Foundations of Addictions

Week 7

Glenn Maynard, LPC Review of Psychoanalytic Theory

• Pathology occurs as ego defenses are unable to contain struggle between instincts and social realities • Freud thought of personality as consisting of structures called the id, ego and superego • These structures act on humans in different ways through developmental changes The Big Three Structures

• Id- instinctual urges. Freud placed emphasis on sexual () urges; some of his followers added aggression and later all drives (relationships) • Superego- develops with experience; internalizes social values and expectations • Ego- organizes experience; attempts to balance the struggle between the id and superego with defenses Defense Mechanisms

• Rationalization-justifying ones mistakes • Compensation-dealing w/deprivation by overindulging • -withdrawing into a passive state • Displacement-directing pent-up toward a less dangerous object • Regression-retreating to an earlier developmental stage • Denial-inability to percieve an unacceptable reality • Projection- assuming others feel badly of one wo evidence • Fantasy- gaining gratification by imagining • Undoing-atoning for an unacceptable act Developmental Course

• Oral stage- the infant incorporates what is pleasurable from the environment (breast) into sense of self • Anal stage- incorporation of values; sense of control and power • Phallic- Oedipal and Electra; competition with powerful others • Latency- consolidation • Genital- adolescence Freud and Drugs

• Discovered the euphoric effects of cocaine and recommended its use to clear the mind and for energy • After recognizing his own addiction, recanted and explained addictions as oral dependency • Alcoholics had a pre-existing personality pathology that drove the addiction Freud and Drugs

• Addiction is a secondary problem • Treatment is directed at the underlying pathology • The patient would voluntarily discontinue using drugs once insight about the underlying pathology was understood • Early psychoanalysts seemed to recognize addictions were not easily treated by the talking cure; got in the way Object Relations Theory

• Psychodynamic • Differs from Freud in describing pathology as resulting from the interaction between the person and the environment • Object- someone toward whom or action is directed • Self- broad organization of the person that includes the ego Object Relations Theory

• Representation- how a person psychically represents an object • Object representation- how the person “sees” or experiences others • Part whole objects- part objects are incomplete and lead to , etc • Self representation- how a person “sees” or experiences him/her self Object Relations Theory

• Predominant pathological defense is splitting • Splitting occurs when two part objects come into conflict • One object is usually experienced as “good” and the other object is usually experienced as “bad” Self Psychology and Narcissism

• As described by Kohut, narcissism is a defective core personality • Defects are acquired during childhood in interaction with the environment • In normal development, the grandiose self and the idealized object come to terms and act to create a healthy narcissism in the child Self Psychology and Narcissism

• In normal development, the healthy parent mirrors to the child in accomplishments • The child’s grandiose self is satisfied and the child learns that others are valuable persons • In abnormal development, the parent(s) do not mirror and are self absorbed • The child’s grandiose self is not tamed and the child searches for idealized others The Therapeutic Relationship

• Transference=thoughts, feelings, attributes and motives patient has experienced in past relationships, applied to the therapist • Countertransference=thoughts, feelings, attributes, and motives therapist has experienced in past relationships, applied to the patient So, what does all of this have to do with addictions? • Contemporary psychodynamic theorists have adopted relational models to explain addictions as resulting from disturbed core personalities • Psychodynamic clinicians recognize that abstinence must be addressed at the on-set of therapy • Argue that psychodynamic therapy offers more complete (and expensive) recovery Psychodynamic views of addiction • Drugs are used to manage intolerable affects; self-medication of psychic • Drugs are used as object substitutes or to activate “all-good” self and object images • Drugs used to to restore collapsed grandiose self or idealized object • Drugs as an external object to take care of self in defiance of an internal prohibition against pleasure Khantzian’s self-medication hypothesis and cocaine addiction • Compulsive drug use resulting from psychological vulnerabilities and personality make-up • Vulnerabilities in four areas Accessing and tolerating Problems in relationships Self-care failure Self-esteem deficits Drug of Choice Related to Psychological Distress • Opiates=primarily trauma sufferers. Calms intense • Sedative-Hypnotics=dissolve defenses of denial and splitting. Allow “safe” experience of loving and aggressive feelings • Cocaine=low energy-overcome fatigue and depletion, ,: high energy- increased self-esteem, assertiveness, frustration tolerance Cocaine addicts

• Cocaine is in response to unremitting and impaired esteem • Depression is not tolerated or may not be recognized • Family conflicts reinforce low esteem helplessness • Cocaine addicts may have a strong need for recognition that is unmet Cocaine

• Modified Dynamic Group Therapy developed at Harvard University • Short term therapy that focuses on the 4 vulnerabilities • Attention to helplessness and using group resources to reinforce control over this sense of self Compulsion, Addiction and Narcissism • Compulsion is commonly used by MDs to describe addictive behavior • A compulsion is initially an ego dystonic behavior that over time may become ego syntonic • This may be due to reinforcement principles Compulsion, Addiction and Narcissism • Addicts are narcissistically vulnerable • They have deep seated helplessness • When helplessness is challenged they may respond with an aggressive drive that results in using drugs or alcohol • Principle defense is displacement • Sense of power and control that comes from using drugs is displaced from a real sense of power and control Stages of Recovery

• Stage I: I can’t drink or drug

• Stage II: I won’t drink or drug

• Stage III: I don’t have to drink or drug Preferred Defense Structure of the Alcoholic-Wallace • Denial • All or nothing thinking • Conflict minimization/avoidance • Self-centered selective attention • Non-analytical modes of thinking and perceiving • Obsessional focusing Problems with psychodynamic models of addiction • Based on anecdote and favorite theory • Drives and states like helplessness are difficult to measure and at best are inferred • Which comes first? Helplessness and then addiction or addiction and then helplessness • Treatment models are long term except for models like MDGT Myths of Psychodynamic Therapy • Can develop a therapeutic relationship and then wean patient off substances • Substance use will disappear with understanding • Once conflicts have been resolved patient can return to social use • Addiction is always a symptom, not a primary problem Strengths of psychodynamic models • When used appropriate they often fit with the addicts experience • Good point of reference for counselor • Offer a sense of control that biological models may not offer • Can be adapted to groups in the hands of a skilled counselor • Can lead to broad based treatment