Pride & Prejudice – Psychodynamics of Addiction

Adina Parkes

Despite addiction representing a significant ongoing public health concern, the literature on psychodynamics of addiction remains sparse compared to that of other psychiatric disorders.  This is also reflected in the healthcare service design where professionals other than mental health services deal with drug & alcohol use disorders and their comorbidities, for example pain clinics who manage patients for whom opioid dependence started as part of pain management [1].  This practice influences the decision-making process of many mental health professionals as clinicians look at each problem separately when treating and signposting patients to each of these services.

Violent behaviour and assaults on staff in healthcare settings including Accident and Emergency (A&E) and GP surgeries is a growing problem [2,3,4]. The relationship between such behaviour and illicit drug use is well established; intoxication may be described as reduced inhibitory response during stressful situations, over-reaction, negative thought pattern, reduced self-reflection, increasing concerns about personal power and underestimation of consequences [3]. Therefore, modification of relevant communication approaches could serve as a potential preventative measure, and an understanding of interpersonal dynamics in this context could add value to developing communication and management strategies that help reduce the risk of violence.

This review of some basic psychodynamic concepts is being carried out with a view to helping improve the understanding of addictive behaviour, associated clinical decision-making and communication approaches for clinicians working in different settings.

 A classic triangle

 Regardless of the setting, in every encounter with an individual drug addict you have three actors in play – the clinician, the user and the drug [5]. Before jumping into telling the user how damaging illicit drugs are, it is worth reflecting on this aspect to avoid conveying a counter-therapeutic interaction.

The Drug and the User

 Whilst the effects of drugs are widely described, the literature on psychodynamics of drug use is sparse. This is surprising because the relationship between the individual and the drug is most often a long term one. Based on attachment theory [6], it seems drug users develop affectional bonds with their drug of choice. The word, “addiction” stems from the Latin addictiōn– (stem of addictiō) which means “a giving over, to surrender”, and “dependence” from the Latin dēpendere, which means “to hang down” both implying a surrender to the relationship with the drug. Moreover, if one searches the word “dependence” in Dictionary.com, it means a state of relying on someone for support, and an object of reliance or trust. Bowlby [6] suggests that we have an innate tendency to seek and maintain proximity to certain preferred others.

The story of Konrad Lorenz and the ducklings is common knowledge; whilst ducklings attach themselves to a mother figure through the process of imprinting, it is a distinct feature of human beings to cultivate attachment over time, creating different relationships with specific and distinct others so that attachment becomes a different component in a relationship than simply need-driven dependency [7]. In a secure attachment relationship four components are important:

  1. The need for proximity and secure base when a child has a constant and reliable presence of an attachment figure during their development
  2. Homeostasis where the couple will work towards protecting their relationship from external threats and maintain it unchanged
  3. Internal working models when experiences with others become internally represented and form a template for future relationships. There is growing neurobiological evidence for how the early childhood experiences influence “the wiring of the brain” [8].
  4. Capacity to mourn the loss by “moving on” and working through the loss is developed during secure attachment

Similarly, when we examine affectional bonds of the addicted person with the drugs of choice, there is clear evidence of a relationship and attachment beyond its chemical components. For example, a patient who engages with psychiatric treatment and maintained abstinence from oral and injectable illicit drugs prefers to receive antipsychotic treatment in the form of tablets as it maintains his life in a comforting routine. Such patients often decline injectable medication as just the act of being injected would bring back the cravings for opioids. So, on one hand they choose to maintain a positive attachment with prescribed medication relying on a previous familiar experience but also choose to avoid triggers e.g., needles that remind them of the destructive negative attachment to injectable drugs. They seek proximity to something familiar, knowing it is always there and they could turn to it for comfort. It is not dissimilar to how an infant turns to his mother in times of distress to seek re-assurance and comfort.

This is an ambivalent relationship – love but also hate. There are times when the person dependent on drugs feels disgusted with the habit, but shortly after the same person seeks new supplies as he struggles to find internal resources to deal with dependence.

The User and the Clinician

The relationship between the treating clinician and drug user is also an ambivalent one. The clinician’s intention to help might be obvious, but what might be less obvious is that he or she will be perceived as a threat to the affectional bond with the drug based on homeostasis, as described above. This is illustrated by the denial and rationalization that many patients use as defence mechanisms when discussing negative effects of drugs. Despite the reason that has brought them to that clinical encounter and the evidence-based literature, some still insist on denying that the drug does them any harm, suggest alternative benefits or even go further to advocate that some illicit drugs should be legalized.

The Clinician and the Drug

The clinician perceives the person addicted to drugs as well as the dependence, and countertransference will shape that interaction due to unconscious internal forces. The clinician, with a profound desire to save the user from the drug, might take pride in his professional role, and unleash the fantasy of omnipotence. By embracing the role of an omnipotent saviour, he risks disillusionment when the user relapses or even dies as consequence of the drug habit. Some clinicians will find themselves becoming detached and thinking that they are becoming rational. They might give up hope that their efforts will bear fruit and feel helpless in the process. This is where the clinician is at risk of becoming judgemental and adopting a moral stance when seeing drug users. For example, “they do it to themselves” is not an uncommon phrase or thought amongst healthcare workers in emergency settings when faced with intoxicated patients. Different healthcare professionals will be on a continuum between these two extremes, and the same clinician can move along this continuum depending on the situation. Of course, this is only a somewhat simple example out of the multitude of complex emotions and dynamics which could occur between the clinician and drug user.

 What is gained and what is lost?

 How and why does an attachment to one or more drugs take place, and what does the drug user get out of this relationship? The theoretical framework of “containment” might come into play here; the assumption being that we are not born with the capacity to contain our own emotions. In the first “container” (child with his mother), the newborn experiences emotions e.g., fear, anger, hunger, as a threat (“the end of the world”), but the mother offers containment and soothing as a maternal function. If there are insufficiencies in the maternal function, the adult will develop various self-regulating deficits.

There is an overall understanding in the psychodynamic framework that people addicted to drugs are likely to suffer self-regulating deficits in affect, behaviour, and self-esteem which influence their relationships. They might be incapable of tolerating and regulating interpersonal closeness. The ingestion of a drug can be seen as a desperate attempt to compensate for these deficits.

Recent psychoanalytical thinking has tried to connect the understanding of drug addiction with recent developments [7,8]. Some suggest three forces contributing to addictive tendencies:

  1. A difficulty in tolerating affect coupled or derived from reduced capacity to tolerate mental pain
  2. The object constancy problem (meaning deficits in early development) which makes the person use drug as a soothing internal object, as a substitute for a containing soothing mother
  3. The biological based craving

Based on A. H. Williams, Container and Contained: the school of Bion,

The Psychodynamics of Addiction 2002

 The drug is used as a search for a reliable container to contain the individual or their unbearable emotions. Drugs offer an immediate solution to the painful affect, whatever that is, and therefore users frequently request medication to alleviate these painful affects. Treatment guidelines may appear disappointing to some of these patients as they do not support any quick fixes. This might also be the reason why many doctors feel under pressure to prescribe: “do something about it, now”. However, imagine someone with limited capacity to tolerate having discovered a “miraculous substance” which offers that relief. How can one think about the future and wait for it when they struggle in the present? We ask our patients to give up the drug, engage with substance misuse services and work hard in a long psychological treatment which might alleviate some of the pain– in the user’s perception this could be an uncertain future.

The problem with this solution is its temporary nature, as greater and greater amounts of the drug will be necessary to obtain the same effects and relief because the person will develop tolerance. Some drugs might be more containing than others, but they will weaken and destroy the ability to tolerate emotional pain, which the addicted person must endure no matter how fragile – the self becomes weaker by reducing exposure to pain. It is not dissimilar from avoidant behaviour in anxiety. Some propose that this cycle could lead to a Pharmacotoxic crisis. The exit from this crisis could have 3 potential consequences: flight into a drug free period – defence of a manic kind which will lead to collapse in subsequent states of anxiety; suicide; or psychotic breakdown.

Another theoretical framework is narcissism, where a similar vicious cycle derives from deficits in self-esteem, which the person addicted to drugs is trying to regulate. Kohut [5] believed that the drug functioned not as a substitute for a love object, but a replacement for a defect in psychological structure. When the person struggles with low self-esteem, worthlessness, poor ability to self-soothe, the drug becomes an alternative for dealing with life experiences by improving mood, self-esteem, and a sense of power or assertion. The problem with this solution is its ephemeral nature; as no internal reliable structures are built, the defect in self remains. This short-lived gain of a manufactured sense of power and importance disappears along with the chemical effects of drugs.

The spiral of addiction is described by some as a self-defeating process. The person finds himself in a worse situation than before as their feelings of guilt and shame might add to the internal burden of that deficit [9]. They realize that they have not managed to solve the original problem, so the self-confidence gets hit. They must resort again and again to the same chemical temporary solution. Based on this framework, one can better understand the scenario in healthcare settings like A&E where patients may have sought to become intoxicated because they struggle with low confidence [7]. As a healthcare professional by default holds a position of authority, these patients could interpret such interactions as being “told off”, causing further injury to an already very fragile self-esteem. In this situation, with inhibitory responses already compromised, the patient will react in an aggressive manner. Understanding these psychodynamics can allow professionals to adopt useful communication approaches in such interactions.

The Broader Picture

It needs to be mentioned that some of the complex emotions and scenarios discussed above will be replicated at organizational and societal level [5].  There is evidence that teams working with drug users and treating drug addiction need regular supervision to address the dynamic difficulties inevitably arising in their work. At organizational level, these difficulties become more evident at multiple interfaces when different services deal with different aspects of an individual’s difficulties. A patient who already has a milieu of inconsistent patterns of attachment in their internal world will unconsciously replicate patterns of interaction with the clinicians involved in their care by various defence mechanisms including projection and projective identification.

Society itself seems to remain ambivalent at multiple levels in relation to the drug addiction. There are countries where drug use and/or intent to supply are criminalized, and in other countries these are decriminalized. The modern western society seems to be able to “demonize and glamorize” drug use at the same time where it attaches moral stigma to the drug addiction and individuals struggling with it, but it can equally harbour fascination and adulation as seen in the catwalk fashion of the 90s with the “heroin look”. Therefore, the overall picture and its dynamics are complex at individual, organizational and societal level. The psychodynamic literature in this area also remains somewhat limited with a huge scope for exploration with support from public health resources.

References

[1] Banerjee, S; Clancy, S : Carmel I. Co-existing problems of mental disorder and substance misuse (dual diagnosis) -An Information Manual. 2002 – available at- dualdiagnosis.co.uk

[2] Højsted, J and Sjøgren, P -Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 2007, 11(5) pp 490-518

[3] Lyneham J. Violence in New South Wales emergency departments. Australian Journal of Advanced Nursing, 2000 18 (2), pp AXA PPP 6890117S, EDE39178-17.

[4] Ferns, T. Characteristics of people who assault nurses in clinical practice. Nursing Standard 2007. (21(50), pp 35-9.

[5] Wergmam, M and Cohen A, editors. The Psychodynamics of Addiction. London: Whurr Publishers Ltd, 2002

[6] Bowlby J Separation: Anger and Anxiety. Attachment and loss. Vol. 2. London: Hogarth, 1973.

[7] Gabbard, G. O. Psychodynamic Psychiatry in Clinical Practice, Fifth Ed. London: American Psychiatric Publishing, 2014.

[8] Fox, S. E.; Levitt, P; Nelson III, C. A. How the Timing and Quality of Early Experiences Influence the Development of Brain Architecture. Child Development, 2010, 81 (1) pp 28-40

[9] Khantzian, E. J., An ego self-theory of substance dependence. In Khantzian E. J., Halliday, K. S. and McAuliffe, W. E., Addiction and the Vulnerable Self: Modified Dynamic Group Psychotherapy For Substance Abusers, New York: Guildford Press, 1990

About the authors

Dr Adina Parkes is a Consultant Psychiatrist at Kent and Medway Partnership Trust (KMPT).