankind about outer control have been fulfilled, whereas most of the techniques used in the past to gain an (albeit often spurious) sense of inner mastery and control have been discarded. Drugs provide a sense of magical domination and manipulation over one's inner life, analogous to that which science and technique appear to have over the outside.
Another socially more relevant value conflict is that between easy pleasure, immediate material gratification, and indulgence versus the often bizarre harshness of the responses by representatives of punitive and often corrupt authority (the death penalty for some small drug sales, sentences of 25 years for the giving away of one marijuana cigarette, entrapment and degradation of drug users by law enforcement officials). Thus, belonging to a drug-using countergroup can serve as protest against a profound inconsistency in the cultural fabric.
Another such factor may be the changed role of genital sexuality. For many, easily accessible sexuality is a source, not of anxiety, despair, and commitment, but of tedium and routine. The denied, split-off emotions involved in sexual yearnings are sought instead in other avenues, particularly with the help of pharmaca. Moreover, we might wonder how much the shallowness of, and presentation of shortcuts to, gratification by television, viewed for many hours daily from early childhood on and thus substituting a passive form of presentation for the development of an active fantasy life, may contribute to this search for easy stimulation (Grotjahn, 1971).
But most of all, we have to cite the social factors in the slums: social degradation, overcrowding, and overload in stimuli (especially noise and violence); the socially important role of the drug-using peer group as a substitute for the lacking family structure; and the even more relevant function of the drug traffic, and the black market needed to feed it, as an economic equalizer between ghetto and dominant middle-class society. All in all—these are unspecific broad factors—valid as much for occasional and recreational users (if indeed not more so) as for compulsive drug users.
Finally, we have to return to what I described phenomenologically as the "entrance of the drug" and labeled "adventitious": d. "??? we may characterize as the precipitating or releasing cause the one which makes its appearance last in the equation, so that it immediately precedes the emergence of the effect. It is this chronological factor alone which constitutes the essential nature of a precipitating cause" (Freud, 1895, pp. 135—136).
We would assign the previously mentioned easy availability of drugs and the seduction by peers to this category ("social compliance" [cf. Hartmann, 1939]. The advent of the drug suddenly allows the previous desperate search to crystallize around the one object and activity that relieves the unbearable tension. In sum: there is no compulsive drug use without this trigger factor; but there is still an overriding emotional compulsiveness directed toward other activities and objects. It can be assumed that only the latter two sets of factors (concurrent and precipitating ones) are identical for experimenters and compulsive users alike.
Clinical Observations About Preconditions and Specific Reasons
We turn now to a more detailed study of the first two sets of factors: what has been found so far in regard to the essential personality structure predisposing to, and the acute crisis immediately evoking drug use, and how these factors are matched by the pharmacological effect of various drugs.
The psychological factors of impulsiveness and low frustration tolerance are well known and undisputed. I should like to attempt an analysis that goes beyond these sweepingly general characterizations and may open the way to a deeper understanding of some actions and attitudes of these patients (perhaps of "sociopaths" in general?). Much is vague, tentative, even contradictory in what follows. Large gaps need to be filled. Careful longitudinal studies in depth, particularly in psychotherapy, psychoanalysis, and family research are needed to advance our knowledge.3
The Defect of Affect Defense
We start with what I believe to be the most important concept in a dynamic understanding of drug use. I consider all compulsive drug use an attempt at self-treatment.4 The importance of the effect of the drug in the inner life of these patients can perhaps be best explained as an artificial or surrogate defense against overwhelming affects. Moreover, there evidently exists some specificity in the choice of the drug for this purpose. Patients prefer those drugs which specifically help them to cope with the affects that trouble them most.
In the past, the satisfying, wish-fulfilling aspects of the drug effects have been emphasized. To put this in a catch phrase: drug use was seen as an expensive search for a cheap pleasure. This is certainly the popular and unreflective concept of why people take drugs. Earlier analytic theoreticians (Glover, 1932), (Rado, 1926), (1933), (1963) subscribed to this idea, except that they saw in drug use, as in other symptoms, the satisfaction of unconscious wishes.
In other psychological studies of drug abuse, the focus was on the symbolic (again chiefly wish-fulfilling) meaning of drug intake as such (as oral supplies, illusory penis, or its self-destructive, self-punitive aspects) with little regard for the psychodynamic impact of the pharmacological effects themselves.
The view that drug use is an escape has also been popularly held, but largely with regard to intolerable external situations. The concept of the need for drugs as a defense against intolerable internal factors—and, more specifically, affects—has been described but scarcely until a very few years ago. Most tragically, legislation and public policy totally disregard this central factor.
Homer sang of Helena having "drugged the wine with an herb that overcomes all grief and anger and lets forget everything bad."
Freud (1930), too, described narcotics as a means of coping with pain and disillusionment. Glover (1932) was explicit with regard to "drug addiction" (referring to cocaine, paraldehyde, and presumably also to opiate addictions): "Its defensive function is to control sadistic charges, which, though less violent than those associated with paranoia, are more severe than the sadistic charges met with in obsessional formations" (p. 202) and: "Drug addiction acts as a protection against psychotic reaction in states of regression" (p. 203). In turn, he saw in unconscious homosexual fantasy systems "a restitutive or defensive system ??? [acting] as a protection against anxieties of the addiction type" (p. 203).
Rado (1963) named this aspect of affect defense "narcotic riddance" and opposed it to what he called "narcotic pleasure" and "narcotic intoxication" (a climactic sense of triumphant success). Fenichel (1945, p. 380) wrote: "??? the addiction can be looked upon as a last means to avoid a depressive breakdown?— Similarly, Chein et al. (1964) have described the "opiate's capacity to inhibit or blunt the perception of inner anxiety and outer strain??? In this sense, the drug itself is a diffuse pharmacological defense" (p. 233). Dora Hartmann (1969) pointed out that the conscious motivation for the use of drugs was in most cases "the wish to avoid painful affects (depression), alleviate symptoms, or a combination of these factors" (p. 389).
Wieder and Kaplan (1969) describe the drug of choice as "acting as a psychodynamic-pharmacogenic 'corrective' or 'prosthesis'" (p. 401). Their approach is almost identical to the one here suggested. They write:
Chronic drug use, which we believe always occurs as a consequence of ego pathology, serves in a circular fashion to add to this pathology through an induced but unconsciously sought ego regression. The dominant conscious motive for drug use is not the seeking of 'kicks,' but the wish to produce pharmacologically a reduction in distress that the individual cannot achieve by his own psychic efforts [p. 403].
Krystal and Raskin (1970) emphasize the dedifferentiated, archaic, resomatized nature of the affect; because of the traumatic nature of affects in such persons, "drugs are used to avoid impending psychic trauma in circumstances which would not be potentially traumatic to other people" (p. 31).
The idea of defense against affects is also a well-known analytic concept and has been elaborated by Jones (1929), Anna Freud (1936), Fenichel (1934), and Rapaport (1953).
In all categories of compulsive drug use, the preeminence of archaic, chiefly narcissistic, conflicts is evident; what changes are some of the affects presenting the most immediate problem to the patient concerned. These affects are close to consciousness, are not really repressed, but cannot be articulated for a reason I shall subsequently describe.
Narcotics and barbiturates apparently calm intense feelings of rage, shame, and loneliness and the anxiety evoked by these overwhelming feelings.5 In the words of a 22-year-old white heroin addict: "Everything in my life has to have its peak. I cannot accept things for what they are. The actual happening is a letdown compared to the anticipation. It seems then as if all of life comes down on me—in a sense of total despair. Then my first reaction is to get me some dope—not to forget, but to put me farther away from the loneliness, estrangement, and emptiness. I still feel empty and lonely when I am on dope, but it does not seem to matter as much. All is foggy and mixed up."
Heroin, for him, was a cure for disillusionment. He went so far as to say: "Heroin saved my life. I would have jumped out of the window—I felt so lonely." He wants to re-create the feeling of full acceptance and union, a fantasy whose reality he postulates as having characterized his early childhood; "I was given everything. I had a protector. Later, I realized I did not have it anymore: no protector, no shield—only myself" (Wurmser, 1972b).
This effect can be witnessed with particular clarity in patients who are put on methadone maintenance—especially if they are followed in psychotherapy both during periods of abstinence and while on the narcotic. I have seen 19 such patients in intensive psychotherapy, 14 of them for a prolonged period (several months to several years). A summary of these observations (Wurmser, 1972b) follows.
All the patients described feelings of loneliness, emptiness, and depression, of meaninglessness and pervasive boredom preceding drug use and following withdrawal. In all of them, very intense feelings of murderous rage and vengefulness; or of profound shame, embarrassment, and almost paranoid shyness; or of hurt, rejection, and abandonment, were discovered during psychotherapy. In all of them, these feelings of rage, shame, and hurt were reduced as soon as they were on methadone; in a few of them, they disappeared altogether; in some, they still occurred occasionally, but had a less overwhelming quality. Some of the patients said the drug made them feel normal and relaxed—implying that they felt those pervasive feeling states to be abnormal, sick, intolerable.