PSYCHODYNAMICS OF DRUG DEPENDENCE US DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE • Public Health Service • Alcohol, Drug Abuse. and Menial Health Administration PSYCHODYNAMICS OF DRUG DEPENDENCE Editors Jack D. Blaine, M.D. Demetrios A. Julius, M.D. Division of Research National Institute on Drug Abuse May 1977 NIDA Research Monograph 12 U.S. Department of Health, Education, and Welfare Public Health Service Alcohol, Drug Abuse and Mental Health Administration For sale by the Superintendent of Documents, U.S. Government Printing Office Washington. D.C. 20402 Stock No. 017-024-00642-4 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